Original Journal Pace Article

From the Editor . . .
Certification of Special Competence in Cardiac Pacing

It is reliably estimated that 100,000 new pacemaker implants are performed in the United States annually and that about one-half million people are alive with implanted pacemakers. The procedure is performed in university hospitals, major teaching affiliates, community hospitals, and in those of very small bed capacity. The implanting physicians and surgeons include thoracic and cardiovascular surgeons, cardiologists who undertake a variety of invasive procedures, those whose only invasive efforts are pacemaker implantations, and general surgeons who implant pacemakers as their only cardiovascular procedure. These pacemakers are implanted by teams including surgeons and cardiologists, by surgeons, cardiologists, or internists alone. Implantations are done in an operating or radiology room, cardiac catheterization laboratory, or special procedure room with fixed or “portable” fluoroscopy. Those involved in pacemaker implantation may be only hospital and medical staff or may include, on a routine basis, a manufacturer’s sales representative or engineer. Follow-up, programming, and troubleshooting are commonly accomplished by commercial services and by manufacturer’s representatives as well as by physicians and their office and hospital staffs. The conclusion sometimes reached by observers of pacemaker implant and follow-up is that there is a wide diversity of medical knowledge and competence concerning indications for implantation, operative techniques, electrocardiographic interpretation, and follow-up procedures involved in cardiac pacing.

The North American Society of Pacing and Electrophysiology (NASPE)was founded to raise the level of professionalism in the practice of cardiac pacing. It has included the organization of tutorial and policy conferences and the annual convention. The next step is an attempt to raise the level of knowledge of those who practice cardiac pacing. There is little doubt that the time to begin increasing that knowledge is during residency training. The only systematic indication of what has been taught and learned during the residency is by testing those who have completed training. It is thus routine for physicians and surgeons who have completed a residency training program to seek the imprimatur of a specialty board to attest to their proficiency and knowledge. The existing boards cover many fields of endeavor within their specialties. New fields within a specialty can grow, become major therapeutic endeavors, and still receive little attention in the examination of the broader specialty. Successful completion of the broader exam then does not signify useful knowledge or competence in the narrower field. Members ofNASPEcommonly receive requests from chairs of hospital departments and of credential committees to guide in the determination of who should be given approval to implant or otherwise be involved in pacemaker work. So far there has been virtually no answer. Now, if the process of provision of a “Certificate of Special Competence” is successful, an applicant approaching such a person or committee will be able to indicate that (s)he has indeed taken the time and made the effort to learn about cardiac pacing. Cardiac pacing is now a mature therapy; training and education can no longer be left to a casual and potentially less effective approach.

Formulation of an examination as an instrument for certification is not an attempt to restrict who it is that can implant pacemakers; indeed, a written examination cannot evaluate a person’s surgical skills. Each institution will still make its own decisions. There will be no effort to affect the credentials of those who now practice cardiac pacing in all of its ramifications. But the public does deserve that the profession make efforts to maximize the skill and professionalism of the practice of cardiac pacing. Furtherance of education and skills is a worthy endeavor andNASPEis the logical organization to initiate the effort. If, as with other competency examinations, it increases the incentive to improve education (in cardiac pacing), that is all to the good. The first examination will be held during the fall of 1986.

Reprinted from PACE journal, Vol. 9, No. 1 (January–February, 1986), p 1.