How each hospital determines what medical procedures and which conditions may be treated by each practitioner is known as "delineation of privileges." A clinical privilege is a specific grant or permission by a hospital for an individual to perform diagnostic or therapeutic procedures or other patient care services within well-defined limits. The ultimate goal of this process is to ensure high-quality patient care. It is the right and duty of the medical staff to establish the process of credentialing.

Several controversies may arise in the discipline of thoracic surgery: 1) the performance of pulmonary resection, removal of chest wall tumors and esophagectomy by general surgeons; 2) emergency thoracic care by trauma specialists; and 3) the performance of video-assisted thoracoscopy by pulmonologists. At the present time, these controversies must be resolved at the local hospital level.

What guidelines exist for the credentialing process in thoracic surgery? One might first look at the positions of societies and boards. The American Board of Thoracic Surgery (ABTS) states that ABTS board certification "is not intended to define the requirements for membership on hospital staffs, to gain special recognition or privileges for its Diplomates, to define the scope of speciality practice, or to state who may or may not engage in the practice of the speciality." The Society of Thoracic Surgeons (STS) affirms that the responsibility of credentialing lies with the local hospital but has designed "Guidelines for Hospital Privileges for Thoracic Surgeons" for use in the development of a credentialing process. The American Association for Thoracic Surgery (AATS) endorses these guidelines. These guidelines include sections on the definition of thoracic surgery, clinical competence in thoracic surgery, and the scope of thoracic surgery. The American College of Surgeons (ACS) does not have a position on the granting of clinical privileges for thoracic surgeons, although the ACS recommends that eligibility to perform a surgical procedure be based on a surgeon’s education, training, experience and demonstrated proficiency. The American Board of Surgery (ABS) specifically disclaims responsibility for the designation of who shall or shall not perform particular surgical operations.

Controversies in thoracic surgery credentialing frequently arise because the approach used for credentialing in many hospital has limitations. Methods commonly used include: 1) privilege lists ("laundry" lists with no predefined criteria that are often not inclusive and may be too restrictive); 2) categorization, which is more applicable to medical areas; 3) descriptive approach; 4) delineation by codes (ICD/CPT); and 5) board certification as a baseline. Adoption of a system for dealing with the privilege delineation process is advocated by the Credentialing Resource Center (P.O. Box 1168, Marblehead, Mass., 01945). Such a system is based on predefined criteria for requesting privileges; accurate, specific and detailed descriptions of the clinical privileges and clarification of minimal education, training and experience needed to apply for specific clinical privileges. This approach has been adopted by the Medical University of South Carolina, and the request form for thoracic surgery is attached. This process is consistent, flexible, and most importantly, eliminates the application for privileges by physicians not meeting the present criteria.

Having focussed on the credentialing process itself, one must now critically examine the criteria utilized. The basis of deciding who should do a particular procedure may include such components as training, experience, competence-peer review, volume, outcome, and economic issues. It is incumbent on thoracic surgeons to study and objectively measure these components.

In South Carolina, my colleagues and I have reviewed the demographics of lung cancer surgery in this rural state and compared outcomes of patients undergoing resection by specialty (Chest, in press). We found that in a 5-year period, one-half of lobectomies and 60 percent of pneumonectomies were performed by general surgeons. Mortality was significantly higher in patients who underwent lobectomy by general surgeons versus thoracic surgeons (5.3 percent vs 3.0 percent), p = 0.05) and in patients with extreme comorbidities (43.6 percent v 25.4 percent, p = 0.04) or ages > 65 years (7.4 percent vs 3.5 percent, p < 0.05). Seventy percent of thoracic surgeon performed >10 cases in the series, whereas 75 percent of general surgeons performed <10 cases (p = 0.05).

Realizing that the results of this study cannot be generalized to other areas of the country and acknowledging the study’s limitations, the results do have important implications to access of care, training requirements, and patterns of referral, as well as credentialing issues. Further prospective studies of outcome, economic impact, and risk stratification are needed if we are to preserve our specialty.