At the recent Sonntag Symposium, held at the Barrow Neurological Institute in March, I was asked to comment on the increasing role that endoscopy plays in surgery. A focus of discussion ensued over whether or not surgeons are more qualified than nonsurgeons, and therefore should preferentially be doing endoscopic procedures. It was also noted that many interventional spine specialists are doing endoscopic procedures. In my mind, this raises some fundamental points. Who governs scope of practice? What are the key points for us to consider? NASS is a multispecialty society that has always stood for evidence-based medicine. We have developed practice guidelines based on clinical evidence and have recently moved to the GRADE system when issuing guidelines. NASS is also an organization that advocates for all. Nearly 20% of NASS members are nonsurgeons; we are a stronger organization by being inclusive and allowing all spinal professionals to have a home at NASS. It would not feel right for me to say a priori that surgeons are more qualified to perform endoscopy. Endoscopy is relatively new in US practice. I remember being dazzled by watching videos of Dr. Michael Wang perform endoscopic decompression and interbody fusion at one of our annual meetings. The benefits for patients from the appropriate utilization of this type of minimally invasive surgery are potentially enormous. Moreover, at Roger Hartl’s minimally invasive course in New York, I watched Christoph Hofstetter discuss the incredible use of endoscopy for the removal of thoracic disc herniations. The alternative approach usually involves a thoracotomy and a major recovery for the patient. Both Drs. Wang and Hofstetter are master surgeons who have spent an incredible amount of time to hone their skills. What they do with endoscopy is not possible for many of us. The question is how much training does a surgeon or an interventional spine specialist need before being given privileges to perform endoscopic procedures on patients? We can all agree that a weekend course would not be enough for any spine professional. One of the great values in attending meetings is the chance for meaningful scientific discourse. Dr. Juan Uribe, who was the organizer of the Sonntag Symposium, set up the meeting to permit open discussion. I was introduced to Dr. Evan Rivers who trained extensively on endoscopic procedures under the direction of the Department of Neurosurgery at University of New Mexico several years ago. Dr. Rivers pointed out that the interventional spine specialist starts learning endoscopy with potentially a greater knowledge of how to approach the neural foramen using fluoroscopic techniques than many surgeons. The discussion at the Sonntag Symposium was thoughtful and allowed myself and others to learn from each other. I think that whatever we say about endoscopic procedures, whomever does them has to have adequate training and supervision before doing the procedures independently. There should also be a formalized approach to documenting competency at doing these procedures before being privileged to perform them. The current landscape in our country makes this complicated. Medical privileges are closely monitored in hospitals, but far less so in ambulatory care centers. In private offices, there are usually no privileging bodies to measure competence. All physicians doing spinal procedures must have measures in place to manage complications if they occur. There is no way to manage all of the possible complications that could occur from endoscopy in a private office1, so it stands to reason that endoscopic decompression procedures should never be performed in private offices. As a society, NASS stands for evidence, safety, and advocacy. We must all agree that the safety of our spine interventions for patients is paramount for us as medical professionals. In addition, we must be committed to measuring the effectiveness and the comparative effectiveness of the procedures that we offer to our patients. Furthermore, to ensure access for patients and payment for qualified physicians, it is important to be certain that unqualified physicians should not be coding for procedures that they are not trained to do. So, what do we do about endoscopy? NASS has previously stated that only orthopedic or neurosurgery-trained spinal surgeons should be performing arthrodesis of the spinal column.2 We are not a credentialing body, and in order to adhere to the principles of NASS, I think it is imperative that we agree on having methods in place to determine and certify competence for physicians learning new techniques. Additionally, we must have registries to document outcomes and safety of spinal procedures—both surgical and interventional. NASS should be working collaboratively with other major societies to develop these standards of practice.