This column was written on behalf of the American Society of Anesthesiologists, and was first published by KevinMD on December 22, 2013.
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 that 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 most 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.”
great article…work w AA’s every day in St. Louis, MO
Thank you for this extremely informative blog post. I am very interested in the medical field but I know I do not have what it takes to be a physician. To me AA is the next best thing.
I just hope my age will not be a hindrance as I am well past the age of most college and even graduate school students.
Maturity and experience are assets too, especially in dealing with patients. Investigate the requirements for entering AA programs, and see if you have all the prerequisites. Best of luck!
Why did you not include CRNA’s?
Nurse anesthetists are already licensed to work in every state. Anesthesiologist assistants would simply like to have the same opportunity.
Are nurse anesthetists as safe as Anesthesiologists? And if they are not as safe, can you point me towards some research or data to confirm this.
I’m a non-traditional type of student hoping to enter this field in the next two years. The medical school runaround is too much as that window of time and opportunity was best fit for when I was in my 20’s. The AA field is definitely hidden gem for those merging over from allied health careers and can be accomplished without a decade of training. First I looked at the CRNA route – 2 years to get my BSN, then at least one year actually working as a nurse, then one year in the ICU, then 2-3 years in CRNA training. At that point I would have wish I just went to MD or DO school. AA’s receive the same, if not more, clinical hours as a CRNA does (2000-3000 hours) but way less than a physician anesthesiologist (12,000+ hours). This is truly a complex and technical field suited for meticulous thinkers.
I am interested in the field of anesthesia, and given my educational background, AA school is by far the most attractive option for me. My only hesitation is the limited scope of where AA’s may practice at this time. I understand it is an ongoing battle fighting for licensure in all 50 states. As you mentioned in your article, AA’s may practice in VA hospital systems. I am very interested in moving to California upon matriculation from AA school, and as you are from California, are you aware of any AA’s currently practicing in the VA system?
Unfortunately, AB 890 didn’t make it out of committee during this legislative session in California, so AA practice here is still a work in progress. It’s true that AAs may practice in VA hospital systems, but to my knowledge none have worked in California VA hospitals as of this time. However, my information may be out of date. I am going to forward your email address to some leaders in the American Academy of Anesthesiologist Assistants, and I’m sure they can provide you with more information. You may also want to have a look at the resources on the AAAA website: http://www.anesthetist.org
Best of luck in your future education and career!
All the best,
Thank you so very much for your response and your assistance getting in touch with the AAAA. Megan has already reached out to me via email and I am so grateful that you all are working to advocate for licensure in California as well as other states where AA’s cannot currently practice. It certainly gives me hope that by the time I am finishing school there will be even more states to practice in!
Hi there! I am going through the same struggle and cannot be any more happier that someone is in the same boat as me. I am a Californian too, and am just really hoping they pass the bill to have AAs come back to work in California. I am applying next year to AA programs, and it has just been in the back of my head the uncertainty of AAs practicing in California. It has been a real problem for me to decide is this job really worth me moving and starting a new life somewhere else?
Do you happen to know how much time the legislators have to make a decision of whether or not AAs may practice in California? (Bill 380)
Thank you so much.
Dear Ms. Jivan,
The bill failed in the last legislative session, but to the best of my knowledge the intention is for it to be reintroduced. The California Society of Anesthesiologists is committed to the cause, and though it may take longer than we wish, I am very hopeful that we will succeed!
All the best,