There are several important aspects to competency in device implantation. First and foremost is expertise in implantation techniques and management of difficult cases and complications. Such training is an integral part of a fellowship in clinical cardiac electrophysiology. However, there are physicians who have completed cardiology fellowships who are trained in pacemaker implantations and who currently have high-volume practices in pacemaker implantation and follow-up. For such physicians, the technical skills required to implant an ICD lead are not very different from those required for a pacemaker implantation. However, there is a great deal of additional knowledge that is necessary that is unique to ICD implantations, such as the use of conscious sedation for device testing, testing of defibrillation thresholds, and proper programming and follow-up. Such knowledge can be attained by a cardiologist experienced in pacemaker implantations, if one has the dedication and interest to pursue that knowledge. This was the rationale behind the recently published Heart Rhythm Society (HRS) clinical competency statement on implantation of ICDs and cardiac resynchronization devices (2), which was also endorsed by the American College of Cardiology Foundation. In addition, the Centers for Medicare and Medicaid Services in their decision memorandum on ICDs earlier this year supported the concept that adequate training is necessary for physicians who implant ICDs. Key components of the clinical competency statement included a sufficiently high-volume pacemaker practice by the operator currently, in addition to didactic training, proctoring, and successful completion of NASPExAM, an examination of knowledge in pacing and defibrillation. It should be noted that only experienced pacemaker implanters should ever consider expanding their practices to include prophylactic ICD implantations because of the difficulties of obtaining the technical skills required for device implantation in general outside of a training program.