ABCD Framework-Based Stratified Analysis of ECG Interpretation Among Chinese Internal Medicine Residents: A...

Deficiencies in electrocardiogram (ECG) interpretation remain a challenge in residency training. The ABCD framework enables competency-based ECG assessment by stratifying findings by clinical urgency and prevalence. However, empirical data on its application in non-Western training settings are scarce. This study applied the framework to evaluate ECG interpretation skills among Chinese internal medicine residents.

In this cross-sectional study, 158 internal medicine residents (PGY-1/2/3) at a Chinese tertiary hospital completed a 40-item ECG examination aligned with the ABCD framework in December 2025. The primary outcome was the proportion meeting a pre-specified Category A (common emergencies) benchmark (≥90% correct). Secondary outcomes included mean accuracy, proportion at or below a screening threshold (≤70% correct), and flawless performance (100% correct). Factors associated with benchmark attainment were explored using multiple logistic regression.

Mean overall accuracy was 68.6% (SD 15.2%). Category A accuracy increased with training year (PGY-1: 78.1%; PGY-3: 92.1%). Only 30.2% of PGY-1 residents met the benchmark (≥90% correct), compared with 94.7% of PGY-3 residents. Performance at or below the screening threshold was observed in 34.0% of PGY-1 residents versus 0% of PGY-3 residents. Flawless performance was achieved by 5.7% of PGY-1 and 34.2% of PGY-3 residents. In adjusted analysis, seniority was independently associated with benchmark attainment (PGY-3 vs. PGY-1: adjusted OR=21.46, 95% CI 4.18-110.23; Firth-adjusted OR=13.07, 95% CI 3.52-79.49). The wide confidence interval reflects near-ceiling performance and warrants conservative interpretation.

Under timed examination conditions, over one-third of first-year residents scored below a pre-specified screening threshold for common emergency patterns, despite moderate group-mean accuracy, highlighting a gap between aggregate knowledge and consistent individual performance. These findings support competency-based ECG curricula that emphasize early mastery of emergency patterns through structured, repetitive practice.