Can you read an electrocardiogram (ECG)?

ECG Interpretation Competency for Healthcare Providers

Direct Answer

Yes, physicians can read ECGs, but competency requires structured training with interpretation of at least 800 ECGs under supervision during residency, and all computer-generated interpretations must be verified by a qualified physician. 1

Training Requirements for ECG Interpretation Competency

Minimum Training Standards

• Internal medicine residents and cardiologists require interpretation of 800 ECGs within a 3-year training period under experienced faculty supervision to achieve competence. 1
• The American College of Physicians recommends 100 ECGs for general internists, while cardiologists should interpret 750 ECGs according to survey data, though the formal recommendation is 800. 1
• Cardiology fellows should read 3,500 ECGs according to the Bethesda Conference recommendations. 1
• Residency training combined with Advanced Cardiac Life Support certification is sufficient for bedside ECG interpretation in routine and emergency situations. 1, 2

Essential Training Components

• Training must include ECG interpretations across a wide variety of clinical situations and abnormalities, not just common patterns. 1
• Review of interpretations with experienced faculty is the cornerstone of proper training—unsupervised reading alone does not ensure competence. 1
• Training settings should include intensive care unit assignments, classroom work, and didactic sessions in addition to dedicated ECG service rotations. 1

Physician Interpretation vs Computer Analysis

Critical Limitations of Automated Interpretation

• Computer-based ECG interpretation is only an adjunct to the electrocardiographer—all computer-based reports require physician overreading. 1, 3, 2
• Computer programs correctly classify only 91.3% of ECGs (median) compared to 96.0% for cardiologists, with important differences between different algorithms. 1
• Computer programs perform less well than expert readers for individual diagnoses, particularly for rhythm disturbances, ischemia, and infarction. 1, 2

When Physician Expertise is Essential

• Cardiologists as primary readers corrected misinterpreted ECGs 94% of the time versus 71% for internists and emergency physicians, demonstrating the value of specialized training. 4
• Cardiologists demonstrate greater accuracy than noncardiologists in ECG interpretation during standardized examinations when minimal clinical history is provided. 1
• Knowledge of the individual patient results in more critical rhythm assessment—primary readers were more accurate (94%) than overreading cardiologists lacking clinical information (72%). 4

Context-Dependent Interpretation Skills

Clinical Context Integration

• Noncardiologists are more influenced by patient history and automated computer interpretation than cardiologists when interpreting ECGs, making systematic approach critical. 1, 2
• The same ECG pattern may occur in different structural and pathophysiologic states, requiring integration of clinical data for accurate diagnosis. 3, 2
• Never interpret the ECG in isolation—clinical signs and symptoms alone lack sufficient sensitivity (35-38%) and specificity (28-91%) to rule in or rule out acute coronary syndrome without ECG and biomarkers. 2

Interpretation Without Patient Knowledge

• Evidence is lacking for competency in interpreting ECGs when the physician is unfamiliar with the patient's clinical status or context. 1
• Clinical privileges for interpretation without patient knowledge may reasonably be based on experience or passing a valid and reliable examination. 1
• Most board certification testing uses ECG tracings combined with clinical vignettes, not isolated tracings. 1

Maintaining Competency Over Time

Ongoing Skill Maintenance

• Continuing medical education through seminars or self-assessment programs is encouraged for physicians who read ECGs infrequently to maintain current skills. 1, 2
• There are insufficient data to recommend a specific yearly minimum number of ECG interpretations to maintain competency. 1
• Random samples of ECG interpretations should be reviewed periodically by independent experts as part of quality assurance programs to confirm continued competence. 1

Available Resources

• The American College of Cardiology offers self-assessment programs in electrocardiography for continuing education. 1
• Quality improvement programs with ECG overreading and feedback by expert electrocardiographers help maintain skills. 1
• Self-paced interactive computer modules and workshops at professional society meetings provide structured continuing education. 1

Special Populations and Settings

Emergency Department Interpretation

• Paramedics and nurses can identify ST-elevation myocardial infarction independently with mandatory initial training and ongoing concurrent medical oversight of all ECG interpretations. 2
• This allows earlier catheterization lab activation and reduced door-to-balloon times in appropriate systems. 2
• Field-transmitted ECG for expert interpretation is reasonable if on-site interpretation is unavailable. 2

Neonatal ECG Interpretation

• Adult cardiologists require specific training for neonatal ECG interpretation, as normal newborn values would be abnormal in adults and vice versa. 1
• The major changes in pediatric ECG occur in the first year of life, requiring reference to age-specific normal value tables. 1
• Neonatal ECGs should include 12 leads, with additional leads (V3R, V4R, V7) potentially providing information for congenital heart lesions. 1

Common Pitfalls in ECG Interpretation

Critical Errors to Avoid

• Do not over-rely on computer interpretation without physician verification, as errors remain common even with modern algorithms. 2
• Do not fail to compare with previous ECGs when available, as this can miss important dynamic changes indicating acute processes. 2
• Do not interpret findings without clinical context, which may lead to inappropriate management decisions and adverse outcomes. 2
• Measurement of QT interval has been found highly variable with poor accuracy even among cardiologists and some electrophysiologists. 1

Technical Considerations

• Verify proper electrode placement and adequate filtering settings before interpretation, as misplaced precordial leads can significantly alter findings and lead to false diagnoses. 2
• Ensure minimum high-frequency response of 150 Hz for adults to maintain diagnostic precision. 2
• Consider technical factors like electrode placement and filtering, which can affect ECG appearance and interpretation. 3