Are we better than cardiologists at reading EKGs?

[prolene60]

I've realized over the years that I read an inordinate amount of EKGs throughout my shifts. Alot of these are ordered out in triage and unecessary in my opinion but we still have to read them. I wondered if with all of these reads this makes us more competent than any other specialty in reading EKGs. I would assume a cardiologist doesn't order an EKG on every single patient in the clinic. Obviously it's difficult to make a statement that just because we read more we are therefore better. We would need some sort of unbiased other person to confirm them. (I could just be misreading EKGs over and over). It would be interesting to know though. I don't know what everyone else's take on this is.

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[JacobMcCandles]

No but there are some really, really good ED docs who are better than most cardiologists.

 

[Jabbed]

I would trust Steve Smith over any of my cardiologists, but I don’t think that it’s a fair comparison.

By and large we are only interested in 1) signs of active ischemia and 2) arrhythmias requiring intervention.

I’m much less likely to pick up (or care) about a sinoatrial exit block or crochetage sign. But when I’m convinced that the patient has active ischemia I will railroad the cardiologist into taking them to cath lab regardless of any “that’s J point elevation not ST elevation” or “their potassium is 3.4” BS that they’ll try to block with.

 

[BoardingDoc]

I've realized over the years that I read an inordinate amount of EKGs throughout my shifts. Alot of these are ordered out in triage and unecessary in my opinion but we still have to read them. I wondered if with all of these reads this makes us more competent than any other specialty in reading EKGs. I would assume a cardiologist doesn't order an EKG on every single patient in the clinic. Obviously it's difficult to make a statement that just because we read more we are therefore better. We would need some sort of unbiased other person to confirm them. (I could just be misreading EKGs over and over). It would be interesting to know though. I don't know what everyone else's take on this is.

No, we aren't. Yes, there are some EM docs out there who are better than cardiologists at ekgs, but that is on the far end of the bell curve.

There are probably a large number of em docs that are reading thousands of ekgs a year and are simply continuing to miss the same thing each time. Practice doesn't make perfect. Practice makes permanent.

By your logic, an NP seeing 6pph in urgent care should be as good or better than an MD who has been working UC seeing 1pph for years. I think we'd all agree that idea is laughable.

 

[AlmostAnMD]

agree with above

we see thousands of EKGS a year in some way

but our formal ekg training is lacking/non-existent.

You don't know what you don't know until you know what you don't know. Silly phrase but true.

Having said that, I'm a dork and after using CME for dumb **** I do occasionally buy and read textbooks.

O'Keefe EKG study guide is one common book used by cardiologists. Relatively brief and mostly for review but has good tidbits.

For extreme EKG details Chou's Electrocardiography in clinical practice is 700 pages of strictly EKG interpretation/theory. That book alone took my EKG skills to the next level. You don't notice the difference in knowledge until you see other people calling cards for things you just wouldn't anymore. All liability is, of course, still on me. But responsibly absorbing more knowledge and making an effort to learn will really only reduce your long term risk, I think, not make it worse. Same goes for how you manage arrhythmias. We still have docs that admit every single new afib patient they see. Or refuse to cardiovert paroxysmal patients compliant with eliquis and stone cold normal labs and no other flags (nuance of possibility of embolism while taking DOACs beyond scope of this point). At some point that's just lazy.

Ultimately, I think, patients are unreliable. They can't name one med they take half the time, why trust their clinical story? But EKGs cannot lie (unless leads are incorrectly placed, book mentions a lot about precordial changes even with just subtle lateral or superior/inferior movements of leads, not just lead switching).

Reading through both gave me a lot more confidence with arrhythmia management. I'll never claim to be better than a cardiologist but I'll claim to be better than I was at EKGs several years ago by miles and miles.

Currently reading Braumwald's Heart Disease. Almost done with the heart failure chapters and it's got like 400 pages of arrhythmia discussion. After this book (two volume set actually) gonna move on to pulmonology.

TLDR: 100% agree that "seeing" thousands of EKGS is not enough to be an expert at them. Formal training of interpretation separates us from the experts, that's why you're calling them when you talk about STEMI/etc. Our group calls cards a lot for STEMIs in patients that are septic/tachycardic/dka/so many mimics of surface EKG eventually that management alone will cause a bad outcome. Read!

 

[Tipsy McStagger]

Anytime I go over an ecg with a cardiologist, especially EP, I am continually humbled by the information they can extract from it. Things that I didn’t even know you could get from an ecg.

There is no way we’re better at reading ecgs than a cardiologist. I agree with the above: you don’t know what you don’t know.

I especially agree with Boardingdoc’s “practice makes permanent.” One of my favorite truths.

 

[timpview]

Every ECG you’ve ever ordered was likely overread by a Cardiologist… same as every other ECG in the hospital..

So on a given call weekend that Cardiologist can read 200-400 ecgs or a 100+ a day, so the volume argument doesn’t go very far.

 

[Tiger26]

Honestly, I think we are as good as cardiology at reading routine EKGs but better at knowing some of the more obscure but emergent findings on them. Maybe it's just our cardiologists but I'm often met with silence when I call them about Wellen's syndrome, Brugada, etc.

I think this is similar to airway management. I feel equally good as anesthesia with regard to intubations but far more skilled at emergent airway management (crash airway, vomiting pt, fiberoptic, etc). If a patient hasn't been NPO for a week and with everything optimized (kidding..sort of), I've seen anesthesia freak out. Us on the other hand put in an ETT on someone hypotensive, battered, and vomiting beer and hot dog chunks before going back to the desk and finishing our dinner.

 

[kjamess]

Every ECG you’ve ever ordered was likely overread by a Cardiologist… same as every other ECG in the hospital..

So on a given call weekend that Cardiologist can read 200-400 ecgs or a 100+ a day, so the volume argument doesn’t go very far.

exactly. reading ECGs for the subset of ED patients you've seen on 10-12 hr shift, 3-4 days a week does not compare to the cardiologist whos not only overreading ALL of your ECGs, but the rest of EM department for that entire week, plus all of inpatient, plus ambulatory outpatient and office, plus post op patients.

 

[Mount Asclepius]

Except we bill for and interpret all of our own EKGs. Cardiology doesn’t look at them, unless we involve them. Even then we still bill for them, not them. Have that fight and rightly take your money. Unless they are going to interpret them all within 10 minutes in real time, they are just taking your money. Guess what, they aren’t willing to interpret in real time. So yeah, we as EPs interpret more EKGs of patients presenting emergently than Cardiology does.

 

[Mount Asclepius]

An ocean wide, 3 inches deep. We’re really, really good in that 3 inches though.

 

[thegenius]

I've realized over the years that I read an inordinate amount of EKGs throughout my shifts. Alot of these are ordered out in triage and unecessary in my opinion but we still have to read them. I wondered if with all of these reads this makes us more competent than any other specialty in reading EKGs. I would assume a cardiologist doesn't order an EKG on every single patient in the clinic. Obviously it's difficult to make a statement that just because we read more we are therefore better. We would need some sort of unbiased other person to confirm them. (I could just be misreading EKGs over and over). It would be interesting to know though. I don't know what everyone else's take on this is.

No

 

[thegenius]

I would trust Steve Smith over any of my cardiologists, but I don’t think that it’s a fair comparison.

By and large we are only interested in 1) signs of active ischemia and 2) arrhythmias requiring intervention.

I’m much less likely to pick up (or care) about a sinoatrial exit block or crochetage sign. But when I’m convinced that the patient has active ischemia I will railroad the cardiologist into taking them to cath lab regardless of any “that’s J point elevation not ST elevation” or “their potassium is 3.4” BS that they’ll try to block with.

Uhh OK. I would think best Cardiologist would beat Steve Smith at reading EKGs.

 

[Tipsy McStagger]

Except we bill for and interpret all of our own EKGs. Cardiology doesn’t look at them, unless we involve them. Even then we still bill for them, not them. Have that fight and rightly take your money. Unless they are going to interpret them all within 10 minutes in real time, they are just taking your money. Guess what, they aren’t willing to interpret in real time. So yeah, we as EPs interpret more EKGs of patients presenting emergently than Cardiology does.

So do we. But cardiology still reads them and bills for them. If you look at an ecg you read a day or two later, you’ll find an official read signed by a cardiologist attached to it.

 

[thegenius]

So do we. But cardiology still reads them and bills for them. If you look at an ecg you read a day or two later, you’ll find an official read signed by a cardiologist attached to it.

Not at our place. You should double check that. If you are receiving CPT RVUs for reading an EKG (worth about 0.28 RVUs), there can't be another MD reading and interpreting the EKG and billing for it a second time.

 

[Tipsy McStagger]

Not at our place. You should double check that. If you are receiving CPT RVUs for reading an EKG (worth about 0.28 RVUs), there can't be another MD reading and interpreting the EKG and billing for it a second time.

Sure there can. Same way that more than one person can bill for critical care time. They’re under different charge masters or accounts or whatever the hospital calls them. This is why I can bill critica care time for an admission where the Ed doc also billed it. Also, every ecg I order is automatically added to my charges for the day as a read. But the cardiologist still officially reads it later (usually the next day or so).

Or are you saying that when you open the ecg a few days later, your read is attached to the ecg? I’ve never seen that but of course that doesn’t mean it doesn’t happen. But most often, if you open that ecg at a later time you’ll see the computer read is replaced with a cardiologist read. Because nobody is going to open an ecg and then look for your note to see what your read was.

Maybe I’m wrong. It’ll be interesting. I’ll talk to some of my cards guys when I see them tonight. It’s intriguing.

What kind of hospital system do you work for? Maybe it’s different?

 

[nVictus]

Nah

 

[Mount Asclepius]

So do we. But cardiology still reads them and bills for them. If you look at an ecg you read a day or two later, you’ll find an official read signed by a cardiologist attached to it.

Nope, you’re wrong. Trust me, we fought this fight. Our Cardiologists never look at our EKGs if they aren’t consulted. We get 100% of the billing on our EKGs.

Or are you saying that when you open the ecg a few days later, your read is attached to the ecg? I’ve never seen that but of course that doesn’t mean it doesn’t happen. But most often, if you open that ecg at a later time you’ll see the computer read is replaced with a cardiologist read. Because nobody is going to open an ecg and then look for your note to see what your read was.

Maybe I’m wrong. It’ll be interesting. I’ll talk to some of my cards guys when I see them tonight. It’s intriguing.

What kind of hospital system do you work for? Maybe it’s different?

Yes, we use a specific program and my official interpretation is attached to the patient’s EKG in the medical record. No interpretation by Cardiology is ever added.

Former independent hospital since merged with a larger academic health system.

 

[Tipsy McStagger]

Interesting! I gotta say I’m surprised an academic system would allow that. But I’ll trust you that I’m wrong.

 

[Mount Asclepius]

If you have to obtain/look at an EKG within 10 minutes and make a decision how is it fair that someone else gets to bill for that decision after the fact? When you present that argument to almost any administrator, it’s actually a pretty quick fight.

 

[AlmostAnMD]

Interesting! I gotta say I’m surprised an academic system would allow that. But I’ll trust you that I’m wrong.

Our place the billing goes to whoever does the read first. So if I don't do it cards will do and bill for it. Quite the practice variability

 

[Tenk]

If you ever want to feel inferior about EKG knowledge, go talk to an EP cardiologist.

There’s actually a book that’s just hundreds of ekgs that a lot of fellowships use. It goes way beyond what we know and see. I know about this because my MS4 year I did an “ekg month” where you just hang out and read EKGs with a fellow. I learned prolly 90% of my ekg knowledge that month and ended up teaching my attendings stuff about EKGs in residency. Not bragging, just the truth.

Funny story though: we had monthly cardiology ekg grand rounds. It was just 1-2 hours of all the attending cardiologists passing that book I mentioned around to fellows, residents, and med students and folding the explanation page so you had to interpret the ekg. There’s prolly 15-20 mixed students, fellows, residents, and attendings. A few months before this I was in Beijing and one of the attendings there showed me an ekg with dextrocardia because it was cool. So it comes to my turn as an MS4 and they hand me the book. One of the older attendings looked at it and said: “oh give him an easier one, he’ll never get that.” I took one look at it, said “it’s dextrocardia” and passed the book to my left. I looked up and pretty much everyone had the same wtf face. It was great.

 

[Mount Asclepius]

Our place the billing goes to whoever does the read first. So if I don't do it cards will do and bill for it. Quite the practice variability

Interesting. I’m sure it’s variable. I can live with the fish bowl, second guessed environment we practice in even if I don’t like it, but the fights I’ve fought tooth and nail are when other physicians try to take money from what we have rightfully earned and are medicolegally liable for. We’re more 24/7/365 than any other specialty. I understand they don’t want to work the hours we do, but losing out on that billing is the trade off.

 

[DeadCactus]

Most people's skills are a pyramid. We've all got a broad base in emergency medicine but we also all pick our little pet topic that we focus on and know better than most. There are some emergency physicians that make their peak EKG interpretation and I don't doubt they are better at identifying acute pathology than many cardiologists particularly when you incorporate the overall assessment and not just the EKG. But no, I don't think pure volume makes up for a formalized, focused academic curriculum like a cardiology fellowship.

 

[Brigade4Radiant]

It depends on what you are looking for would this expertise change a clinical outcome?

 

[Jabbed]

Uhh OK. I would think best Cardiologist would beat Steve Smith at reading EKGs.

Call me a fanboy, but he’s successfully redefining the STEMI/NSTEMI paradigm so that more patients are qualifying for emergent PCIs. Compare this to the hur dur “no I won’t take your VF arrest because it can’t be a STEMI if the potassium is 3.2” that I get from some of our cards guys.

Again, the only thing that we as a specialty should really care about is identifying ischemia and arrhythmias. To that end, I would hold Smith in higher esteem than Chou.

 

[Jabbed]

If you ever want to feel inferior about EKG knowledge, go talk to an EP cardiologist.

There’s actually a book that’s just hundreds of ekgs that a lot of fellowships use. It goes way beyond what we know and see. I know about this because my MS4 year I did an “ekg month” where you just hang out and read EKGs with a fellow. I learned prolly 90% of my ekg knowledge that month and ended up teaching my attendings stuff about EKGs in residency. Not bragging, just the truth.

Funny story though: we had monthly cardiology ekg grand rounds. It was just 1-2 hours of all the attending cardiologists passing that book I mentioned around to fellows, residents, and med students and folding the explanation page so you had to interpret the ekg. There’s prolly 15-20 mixed students, fellows, residents, and attendings. A few months before this I was in Beijing and one of the attendings there showed me an ekg with dextrocardia because it was cool. So it comes to my turn as an MS4 and they hand me the book. One of the older attendings looked at it and said: “oh give him an easier one, he’ll never get that.” I took one look at it, said “it’s dextrocardia” and passed the book to my left. I looked up and pretty much everyone had the same wtf face. It was great.

The book that you’re referencing is O’Keefe?

 

[greatnt249]

Honestly, I think we are as good as cardiology at reading routine EKGs but better at knowing some of the more obscure but emergent findings on them. Maybe it's just our cardiologists but I'm often met with silence when I call them about Wellen's syndrome, Brugada, etc.

This would be more indicative of a cardiologist problem, not necessarily that the ED is better equipped to read EKGs. I echo one of the other posts that a cardiologist is likely signing off on every EKG ordered in the hospital (system), which quickly adds up in terms of numbers.

 

[greatnt249]

Except we bill for and interpret all of our own EKGs. Cardiology doesn’t look at them, unless we involve them. Even then we still bill for them, not them. Have that fight and rightly take your money. Unless they are going to interpret them all within 10 minutes in real time, they are just taking your money. Guess what, they aren’t willing to interpret in real time. So yeah, we as EPs interpret more EKGs of patients presenting emergently than Cardiology does at the facility I work at.

Bolded text added for distinction.

 

[TooMuchResearch]

I've realized over the years that I read an inordinate amount of EKGs throughout my shifts. Alot of these are ordered out in triage and unecessary in my opinion but we still have to read them. I wondered if with all of these reads this makes us more competent than any other specialty in reading EKGs. I would assume a cardiologist doesn't order an EKG on every single patient in the clinic. Obviously it's difficult to make a statement that just because we read more we are therefore better. We would need some sort of unbiased other person to confirm them. (I could just be misreading EKGs over and over). It would be interesting to know though. I don't know what everyone else's take on this is.

For those of us that have put extra effort into learning, yes we're absolutely as good as or better than cardiologists at interpreting emergency ECGs. I've had at least two cardiologists directly tell me this. Because emergent ECG interpretation in the context of clinical scenario is our specialty.

To whoever said we don't have specific ECG training, I certainly did in residency and have read the emergency medicine specific books on the topic. I don't read books outside our specialty that involve elements of ECG I don't need to know.

 

[TooMuchResearch]

Every ECG you’ve ever ordered was likely overread by a Cardiologist… same as every other ECG in the hospital..

So on a given call weekend that Cardiologist can read 200-400 ecgs or a 100+ a day, so the volume argument doesn’t go very far.

That is completely hospital dependent. At our big center, we are the only read on ED ECGs.

At the rural places, they get overread at a later date by cardiology. Either we never miss anything or they don't actually look at the ECGs because no one ever gets sent back to the ED by the cardiologist.

 

[TooMuchResearch]

So do we. But cardiology still reads them and bills for them. If you look at an ecg you read a day or two later, you’ll find an official read signed by a cardiologist attached to it.

Not at our big hospital. We are the only read. Cardiology doesn't touch them.

 

[Brigade4Radiant]

That is completely hospital dependent. At our big center, we are the only read on ED ECGs.

At the rural places, they get overread at a later date by cardiology. Either we never miss anything or they don't actually look at the ECGs because no one ever gets sent back to the ED by the cardiologist.

This is true and what clinical difference do their overreads lead to?

Also we often read peds ekgs as well and have to deal with it

 

[Tenk]

The book that you’re referencing is O’Keefe?

Honestly, not sure. This was over a decade ago now. I’m getting PGY-old.

 

[Brigade4Radiant]

No, we aren't. Yes, there are some EM docs out there who are better than cardiologists at ekgs, but that is on the far end of the bell curve.

There are probably a large number of em docs that are reading thousands of ekgs a year and are simply continuing to miss the same thing each time. Practice doesn't make perfect. Practice makes permanent.

By your logic, an NP seeing 6pph in urgent care should be as good or better than an MD who has been working UC seeing 1pph for years. I think we'd all agree that idea is laughable.

What clinically relevant things are they missing? EM your missed things come back.

I’m the UC example of that UC NP is seeing a good amount of patients they are probably better at seeing these patients quickly especially

 

[thegenius]

Sure there can. Same way that more than one person can bill for critical care time. They’re under different charge masters or accounts or whatever the hospital calls them. This is why I can bill critica care time for an admission where the Ed doc also billed it. Also, every ecg I order is automatically added to my charges for the day as a read. But the cardiologist still officially reads it later (usually the next day or so).

Or are you saying that when you open the ecg a few days later, your read is attached to the ecg? I’ve never seen that but of course that doesn’t mean it doesn’t happen. But most often, if you open that ecg at a later time you’ll see the computer read is replaced with a cardiologist read. Because nobody is going to open an ecg and then look for your note to see what your read was.

Maybe I’m wrong. It’ll be interesting. I’ll talk to some of my cards guys when I see them tonight. It’s intriguing.

What kind of hospital system do you work for? Maybe it’s different?

No it's double billing. It would be like having a Radiologist and an ER doc officially billing for an xray. Or two official reads for an ECHO, colonoscopy, etc.

ER docs can "independently interpret" EKGs, but that falls under the rubric of E/M codes 99282/3/4/5. But EKG billing 93000/05/10 can't be billed more than once.

I work at multiple hospitals and interestingly Emergency Room EKGs are officially interpreted by ER docs at one hospital and read by cardiologists at another.

 

[southerndoc]

No it's double billing. It would be like having a Radiologist and an ER doc officially billing for an xray. Or two official reads for an ECHO, colonoscopy, etc.

ER docs can "independently interpret" EKGs, but that falls under the rubric of E/M codes 99282/3/4/5. But EKG billing 93000/05/10 can't be billed more than once.

I work at multiple hospitals and interestingly Emergency Room EKGs are officially interpreted by ER docs at one hospital and read by cardiologists at another.

I've seen some cardiologists just agree with the computer read 100% of the time. One recently clicked the acute STEMI reading from the computer even though it clearly was not a STEMI in this 19 year old. However, STEMI became the official read of the EKG after the cardiologist signed off on it. I was tempted to just activate the cath lab since he the guy was still in the ED.

 

[Brigade4Radiant]

I’ve never seen cardiology contact the ER for an over read ekg like rads does.

So what is an EM doc “missing” that cards is seeing?

 

[WilcoWorld]

I’ve never seen cardiology contact the ER for an over read ekg like rads does.

So what is an EM doc “missing” that cards is seeing?

I'm wondering the same thing. I'm sure these reads are helpful for hospitalists following inpatients and surgeons getting pre-op ECGs, and I don't doubt that Jamie Corazon can see things I overlook on a tracing, but how do Cards over-reads impact you all in the ED? AFAIK, a Cardiology overread has never impacted my ED care.

 

[timpview]

The overreads basically never impact clinical care. They’re read typically 1-4 days later and I doubt many who order it actually see the final read.

Surgeons and those outpt docs or hospitalists who can’t read ecgs just go off what the computer spits out.. or some will reach out directly to cards to interpret.

It’s just for billing and a name to it

 

[Rekt]

There’s no overreads for us. We read them and bill for them 100%.

I’m in the opposite camp. I got really into ECGs and think it’s very interesting, but I feel like we care about ECGs more than anyone else. Unless it’s a STEMI, cardiology does just not give one single **** about the ECG.

 

[AlmostAnMD]

There’s no overreads for us. We read them and bill for them 100%.

I’m in the opposite camp. I got really into ECGs and think it’s very interesting, but I feel like we care about ECGs more than anyone else. Unless it’s a STEMI, cardiology does just not give one single **** about the ECG.

Mostly true

At a tertiary care place

I've talked to our cards people a lot, they care a lot more in general about the echo. Makes sense really.

 

[alphaholic06]

If you have to obtain/look at an EKG within 10 minutes and make a decision how is it fair that someone else gets to bill for that decision after the fact? When you present that argument to almost any administrator, it’s actually a pretty quick fight.

This was more than a decade ago at a large academic center. We discovered that Cardiology was getting $3,000,000/yr overreading our EKGs from the department. We complained. Nothing changed.

 

[Mount Asclepius]

This was more than a decade ago at a large academic center. We discovered that Cardiology was getting $3,000,000/yr overreading our EKGs from the department. We complained. Nothing changed.

Keep fighting the good fight. Billing per EKG isn’t that much, but it really adds up. It was definitely worth it to our bottom line to ‘take back’ billing that should have always been ours.

 

[JacobMcCandles]

This was more than a decade ago at a large academic center. We discovered that Cardiology was getting $3,000,000/yr overreading our EKGs from the department. We complained. Nothing changed.

Medicare reimburses about $8 per EKG today. That equates to about 375,000 EKGs at Medicare rates and academic centers aren’t known for a well insured population. Somebody was blowing you smoke.

 

[BoardingDoc]

Medicare reimburses about $8 per EKG today. That equates to about 375,000 EKGs at Medicare rates and academic centers aren’t known for a well insured population. Somebody was blowing you smoke.

Yeah, 3M/yr in EKG reads is definitely inaccurate. I don't care how big the academic center is. That said, if you're not collecting the bill for your own ekgs, you're definitely getting screwed. In our group, each full time doc probably makes about 10k/yr from EKG reads give or take a few K.

 

[Zebra Hunter]

Yes, I am undoubtedly better than the average community cardiologist at reading emergency ECGs as is evident every time I call them for subtle or uncommon cases of anything. My last shift I had two separate cardiologists tell me that a patient with deWinter’s pattern just had RBBB and refused to take the patient to the cath lab. The most confusing part was the QRS was <110ms and they were misidentifying the ST depression as part of the QRS complex. Took 5 hours to finally pester them into stenting the obvious LAD lesion.

 

[TooMuchResearch]

This was more than a decade ago at a large academic center. We discovered that Cardiology was getting $3,000,000/yr overreading our EKGs from the department. We complained. Nothing changed.

In collections or billing? My back of the napkin math tells me that if it's $3M in collections, it was probably 350-400 ECGs per day.

 

[BoardingDoc]

In collections or billing? My back of the napkin math tells me that if it's $3M in collections, it was probably 350-400 ECGs per day.

I don't know how 3m/yr equates to 400 ecgs per day. Most people getting an ECG are old. Old people have medicare. An ECG is 0.24 rvu which in Medicare speak is about 8 bucks.

3m/365 days/8 dollars is 1027 ekgs/day.

Granted, the number will be somewhat lower for the insured young people getting them but some of those young people are also uninsured so I doubt it gets down to the 400 range.