Temporary cardiac pacing can be a life-saving manoeuvre. The indications and techniques are well established.1 The procedure is one of the ‘essential’ components of the training programme in general internal medicine. This may be desirable, but is it wise nowadays? Is it achievable? The traditional indication for a temporary cardiac pacemaker is heart block; the usual venue for the procedure is a treatment room alongside a coronary care unit (CCU). Most patients have threatened or actual high-grade transient atrioventicular (AV) block in association with acute myocardial infarction. Some will have Stokes-Adams attacks or established AV block which is sufficiently symptomatic to warrant urgent treatment pending the insertion of a permanent pacing system. For these patients, physicians with on-take responsibilities are required to learn the technique. Most physicians, however, lack the opportunity to maintain their skill. In Cambridge, for example, the number of temporary electrodes inserted in the CCU has dwindled year by year from 57 in 1994, to 29 in 1998; the numbers of procedures performed out of hours were, respectively, 29 and 10. Every hospital has seen a substantial increase in the number of senior medical staff. Many will admit that they have not inserted an electrode for a year or more, and would be nervous of doing so. Corridor conversations should not initiate policy changes, but they may prompt scrutiny of current practice. The reason for this decline is likely to be due in part to decreased need. The past decade has seen a huge change in …