Anesthesiologist assistants should be able to practice in every state

Anesthesiologist assistants should be able to practice in every stateA guest column by the American Society of Anesthesiologists, exclusive to

When you need anesthesia for surgery or a diagnostic procedure, of course you want to know who’ll be giving you anesthesia.  If you live in Texas, Florida, the District of Columbia, or 14 other states, you may be lucky enough to have an anesthesia team taking care of you that includes a physician anesthesiologist and an anesthesiologist assistant, or “AA”.  If you live in many other states — including my own state of California — care from an AA isn’t yet an option.

Many Americans have never heard of anesthesiologist assistants.  Even many physicians are unaware that the profession exists.  But for more than 45 years, AAs have worked alongside physician anesthesiologists in exactly the same way that physician assistants (PAs) work with a surgeon, internist, or pediatrician–using teamwork to deliver the best possible medical care to their patients.

Today, there are more than 1400 certified AAs in the U.S.  Why are they limited to practicing only in certain states?  It’s a complicated question.  The answer involves the fierce opposition of nurse anesthetists to the very existence of the AA profession, our complex American system of state licensure, and the economics of healthcare.

Here’s the background

The AA profession came into being in the 1960s, when we had a serious shortage of anesthesia professionals in the U.S.  The goal was to create a new master’s level program which would enable graduates to deliver anesthesia care under the direction of a physician anesthesiologist.  The first AA programs were established at Emory University in Atlanta and Case Western Reserve University in Cleveland.

To become an AA, the first step is to get a bachelor’s degree with a strong basic science background, taking the same classes that premedical students take to prepare for medical school.  The next step is to take the GRE or MCAT examination and gain admission to one of the nine accredited university programs in the U.S. offering a Master of Science in Anesthesia degree.  Training involves classroom time and hands-on experience in the operating room.  After passing a certifying examination, graduate AAs administer anesthesia as clinical practitioners, always working under the supervision of a physician anesthesiologist.

AAs are recognized by the Centers for Medicare & Medicaid Services (CMS) as non-physician anesthetists with identical standing to nurse anesthetists, and the services of AAs and nurse anesthetists on a care team are paid for by CMS and by commercial insurers on an equal basis.  AAs are authorized to work in any VA hospital, and they work side by side with nurse anesthetists in many academic departments and private anesthesia practices.

The right to practice in every state

In hindsight, it might have been easier if the AA profession had been launched as a subspecialty under the broader umbrella of PAs, who already can be licensed in all 50 states.  Physician anesthesiologists specialize in anesthesia, but practice in every state under a general license as physicians.  Since AAs are defined as a separate profession, however, each individual state must approve AA licensure (or another means of authority) in order for them to practice.  Getting this approval has been a battle, as nursing lobbies and unions have fought hard to defeat legislation authorizing AA licensure in every state where it has been proposed.

Why do nurses oppose AAs so vehemently?  Follow the money.  In states where AAs can’t practice, nurse anesthetists control the market on non-physician anesthesia practice. Annual salaries for nurse anesthetists are the highest in the clinical nursing profession, varying from state to state, but typically starting around $110,000.  Experienced nurse anesthetists can make $180,000 or more.  Clearly, they would prefer to restrict the marketplace and not allow other anesthesia practitioners to compete for these jobs.

There’s a difference in philosophy between AAs and nurse anesthetists as well.  Many nurse anesthetists demand independent practice, which means that a nurse anesthetist may give anesthesia without the supervision of — or even consultation with — a physician.  In contrast, AAs work only under the supervision of a physician anesthesiologist.  That’s how they want it.  They believe strongly in the concept of the care team, where physician and non-physician practitioners work together. Saral Patel, president of the American Academy of Anesthesiologist Assistants, points out that when AAs are on your anesthesia team, they “ensure an anesthesiologist presence in the care of every patient.” The overwhelming majority of patients automatically assume that a physician is in charge of their anesthesia care, and prefer to keep it that way.

The future of anesthesia practice

The market for anesthesia services continues to grow, as the number of surgeries and complex diagnostic procedures requiring anesthesia increases each year.  With the implementation of the Affordable Care Act, millions of people are expected to sign up for insurance and boost the demand for all types of medical care.  The American Society of Anesthesiologists (ASA) strongly believes in the anesthesia care team, and would like to see AAs gain the right to practice in every state.  Why wouldn’t we want to see more qualified anesthesia practitioners enabled to work?

Speaking as a California anesthesiologist, I would be delighted for an AA master’s degree program to start at a California university and for AAs to be licensed here.  It’s a shame that any California student who wants to become an AA has to leave the state for training and can’t come back here to work. We can only hope that legislators will see reason and AAs will gain the right to practice in more states.  Certified AAs deserve to practice in any state where they want to live and work.

“I’m a California native,” says Shane Angus, an experienced AA on the teaching faculty of Case Western Reserve University.  “I’d come back to work here in a minute.”

Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center.  She blogs at A Penned Point.

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  • Shirie Leng, MD

    Karen – love your blog. I have talked about the physician vs. CRNA issue in my own blog I have not actually heard of or met any AAs, but my impression of the ASA is that if it’s not physician-only they don’t want anything to do with it.

    • Karen Sibert MD

      Thanks for writing, Dr. Leng! I am speaking for the ASA in writing this column, as a member of the Committee on the Anesthesia Care Team. The ASA is 100% in support of AA licensure in all 50 states. AAs are proud members of the ASA and supporters of ASA legislative efforts on all fronts. The ASA supports physician-only anesthesia practice, certainly, but also supports the anesthesia care team led by a physician anesthesiologist. The care team may include residents, AAs, and/or nurse anesthetists.

  • Dave Mittman, PA, DFAAPA

    Not exactly the same way. They are not PAs of anesthesia. PAs are trained as generalists first. PAs are capable of treating all kinds of patients. AAs are purely vertically trained, please don’t say just like PAs.

  • guest

    CRNAs are arguing for total independence. AAs want to work in cooperation with physicians. They support physician involvement in the anesthesia team care model, something CRNAs hate.

  • guest

    We had AAs in my training program. I was just a medical student so I had no clue what their political role was. As a physician in private practice we’d work with them in a heartbeat (if we had to bring in midlevels at all). I’d prefer we stay MD only.

  • buzzkillerjsmith

    Physician-based anesthesia is dying. Welcome to the club.

  • guest

    More interesting will be the justification FOR AAs by anesthesiologists. Though harsh, Wayne Jones is on the money. Anesthesiologists want to keep the $$ but not do their own cases. CRNAs have gone rogue. Now, anesthesiologists know they are too expensive to bill solo and must find the new midlevel, the one they can control (and still bill for).

    • TheStigg

      More competition for CRNAs by an equally capable alternative who is not looking to undermine the cost-effective and safe anesthesia care team paradigm. Contrary to what you suggest, doing solo anesthesia cases is much less stressful for an anesthesiologist than supervising multiple rooms staffed by midlevels. Sure, you get paid more, but at the cost of running around like a madman putting out fires all day. What a concept, more pay for more responsibility and work.

      • guest

        FYI, I am an anesthesiologist. I’m an MD who does their own cases. I don’t want or need any midlevel around, though I do not get a sense that my colleagues nationwide feel the same way. The point of the article is that AAs should be allowed licensure in every state. Why? As someone who does their own cases I wonder why we need midlevels at all. AAs are a fine alternative, I suppose, and it allows anesthesiologists to continue to stay relevant as part of some ACT (anesthesia care team).

        I am my own team. I just wish anesthesiologists nationwide felt they were good enough without midlevels polluting our field. I suppose that ship has already sailed.

  • guest

    So why do anesthesiologists advocate for AAs?

  • mphoto

    If you’re a free market economist, licensing should be granted to AA’s in all states in order to help the consumer (patient).

    If you’re a competing provider that favors economic protectionism for personal gain, you’ll do everything you can to lobby, with your union/professional org’s power, against new provider entrants into the market that will reduce your wages.

    Econ 101. As an AA-C and free market economist, I’m in favor of the Care Team and independent practices coexisting and competing to provide the best care in all regions, both urban/academic and rural/underserved. Patients and surgeons/hospitals should have a choice whether they receive/subcontract their anesthesia services from a MD/DO and/or AA/CRNA.

    Ultimately, free market economics maximally benefit the patient. Licensing restrictions produce provider shortages in critical regions under the guise of protecting patients from poor providers. However, continuing (and rising degree reqs) education, and our civil legal system do far well enough to weed out poor providers.

  • buzzkillerjsmith

    This MD, AA, nurse anesthetist stuff is funny in a Schadenfreude kind of way. Parallel to what is going on in general medicine. It’s going around and coming around. If the AAs geld the nurse anesthetists will anyone shed tears?

    Perhaps this is all better settled in cage fight. Someone getting hit over the head with one of those anesthesia carts would be a sight to see.

  • TheStigg

    Yeah, no need to protect the public from snake oil salesmen. Let’s just do away with consumer protections all together while we’re at it. The market will figure it out. Eventually.

    The problem with arguments like yours’ is that they play well to the conspiracy-theory believing public while introducing the possibility of real harm that would otherwise be prevented. It’s a challenge to get folks who think like you to accept that we (anesthesiologists) know what you don’t know, and we’re looking out for the interests of the public while at the same time protecting our turf. It’s the fact that this is win-win that you won’t accept simply because there’s a financial incentive present.

    • NormRx

      Boy, you sure read a lot into my comment that wasn’t there. If you look again you will see that I said “most not all.” I did not say physicians should not be licensed. But, as long as you opened up this can of worms lets delve a little deeper into it. We have surgeons cutting off the wrong limb, doing unnecessary cardiac surgery, unqualified ENT’s doing plastic surgery. unqualified physicians doing liposuction etc. All physicians are licensed and yet these practices still go on. Restaurants are licensed, yet we still have outbreaks of hepatitis, e-coli and other contagious diseases.
      I firmly believe that most physicians are hard working, honest people but you are naive if you don’t think there is a segment in any profession that wants to increase licensing requirements in order to protect there own turf. You seem a little hostile and honestly I don’t blame you, physicians have been under increasing pressure from the government and insurance companies. Many people thinks doctors only care about money. Rest assured doctor I am not one of them, you have my utmost respect.

  • AA-C

    The anesthesiologist is not always in the operating room with an AA-C or nuse anesthetist. AA-Cs and nurse anesthetists are supervised identically when the anesthesia care team model is being used and the anesthesiologist is not personally performing the anesthetic. The supervising anesthesiologist is involved in every aspect of the anesthesia plan and is always available to the anesthetist, whether it is an anesthesiologist assistant, nurse anesthetist, or anesthesiology resident.

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