How do healthcare practitioners read electrocardiograms? A dual-process model of electrocardiogram interpretation

Abstract

Background/Aims: This article aims to improve the understanding of the applied cognitive processes when interpreting electrocardiograms in clinical practice. It will do this by examining the self-reported approach practitioners take to interpret any barriers they encounter. Methods: This was a qualitative study in which medical practitioners, who routinely interpret electrocardiograms (n=31), were interviewed. The semi-structured interviews covered: their experience of interpretation; use of a system; pitfalls; changes to approach over time. An inductive thematic analysis was used to identify commonly occurring themes. A further set of practitioners (n=31), completed surveys that concerned their approach to an interpretation and use of interpretation frameworks/systems. Results: Practitioners find it easier to interpret electrocardiograms as they gain experience, but the process remains difficult. Barriers to successful interpretation include artefacts altering the waveform, lack of familiarity with the presenting condition, stress/panic at the prospect of making an inaccurate judgement, and overconfidence in one's interpretation abilities. Conclusions: The results support a dual-process system model that is developed with experience and enhances performance. Over time, experienced practitioners become able to move fluidly between a more formal systematic method and an experience-driven pattern recognition system. Potential errors that may arise from a reliance on pattern recognition (e.g. missing details) can be mitigated by using a systematic approach.

Interpretation of a 12-Lead Electrocardiogram by Medical Students: Quantitative Eye-Tracking Approach

“…Although more than 300 million ECG tests are performed annually in the United States [ 1 ], relatively little is known about how these ECGs are interpreted among medical professionals. Despite the fact that an ECG is a standardized medical test, procedures and processes to interpret it significantly vary from country to country, let alone from one medical institution to another [ 2 ]. Several professional organizations, including the American Heart Association (AHA), the American College of Cardiology (ACC), and the Heart Rhythm Society (HRS), proposed recommendations for the standardization and interpretation of the ECG in 2007 [ 3 ].…”

“…However, a quantitative study alone might not be enough to unveil complex visual behaviors, such as ECG interpretation. Davies et al [ 2 , 5 , 7 , 9 ] therefore proposed additional studies that used mixed methods, combining both quantitative and qualitative components. Although the authors followed a similar eye-tracking study design as Bond et al [ 6 ], they improved their analysis by adding some quantitative and qualitative methods to better understand the eye-tracking data, such as computing the difference between eye transitions across the ECG.…”

“…Although the authors followed a similar eye-tracking study design as Bond et al [ 6 ], they improved their analysis by adding some quantitative and qualitative methods to better understand the eye-tracking data, such as computing the difference between eye transitions across the ECG. For the qualitative component of the study, however, Davies et al [ 2 , 5 , 7 , 9 ] aimed at better understanding the applied cognitive processes that expert interpreters refer to when interpreting ECGs. The authors interviewed and surveyed a set of medical practitioners.…”

“…The authors found that medical experts develop their own style and system to quickly and efficiently interpret ECGs. Moreover, Davies et al [ 2 , 5 , 7 , 9 ] found that expert interpreters switch between their personally developed style of interpretation and a systematic method of interpretation, depending on the ECG and the severity of the symptoms it conveys.…”

“…Several studies have analyzed the eye-tracking data at the ECG lead level [ 6 , 8 , 10 ]. However, Davies et al [ 2 ] later suggested that using a more granular level of data analysis would be worth exploring, as it may enable more insight. This is especially important as the suggestion echoes Wood et al’s [ 10 ] observation that expert medical interpreters operate at both the ECG lead level and the level of the specificities of waveform abnormalities.…”