July 18th, 2012

Lessons from EKG Class

CardioExchange welcomes this guest post from Dr. Westby Fisher, an electrophysiologist practicing at NorthShore University HealthSystem in Evanston, Illinois, and a Clinical Associate Professor of Medicine at the University of Chicago’s Pritzker School of Medicine. This piece originally appeared on his blog, Dr. Wes.

“Dr. Fisher, can you teach our residents’ EKG lecture series?”

Naively, I said “Sure!”

What I didn’t realize is how hard this is to do today.

Much of this is not residents’ fault.  They only have so many hours in so many days to attend lectures while caring for patients.  Thanks to residency work-hour restrictions, those hours have become even fewer.  To make matters much worse, through the year residents are torn to different rotations at different times and different hospitals.  Since topics for EKG interpretation span over many lectures, it is impossible for residents to attend every lecture over the academic residency year.  Just like when a student misses half the lectures for a college course, it’s hard to get an A.

Yesterday, I stood before a crowded room of about 35 to 40 residents and interns for their first of many EKG classes.  There they sat, with their nicely pressed fluorescent-white lab coats ready to learn.  They were quiet and respectful as they sized up their middle-aged physician attending who apologetically arrived 5 minutes late after seeing an urgent consult in the Emergency Room.  They had no idea what to expect.  In some ways, neither did I.

I plugged in the obligatory USB thumb drive to the obligatory computer to display the obligatory Powerpoint presentation, then stopped.  Up came the image on the screen.  They turned toward it, oblivious how uninterested I was in the contents of the slide.  I asked them a question.

“How many of you don’t know the first thing about an EKG?”

Their heads swung back to me, silently.  Much of the room smiled, not certain where I was going.  Hesitantly, a few hands rose in the air.

I had never seen this before.  As their soon-to-be instructor, I could not help but ask myself silently what the heck these kids have spent at least $200,000 of their parents’ money learning in medical school. How on earth can any student leave four years of medical school education and not know the first thing about an EKG?

I pressed on.

“How many of you know something about an EKG and its basics but realize you need to know more?”

Relieved, I saw many more hands go up.

EKG reading is one of those basic skills about which every physician should at least have a rudimentary knowledge.  Medical school’s controlled classroom-like environment lends itself better to instruction of the basics rather than hurried clinical rotations.  Clinical rotations are where residents should fine-tune their skills in this area.  How and why some medical students are not even exposed to this basic skill before entering their internship is one question, but what these young doctors are receiving for their huge costs of education is an even more important one.

As pressures continue to mount on physician salaries in the years ahead and their corresponding debts climb, perhaps we should ask ourselves why our young doctors continue to pay huge sums for their medical education when the quality of the instruction has been allowed to slip to this level.

Could it be that their academic instructors never attended an EKG class either?

9 Responses to “Lessons from EKG Class”

  1. Donald Hislop, MS MD says:

    I enjoy a review of basic and advanced EKG reading at my yearly Medical Education courses .

  2. Gian Giove, MD says:

    i remember ecg classes when a student and a resident and 80% dont care, they will just read whta the ecg machine says which in general gives a good estimate

    I also do believe that education will depend on self motivation every time more. I also do believe that all this new regulations are just causing residents to be lazier, hope i dont insult anyone but that what ive seen, they expect more doing less work, if you pressure them too much they simply complain and quote new regulations
    from a teaching point of view, is true that many times its impossible to attend to all lectures but again, self motivation and interest in something is key, specially if as you said lots of $$$ is being payd which will take everytime longer to payback with new medical reinbursment regulations
    programs could try to implement online recorded lectures, i do find them helpful

  3. Robin Motz, M.D., Ph.D. says:

    When I criticized a second-year resident for not doing a cardiac exam with the patient in all three positions including LLD, he told me that the exam was immaterial because he was ordering an echocardiogram anyway.

  4. Wesley Haisty, MD says:

    I find our cardiology fellows much more interested, oriented, and many have a great background due to the area of interest.
    However, the clinical schedule does compete with education, and I don’t think that our cath attending can do a case without 1 or 2 fellows holding their hands. Totally different than most EP cases!

  5. Sanjay Verma, MD says:

    Frankly, I think that EKG is not taught well in most medical schools and programs. They spend a lot of time in theory explaining the different findings in various pathologies. While schedules are busy and must is left to independent learning, I strongly believe that the only way to truly learn EKG’s is to practice, practice, practice. It’s no different than music or sports. You can learn the sheet music or the playbook, but one will only truly learn it by practicing. Really, what ought to be done is several hundred practice EKG’s, interpreted systematically.

    I also find that many who teach EKG like to go too quickly to interesting findings (ones that most residents will not encounter that often). This may seem interesting in the lecture but it doesn’t lead to long-term learning and memory retention.

  6. george Ritter, BSci, MD FACC,FACP says:

    i am of the generation that learned EKG from one of the original masters: Gordon B Myers. He insisted that EKG reading should NOT be taught to students. At the time I thought it odd but after reading EKGs for some 50 plus years for a large hospital I agree with him.
    It is a skill that has to be continuously practiced (like music).These machines that “read” as part of their print out are probably safer than than an unskilled GP ( PCP) who sees one or two a week and almost all normals. Unles one is reading almost daily and getting watched by others EKG reading accuracy will be poor.

  7. Karen Politis, MD says:

    I think the most useful thing I learned many years ago was to think of the source of the ECG (after all, as students we are still pretty good at physics, having crammed to get into med school) and then see how it is recorded in the respective leads. That is the scientific basis for interpreting ECG’s, and that is what separates us from our wonderful, experienced nurses. And then, of course, practice…but never forgetting a systematic approach. Even when I was in med school many years ago there were excellent audiovisual aids to help our instructors and us. I agree that this should be part of a physician’s basic training, after all, the way the ECG is recorded is not likely to change. The knowledge will be useful for a career that spans decades, unless pocket ultrasound scanners or other new methods render ECG’s entirely obsolete.

  8. William DeMedio, MD says:

    Dubin’s book on learning how to read an EKG was the best, fastest, and most efficient way to rudimentarily learn how to read an EKG I have ever seen. Combine this with an ACLS course and you have the basic needs for a physician to read an EKG. Throw in a few rotations with a cardiologist who takes a little time to challenge you with real EKG’s for practice and you are well on your way. Then continue in your general practice, running, looking and reading them.
    By the way, the most interesting “challenge” EKG I ever saw was NSR, no acute changes. It was PEA, and the guy was dead. Always look at the patient and get history first.

  9. Judith Andersen, AB, MD says:

    My spouse, a fully trained and boarded academic internist, took a less traveled road and became an emergency physician, but his love of cardiology and ECG interpretation has impelled him to collect ECGs (he has an electronic collection of thousands) and teach their interpretation to Wayne State medical students and both internal medicine and emergency medicine residents. And they thrive on this instruction. I’m a bit embarrassed that there is no one quite as good as he in the Department of Internal Medicine, but delighted to have an in-house consultant. A teacher who loves the discipline and is passionate about teaching it makes a huge difference in the willingness of students (residents, fellows, other attendings) to learn a discipline and Bill’s sessions are always crowded with learners, young and old.