pECGreview: Using "Not-to-Miss" ECG diagnoses to assess competency of trainees and faculty in ECG interpretation via a weekly online ECG education program.

Background: Trainees and practitioners are suboptimal in their pediatric electrocardiogram (pECG) interpretation skills. We have previously validated a pECG educational tool, Pediatric ECG Review, as a weekly, Web-based program inviting free-text pECG interpretations and providing direct feedback. Objective: We expanded the pECG education tool by introducing a novel approach to pECG interpretation: "Not-to-Miss" (NTM). We evaluated the validity of this approach as an assessment of pECG reading accuracy and competency for a cohort of pediatric cardiology fellows and faculty. Methods: A multiple-choice selection of 18 critical NTM diagnoses was added to our existing Pediatric ECG Review program. We retrospectively reviewed 2846 responses, before (group 1) and after (group 2) the addition of the NTM approach ("NTM group"). Group 1 contained previously assigned accuracy scores based on free-text responses ("Accuracy group") and retrospectively assigned NTM diagnoses for comparison ("assignedNTM group"). Each response was classified as correct, underdiagnosis, or overdiagnosis. Results: Frequency of underdiagnosing was similar in NTM and assignedNTM responses (17% and 18%). Overdiagnosing was more common in the NTM group than assignedNTM and accuracy groups (31% vs 21% and 10%). Frequency of correct scores was 62% for assignedNTM and 50% for NTM vs 84% for accuracy scores. Atrial fibrillation, high-grade atrioventricular block, and supraventricular tachycardia were most frequently underdiagnosed in the NTM groups but less frequently missed in the accuracy group. Conclusion: The NTM approach is a feasible way to emphasize critical diagnoses and automate the assessment of competency in pECG interpretation. Cognitive bias leads to overdiagnosing when prompted with a multiple-choice format.