Beyond the badge: quantitative insights of skill gaps in licensed early-career cardiac device implanters and evidence-based pathways to proficiency.

Cardiac implantable electronic devices (CIEDs) are widely used to manage rhythm disorders. However, implanters' training still follows an apprenticeship model, conducted in vivo from the outset, with wide institutional variability and lacking objective performance criteria to assess competence. Using objective validated metrics, this study evaluated procedural skills of early-career operators licensed to independently perform implantations and explored potential benefits of additional simulation-based training. Fifteen CIED implanters from six European countries underwent a three-task simulation assessment: (1) virtual reality dual-chamber pacemaker lead implantation scored using validated procedural metrics; (2) suture selection for lead fixation; and (3) knot-tying tested for security via tensiometer. Primary outcomes included total procedural errors (All-Errors), correct suture choice, and knot integrity. Performance was benchmarked against expert-defined proficiency standards. A supplementary analysis compared results with prior cohorts trained via traditional simulation-based training (SBT) or proficiency-based progression (PBP) approach. Participants made a median of 7.0 All-Errors (IQR 4.0-8.5) in the implant task, with only 20% meeting proficiency criteria. Correct suture selection occurred in 73%, and 67% tied secure knots. No significant correlation was found between implant experience and All-Errors rate. Compared to study participants, PBP-trained peers made 76% fewer errors (p < 0.001), while SBT training offered no significant advantage. Despite being licensed first operators, most early-career CIED implanters did not meet proficiency benchmarks. These findings highlight limitations in current training and certification. Proficiency-Based Progression may address these gaps by ensuring objectively verified readiness on simulation before in-vivo practice. Future studies should evaluate its impact on clinical outcomes.