CLEAR News - Summer 2003

Licensure of AAs - "A-Okay" or "No Way"?

�They aren�t adequately trained.�  �They have restricted scope of practice.�  �Their safety record has never been studied.�  �It will make healthcare more expensive.�

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�They will help reduce the increasing shortage of anesthesia providers.�  �It will make anesthesia administration a more attractive career choice.�  �They offer expertise in testing and calibrating anesthesia delivery systems.�

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These are some of the arguments being heard from opponents and supporters in the debate over licensing anesthesiologist assistants.  According to the American Medical Association�s (AMA) definition, an anesthesiologist assistant (AA) is a health professional who works under the supervision of a licensed anesthesiologist and assists the anesthesiologist in developing and implementing the anesthesia care plan.  (A detailed description of job duties is available on the AMA web site.)  Currently, only six states � Alabama, Georgia, New Mexico, Ohio, South Carolina, and Vermont � license anesthesiologist assistants.  Some states allow AAs to practice under physician delegatory authority.  Other states are considering legislation to license AAs.  But the battle is fierce as those on opposing sides of the issue clash in lobbying efforts to push or kill proposed legislative bills.

The Florida Association of Nurse Anesthetists is one group that has voiced strong opposition to AA licensure in their state.  Prior to the legislative sessions in which the AA bill was to be introduced, the FANA website prominently asserted opposition to Legislation to Lower Standards of Anesthesia Care.  The site lists a number of reasons why they believe licensure of AAs is not needed in Florida:

* Approving a new type of anesthesia provider to reduce the shortage of providers is not justified because nearly 100 new certified registered nurse anesthetists (CRNAs) will graduate this year and new programs are opening.

* Licensure of AAs may actually discourage people from going into nursing and worsen the shortage.  A new provider in competition with nurse anesthetists will indicate a restriction to advancement in the nursing field and make nursing a less attractive career path.

* AAs are not required to have healthcare training or experience prior to their AA training, whereas Certified Registered Nurse Anesthetists (CRNAs) must be registered nurses and typically have 5 to 7 years of experience as RNs before entering an anesthesia program.

* AAs have limited training in that they do not receive instruction in administration of regional anesthesia.

* The cost of regulating a new profession is high especially during these difficult financial times.

* Expansion of the existing nurse anesthesia programs in Florida is a better solution to the shortage than bringing in AAs from other states.

However, many anesthesiologists in Florida argue that the shortage of anesthesia providers necessitates licensing anesthesiologist assistants as alternative providers.  No figures are available specifically for nurse anesthetists, but a study in October 2002 by the Florida Hospital Association shows that 1 out of every 8 nursing positions is unfilled.  The Health Resource and Services Administration Bureau of Health Professions National Survey of RNs projects that by 2020, demand for nurses will exceed supply by 33% in Florida and 29% nationally.   Supporters of AA legislation claim that allowing anesthesiologist assistants will reduce the shortage of traditional bedside nurses because, unlike RNs who advance to become CRNAs, AAs do not draw from the pool of general nurses.  Anesthesiologists also cite the burden of the efforts they must expend against the nurses trade union as nurse anesthetists campaign for the right to practice with no anesthesiologist supervision.  AAs would not present this problem.

As of late May, it seems that the nurse anesthetists have won the battle in Florida.  The Florida Legislature adjourned without passing the Anesthesiologist Assistant bill.  FANAs web page was updated after the legislative sessions to claim that the Grassroots Lobbying Effort Successfully Thwart[ed] AA Legislation.

The same battle is being waged in Missouri, with the Missouri Association of Nurse Anesthetists (MOANA) taking a prominent position in opposition to Anesthesiologist Assistant legislation.  During the legislative sessions, the MoANAs website homepage listed a call to all CRNAs and other people concerned about the safety of anesthesia in Missouri to contact their state Senator and Representative to ask them to vote no on the AA bills.  The site offers a Fact Sheet for Legislators listing many of the same opposition points as FANA.  MoANA also cites problems with the anesthesiologist supervision requirements for AAs.  This will increase the expense of healthcare because two anesthesia providers will be necessary.  Also, unlike CRNAs who are the sole anesthesia providers for 71% of Missouri rural counties, AAs could not work independently in these areas.

On the MoANA website, clicking on the link CRNAs in Florida also fighting AA bill opens an Internet Explorer warning box (complete with yellow triangle and exclamation point) with a message from the MoANA President.  The message claims that AAs are lesser trained anesthesia providers and asks readers to let politicians know that CRNAs are your first choice to be your anesthesia provider.  The message links to an article about the CRNA who helped save Pfc. Jessica Lynch, a POW in Iraq, and states: If Lt. Col. Steven Hendrix, CRNA, is good enough to rescue and save the lives of others in the battle field in IRAQ [sic], he and other CRNAs must be good enough to deliver your anesthesia in the USA.

Despite the lobbying efforts from those opposed to the bill, the Missouri House has passed the measure, and it is still being considered on the informal calendar in the Senate.

On the national level, the American Association of Nurse Anesthetists is taking a stand against AA legislation.  In a May 29 press release (Americans Say No to Low-Level Assistants Providing Anesthesia to Civilian and Military Patients, Survey Reveals, the AANA cites a nationwide survey conducted by Public Opinion Strategies in which 85% of surveyed Americans responded that they would be concerned if they or a family member were to have surgery under anesthesia administered by an AA.  The survey also revealed that 83% of respondents are concerned about the federal government approving AAs for practice in the Department of Veterans Affairs and TRICARE programs for military personnel, veterans, and their families.  More specifically, respondents were concerned that:

* anesthesiologists are not required to stay in the operating room with the AA throughout the surgery (72%)

* no studies of the safety record of AAs have been conducted (66%)

* AAs can take the certification exam up to 6 months before completing the training program (63%)

* AAs are not trained to administer all types of anesthesia (59%)

Also in opposition to the VA / TRICARE proposal, Stars & Stripes published a full-page ad, appearing 5/23, 5/25, 5/29, and 5/31stating, The person putting you under for this surgery could be an assistant.  The photo shows a patient receiving anesthesia from a healthcare professional with a very confused look on his face.  The ad urges readers to contact their Representative or Senator and say No to Anesthesiologist Assistants in TRICARE.  The VA / TRICARE proposal was published in the Federal Register, Volume 68, Number 64, April 3, 2003, and the last date for public comment was June 2.

In the face of all this opposition to AA legislation and proposals, what do supporters say?  Regarding the training of AAs, supporters argue that it is more than adequate.  There are currently two AA training programs - Emory University in Georgia and Case Western Reserve University in Ohio.  Applicants for admission to the programs must have a bachelors degree from an accredited college and coursework in biology, chemistry, physics, and mathematics similar to pre-med requirements.  Applicants must also take the Medical College Admission Test or Graduate Record Examination.  Unlike CRNAs, AAs receive extensive training in the technological aspects of anesthesia administration testing and calibrating of anesthesia delivery systems, electric circuits, biophysics of life support, and monitoring of anesthesia.

Licensed anesthesiologists are directly involved in all aspects of the training programs.  Training programs must be accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP).  The CAAHEP has approved the Standards and Guidelines for Anesthesiologist Assistant Education developed by the Review Committee composed of anesthesiologists and graduate AA members.  One of the guidelines is that anesthesiologists are involved in the curriculum design, admission criteria, and classroom and clinical education for AA training programs.  Supporters claim that anesthesiologists involvement in AA education will ensure that AAs training adequately prepares them for working with the anesthesiologist in the operating room (Wesley T. Frazier and John F. Kreul, The Physicians Role in AA Education and Practice, ASA Newsletter, Volume 67, March 2003).

Graduates or seniors in an AA program are awarded initial certification by successfully completing the Certifying Examination for Anesthesiologist Assistants administered by the National Commission for Certification of Anesthesiologist Assistants (NCCAA).  To maintain certification AAs must complete 40 hours of continuing medical education every two years and pass the Examination for Continued Demonstration of Qualifications every six years.

So, as the debate continues in some states and other state associations of nurse anesthetists monitor the situation for any indication of AA legislation proposals, what about states that already license AAs?  In an article about the Florida debate (Susan Lundine, Docs, nurses square off in new turf war, Orlando Business Journal, 14 March 2003), Rob Wagner, president of the American Academy of Anesthesiologists Assistants, claims that in states where both anesthesiologist assistants and nurse anesthetists are licensed, there is plenty of work for both and very little conflict. 

The approved legislation in Alabama, Georgia, New Mexico, Ohio, South Carolina, and Vermont details the educational requirements for applicants for AA licensure including continuing education.  The laws state requirements for anesthesiologist supervision of AAs.  In Ohio, representatives from the Ohio State Association of Nurse Anesthetists monitored the drafting of the Medical Boards AA practice rules.  In South Carolina, the Anesthesiologists Assistants Practice Act creates an Anesthesiologists Assistant Committee to serve as an advisory committee to the Board of Medical Examiners. The Committee, consisting of three licensed AAs, three physicians, and two consumers, evaluates the qualifications for licensure and continued education and makes recommendations to the Board as necessary.

AAs currently make up about 1% of anesthesia providers in the US.  As legislation is proposed and debated, will AA training programs expand?  If AAs become licensed in more states, will nursing shortages be reduced, or will the quality of anesthesia care be compromised as opponents fear?  CLEAR will continue to monitor the situation and keep you updated of any changes.

Related Web Sites
American Academy of Anesthesiologist Assistants
Association for Anesthesiologist Assistant Education
American Society of Anesthesiologists
American Board of Anesthesiology
Anesthesia and Analgesia
American Academy of Physician Assistants
Commission on Accreditation of Allied Health Education Programs