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Junior psychiatrists' electrocardiogram interpretation skills

  • Noel Collins (a1), Uttara Mandal (a2), Gabrielle Pendlebury (a3) and Jenny Drife (a3)
Abstract
Aims and Method

We checked whether psychiatric junior doctors could identify common electrocardiogram (ECG) abnormalities. Participants were directly approached at three London sites during induction or teaching programmes.

Results

The survey had a total response rate of 65% (36/55). Psychiatry junior doctors displayed an overall success rate of 97% in detecting whether an ECG is grossly abnormal, but were much less competent in specifying exact ECG diagnoses (success rate of 41%). Accuracy rates for some diagnoses (e.g. paced rhythm) fell to as low as 11%. General practitioners performed no better than psychiatry trainees.

Clinical Implications

There is little consensus about minimum acceptable standards in medical skills such as ECG reporting in junior doctors. These competencies are generally ignored in new curriculums. Questions regarding the appropriate remit of psychiatry doctors in this area are raised and the need for more monitoring and education of these skills is queried.

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Copyright
This is an Open Access article, distributed under the terms of the Creative Commons Attribution (CC-BY) license (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
References
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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
  • URL: /core/journals/bjpsych-bulletin
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Junior psychiatrists' electrocardiogram interpretation skills

  • Noel Collins (a1), Uttara Mandal (a2), Gabrielle Pendlebury (a3) and Jenny Drife (a3)
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eLetters

Medical Skills for Trainee Psychiatrists

Fabida Noushad, CT3
17 September 2008

The recent article by Noel Collins et al on junior doctors’ electrocardiogram interpretation skills opens important areas regarding training.

In the MRCPsych exams a main focus is to rule out organic causes and this is well tested in MCQs and OSCE stations.A previous survey by Laura Robinson highlighted the fact that trainees provide a considerable amount of physical care to patients in their wards, and 62 of63 respondents felt trainees should receive further training in emergency situations.

Lack of ongoing training could result in trainees being out of date with regard medical conditions; this in turn may affect patient care. Certainly, trainees vary with regard the amount of time spent doing physical examination and ordering investigations.

Other than interpreting ECG, there are many areas where trainees would benefit from formal training. These include knowledge of conditions such as sepsis, dehydration, starvation, COPD, chest pains, diabetes and epilepsy.

This could possibly reduce morbidity and at the same time save money by reducing numbers of patients transferred to general hospitals.With the inclusion of foundation training, many doctors will have some experience of emergency medicine unlike previous systems where one could go to a psychiatry training scheme soon after graduation. Even so, a 4 to 6 monthly refresher would help keep one's knowledge and skills up to date and aid confidence in dealing with medical conditions.

Integrating teaching sessions with medical and GP trainees, short placements in A&E might be one way to help improve training. Workplace based assessments might also include discussion of a medical condition once every 6 months.

References

1. NOEL COLLINS,UTTARA MANDAL,GABRIELLE PENDLEBURY, JENNY DRIFE (2008) Junior psychiatrists’ electrocardiogram interpretation skills Psychiatric Bulletin,32,353-355

2. ROBINSON L. (2005) Are psychiatrists real doctors? A survey of themedical experience and training of psychiatric trainees in the west of Scotland. Psychiatric Bulletin, 29, 62-64

Declaration of Interest - none

Author

Fabida Noushad CT3, Coventry and Warwickshire Partnership NHS Trust, Walsgrave, Coventry, West Midlands, CV2 2TE.
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Conflict of interest: None Declared

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Psychiatric Trainees ECG interpretation skills

Imran Mushtaq, Associate Specialist-Child & Adolescent Psychiatrist
17 September 2008

We read Collins et al study (2008) with great interest. Whilst it is encouraging to know that junior psychiatrists can detect grossly abnormal ECGs, competently in 97% of the cases. It is quite alarming for them to detect the exact abnormality in only 40% cases. Although worrying but not surprising that GP trainees, not doing better than their psychiatric colleagues. One would expect that GP trainees would do lot better. As a patient, we all encounter general practitioner in our daily life, when we are ill and expect them to recognise the illness, investigate it properly and initiate the appropriate management plan.

American Academy of Family Physicians (AAFP, 2000) statistics show that 89.8% of family physicians interpret ECGs in the office setting, and that 36.0% include ECG interpretation in their hospital practices. On average, the GPs would not have referred 17.8% of the appropriate cases i.e. those with abnormal ECGs. Within this 17.8% of cases, the GPs missed 5.6% of the total number of left ventricular systolic dysfunction (LVSD) patients while the ECG machine interpretation missed no LVSD cases (Jeyaseelan et al, 2006).

It is not only the psychiatrists and GPs who have difficulty in interpreting ECGs but other clinicians as well. A Swiss study (Berger et al, 2004) found low concordant (74%, kappa = 0.51) between Emergency Physicians (A& E medics) and Specialist Physicians in interpretation of normality or abnormality of the ECG.

In forensic settings, admissions are generally for a long period of time and the patients do not have access to primary care. Hence it is the responsibility of the secondary care to do physical health checks periodically - including an ECG. There is a growing body of research thatshows a greater problem with physical health in psychiatric patients; the difficulties include diabetes, cardiovascular disease and obesity. However this aspect of our patients’ care frequently gets overlooked with the focus being on their mental health.

We agree with Collins that ECG interpretation and other skills shouldbe part of core curriculum for junior psychiatrists. It is true that courses are expensive and trainees have very limited study leave budget but they can use online resources. We suggest online educational modules, such as BMA Learning and Doctors.Net modules on ECG interpretation, physical examination, consultation skills, etc., can be useful source and do not cost you a penny other than your time.

Last but not the least we recommend trainees refer to basic texts to help them with their day to day practice and interpretation skills. The physical health check equipment including ECG machine in psychiatric wards needs to be updated periodically. If this were done it may encourage and motivate more junior doctors to participate in improving their skills.

REFRENCES:

1. Noel Collins, Uttara Mandal, Gabrielle Pendlebury, and Jenny Drife(2008) Junior psychiatrists’ electrocardiogram interpretation skills. Psychiatr Bull 32: 353-355

2. American Academy of Family Physicians. Practice profile survey II.Leawood, KS: American Academy of Family Physicians; 2000

3. Jeyaseelan et al (2006)The Accuracy of ECG Screening by GPs and byMachine Interpretation in Selecting Suspected Heart Failure Patients for Echocardiography Br J Cardiol. 13(3):216-218

4. Berger et als (2004) ECG interpretation during the acute phase of coronary syndromes: in need of improvement? Swiss Med Wkly; 134:695–699

Authors:

Imran Mushtaq, Associate Specialist-Child & Adolescent Psychiatrist, Milton Keynes SP-CAHMS, Eaglestone Centre, Standing Way, Milton Keynes MK6 5AZ

M Samiulla, Staff Grade-Forensic Psychiatrist, Marlborough House Regional Secure Unit, Oxfordshire & Buckinghamshire Mental Health Partnership NHS Foundation Trust, Milton Keynes, MK6 5NG

Nazrul Islam, CT2 in Forensic Psychiatry, Marlborough House Regional Secure Unit, Oxfordshire & Buckinghamshire Mental Health Partnership NHS Foundation Trust, Milton Keynes, MK6 5NG

Shafiq Javed Muhammad, CT2 in Child and Adolescent Psychiatry, CAMHS,Birmingham Children Hospital NHS Trust,Steelhouse Lane, Birmingham B4 6NH

Declaration of Interests: None.
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Conflict of interest: None Declared

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