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Electrocardiogram interpretation skills in psychiatry trainees

  • Rashmi Yadav (a1) and Ankush Vidyarthi (a1)
Abstract
Aims and method

To assess the competence of psychiatry trainees in identifying major abnormalities in a 12-lead electrocardiogram (ECG). This was a three-stage prospective study. In stage 1, selected ECG traces were presented to the trainees. They were then asked to comment on any abnormalities of note on the ECG traces. In stage 2, an ECG e-book was made available to the trainees and the survey repeated. In stage 3, ECG workshop sessions were introduced in the mandatory teaching programme and the survey was repeated.

Results

The number of correct responses after the introduction of the workshops were significantly more when compared with correct responses in stage 2 (P = 0.0002), and stage 1 (P = 0.0091). When compared with stage 1, the correct responses in stage 2 actually showed deterioration (P = 0.0284).

Clinical implications

Our study not only shows that providing access to an e-book is not enough to improve these skills, it also shows that ECG refresher sessions improved the diagnostic accuracy markedly.

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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.
Corresponding author
Rashmi Yadav (rashmi.yadav@nhs.net)
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Waddington, JL, Youssef, HA, Kinsella, A. Mortality in schizophrenia. Antipsychotic polypharmacy and absence of adjunctive anticholinergics over the course of a 10-year prospective study. Br J Psychiatry 1998; 173: 325–9.
2 Osborn, DP, Levy, G, Nazareth, I, Petersen, I, Islam, A, King, MB. Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom's General Practice Research Database. Arch Gen Psychiatry 2007; 64: 242–9.
3 Borini, SB, Terrazas, JH, Ferreira, A. Jr Female alcoholics: electrocardiographic changes and associated metabolic and electrolytic disorders. Arq Bras Cardiol 2003; 81: 506–17.
4 Ray, WA, Meredith, S, Thapa, PB. Antipsychotics and the risk of sudden cardiac death. Arch Gen Psychiatry 2001; 58: 1161–7.
5 Liperoti, R, Gambassi, G, Lapane, KL, Chiang, C, Pedone, C, Mor, V, et al. Conventional and atypical antipsychotics and the risk of hospitalization for ventricular arrhythmias or cardiac arrest. Arch Intern Med 2005; 165: 696701.
6 Srikanthan, VS, Pell, AC, Prasad, N, Tait, GW, Rae, AP, Hogg, KJ, et al. Use of fax facility improves decision making regarding thrombolysis in acute myocardial infarction. Heart 1997; 78: 198200.
7 Willems, JL, Abreu-Lima, C, Arnaud, P, Brohet, CR, Denis, B, Gehring, J, et al. Evaluation of ECG interpretation results obtained by computer and cardiologists. Methods Inf Med 1990; 29: 308–16.
8 Southern, WN, Arnsten, JH. The effect of erroneous computer interpretation of ECGs on resident decision making. Med Decis Making 2009; 29: 372–6.
9 British Heart Foundation. Factfile 12: Compu Interpretation. BHF, 2005.
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BJPsych Bulletin
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  • EISSN: 1758-3217
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Electrocardiogram interpretation skills in psychiatry trainees

  • Rashmi Yadav (a1) and Ankush Vidyarthi (a1)
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eLetters

A message to psychiatry trainees: keep your finger on the pulse

Alison S Lennox, CT1 in psychiatry, Oxford Health NHS Foundation Trust,
14 May 2013

In light of the recent report on achieving parity between mental and physical health (1), we were particularly interested in the article by Yadav and Vidyarthi (2). We feel this article was a timely illustration of the need for trainees to take responsibility for their continuing professionaldevelopment and the role of the Royal College of Psychiatrists. Patients put their faith in doctors of all specialties to look after them. In an acute situation they implicitly trust us to be able to perform investigations, interpret the results correctly, and act appropriately in order to instigate swift and appropriate management. In the UK the overarching duties of a doctor are laid out by the GMC (3). One such duty is to "keep your professional knowledge and skills up to date, recognise and work within the limits of your competence, and work with colleagues in a way that best serves the patient's interest". This isechoed in Good Psychiatric Practice, 3rd Edition (4). We hope most trainees would agree with Craddock et al (5) who believe that psychiatrists are "first and foremost highly trained doctors".

Additionally the specialty suffers from esteem issues, but if we wantto be respected as doctors we must commit to continued professional development to improve the care for our patients. The NHS Outcomes Framework hopes to improve professionals' attitudes towards patients. Aren't we discriminating against our own patients if we fail to take responsibility for keeping our clinical skills up-to-date?

We reviewed the CANMEDS competencies framework (6) which is used by anumber of varied specialties both in the UK and abroad. "Medical expert" is a key domain. This is not to suggest a trainee must be "expert" in sayreading ECGs, but rather that they should be able to integrate knowledge, clinical skills and professional behaviours in order to provide excellent care for their patient. The RCPsych has carefully mapped the CANMEDS competencies onto its curriculum for core trainees (7). However we caution that there is not a clear expectation or way of assessing trainees' medical skills.

In contrast, the core curriculum for core medical trainees (8) comprehensively addresses the knowledge, skills and behaviours required tomanage psychiatric emergencies. As well as acute medical presentations, core medical trainees must also demonstrate competencies in the following presentations: suicidal ideation; aggressive/disturbed behaviour; acute confusion/delirium; alcohol and substance dependence. Furthermore, there is clarification of what they should demonstrate. For example, every coremedical trainee should "be competent in predicting and preventing aggressive and disturbed behaviour, using safe physical intervention and tranquillisation... and investigating appropriately and liaising with the mental health team." Psychiatry trainees frequently complete a workplace based assessment on ECT. Perhaps performing an ECG or physical examination and interpreting the findings may be sensible competencies. It is heartening that the Royal College of Psychiatrists seem to recognise the need for trainees to maintain essential medical knowledge. In our view there are really some very good online CPD modules such as "Taking a general medical history in psychiatry" and the appositely named "Don't shrink from ECG" (9). We welcome the planned expansion of the free CPD modules and anticipate theremay be more on medical themes. The December 2012 diet of the MRCPsych Paper One featured a question on ECG interpretation. Some trainees found this controversial, but others would regard this as a pass/fail question.

We therefore argue the current psychiatry core curriculum could better address the medical competencies required in sufficient detail to motivate all trainees to attain and maintain their skills. Let's work with and learn from our medical colleagues.

References: 1. Royal College of Psychiatrists. Whole-Person care: From Rhetoric toReality (Achieving Parity Between Mental and Physical Health). Royal College of Psychiatrists, 2013.

2. Yadav R, Vidyarthi A. Electrocardiogram interpretation skills in psychiatry trainees. The Psychiatrist 2013; 37: 94-97.

3. General Medical Council. Good Medical Practice. General Medical Council, 2001.

4. Royal College of Psychiatrists. Good Psychiatric Practice. Council Report CR83. Royal College of Psychiatrists, 2000.

5. Craddock N, Antebi D, Attenburrow MJ, Bailey A, Carson A, Cowen P, et al. Wake-up call for British psychiatry. Br J Psychiatry 2008; 193: 6- 9.

6. Royal College of Physicians and Surgeons of Canada. CanMEDS 2005 Framework. The Royal College of Physicians and Surgeons of Canada, 2005.

7. Royal College of Psychiatrists. A Competency Based Curriculum for Specialist Core Training in Psychiatry. RCPsych, 2012. http://www.rcpsych.ac.uk/pdf/CORE_CURRICULUM_2010_Mar_2012_update.pdf

8. Joint Royal Colleges of Physicians Training Board (JRCPTB). Specialty Training Curriculum for Core Medical Trainees. JRCPTB, 2009 amended 2011. (http://www.gmc-uk.org/2009_CMT_framework___with_major_revision_2011.pdf_43574458.pdf

9. Solomons L, Crabb J, Treolar A and Smith N. Royal College of Psychiatrists. Don't shrink... from ECGs: Part 1 ECG interpretation made easy for psychiatrists. RCPsych, 2013.

http://www.psychiatrycpd.co.uk/learningmodules/ecgsforpsychiatristspart1.aspx

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Conflict of interest: None declared

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