“It takes 10,000 hours of intensive practice to achieve mastery of complex skills and materials, like playing the violin or getting as good as Bill Gates at computer programming.” – Malcolm Gladwell1
While the exact number may be debated, the principle is clear: true expertise demands time, focus and repetition. In medicine, nowhere is this more evident than in procedural specialties such as cardiac electrophysiology (EP). Competence in EP – implanting devices, interpreting intracardiac electrograms and ablating arrhythmogenic foci – cannot be rushed. It is a craft built in labs, not on wards; through doing, not just observing. And these practical skills represent only part of the expertise required of the modern arrhythmia specialist. Year on year, the number of patients with implanted devices under follow-up continues to rise.2 As the population ages, the prevalence of rhythm disturbances increases, along with the need for expert management of both acquired and inherited arrhythmic conditions. Today’s health service requires specialists who not only perform procedures, but also have the time and experience to guide patients through complex decisions that impact morbidity and mortality. The ability to synthesise clinical data, interpret risk and communicate nuanced treatment options is developed through sustained exposure and experience.
Yet current UK training pathways are pulling would-be EP specialists away from the environments in which they must hone their skills. The 2013 Shape of Training review, though well-intentioned, prioritised a return to generalist practice across medicine, under the rationale that NHS patients are increasingly older, frailer and multimorbid.3 This incontestable truth was subsequently transmuted through a misguided trickle-down process, whereby delegated institutions implemented a blanket requirement for all cardiologists to dual accredit in general internal medicine (GIM).4 This was the bluntest of instruments with which to pursue the goal of preserving generalist skills – an approach further undermined by the failure to uphold the original commitment to protect 80% of training time for cardiology. In practice, service delivery pressures have eroded this principle, often justified under the fig leaf of inflated GIM training requirements.
Through this process, a critical truth has been lost: while all doctors must be generalists to some extent, some must also be experts.
Although the new cardiology curriculum was only formally ratified in 2022, trainees entering specialty training from 2020 onward have been required to plan for dual accreditation in GIM. This shift coincided with the enduring impact of the COVID-19 pandemic.5 As a result, advanced cardiology trainees – particularly those pursuing craft sub-specialties such as EP or interventional cardiology – are finding themselves diverted from procedural training at the very point when they should be consolidating their skills.
EP is a sub-specialty with a steep learning curve. Mastery of pacing and ablation techniques requires high procedural volumes and repetition under supervision.6 To ensure safe and competent practice, the British Heart Rhythm Society (BHRS) sets out minimum training requirements: 35 pacemakers and 30 ICDS or cardiac resynchronisation therapy devices annually as first operator; 200 simple ablations (with 50 as first operator); 100 complex atrial ablations (50 as first operator); and at least 20 ventricular arrhythmia ablations (10 as first operator).7,8 These are not aspirational targets; they are patient safety thresholds.
But these standards are increasingly out of reach. EP trainees now face extended periods managing acute GIM inpatients, covering unselected medical takes and participating in ward-based care far removed from the EP lab or arrhythmia clinic. In some centres, even accessing basic device implantation opportunities is a challenge. The irony is stark: as EP technologies rapidly advance, and demand for rhythm interventions grows, the training pipeline is constricting.9
The British Junior Cardiologists Association, supported by the British Cardiovascular Society and endorsed by BHRS, has already highlighted this issue.10 Their 2025 position statement warned of a “generational crisis of inadequately skilled consultants” due to declining procedural exposure. These concerns are not merely theoretical; patients may soon be treated by clinicians who have not had sufficient experience to perform complex procedures safely and independently.
The situation raises urgent questions about the structure and intent of medical training in the UK. Should procedural sub-specialists be expected to maintain GIM competency at the expense of technical mastery? Can a single training pathway truly serve both the generalist and the interventionalist? Without reform, we risk producing cardiologists who are nominally accredited but practically unprepared.
This is not a call to abandon generalism. The NHS unquestionably requires doctors who can manage complex, multimorbid patients, and the inclusion of an internal medicine 3 (IM3) year – along with a continued expectation that both trainees and consultants demonstrate competence in a broad range of non-cardiac issues – is entirely appropriate. But we also need a system that protects time for those training in high-stakes procedural fields. There is a clear and pressing need to rebalance cardiology training to ensure that future consultants are not merely credentialled, but competent.
A Path Forward
Despite the gravity of the problem, solutions are achievable and within reach. The following strategies should be considered nationally to safeguard EP sub-specialty training in the UK.
Opportunities in Early Specialist Training
To attract the most suitable trainees from across cardiology, all should be given the opportunity to observe and participate in specialist practice early in their training. Encouraging exploration of aptitude through supervised exposure during the first 2 years is essential to informed career development.
Flexible Dual Accreditation Pathways
GIM requirements should be front-loaded, allowing trainees to complete general medical training earlier in their programme. This would enable protected, concentrated sub-specialty training time in the later years, when procedural skills and other advanced practice must be consolidated. For the 20% of cardiologists who will practice an unselected take, the option of dual accreditation should be encouraged and preserved.
National Accreditation of Training Centres
Training centres should be formally assessed for their ability to deliver meaningful procedural exposure. Accreditation metrics should go beyond overall centre volume to include trainee access to a full range of procedures, quality of supervision and individual trainee case numbers. Centres that do not meet these standards may need to reconsider their training role and, if necessary, face the loss of sub-specialty trainees to ensure training quality is maintained across the system. Crucially, this training must be provided to rotational national training number (NTN) holding trainees, not a segregated group of post-Certificate of Completion of Training (CCT) or international fellows.
Structured Post-Completion of Training Fellowships
The core functions expected of most arrhythmia specialists must be achievable within the years allocated to their NTN. However, for specific areas of advanced practice – and for those trainees underserved by the training programme – the opportunity to further develop skills within a structured, quality-assured fellowship is an essential safeguard. Such fellowships should be offered only by centres that already meet their obligations to NTN-holding rotational trainees and demonstrate a capacity to deliver training beyond the standard curriculum. Going abroad to complete training should be a choice, not a necessity.
Engagement with Patients and the Public
Patients rightly expect that the consultant responsible for their care has undergone rigorous, high-quality training and is fully competent to deliver specialist procedures safely and effectively. As awareness grows about the pressures facing medical training, it is essential to involve patients and the public in advocating for high-standard training environments. Public support will be crucial in ensuring that training is not sacrificed to short-term service demands, and that the next generation of consultants is equipped with the expertise patients deserve.
Conclusion
The intention behind Shape of Training was honourable, and its core aim of embedding generalist skills is both valid and achievable. However, in seeking to address the complexities of contemporary medicine, its implementation via mandatory dual accreditation has inadvertently made the path to sub-specialty expertise more difficult. Nowhere is this more evident than in the field of EP, where training time is being swallowed by GIM service obligations at the expense of procedural skill development.3
We must urgently revisit how we train our future EP consultants. If we continue down the current path, we risk failing our trainees and, more importantly, our patients. The NHS and its regulators must recognise that generalism and sub-specialism are not opposing forces, but rather complementary pillars of excellent care. A training system that respects both will build the consultants of tomorrow: skilled, safe and ready.