March 2001
Volume 65 |
Number 3
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| Anesthesiologists’
Assistants: Being A (Care) Team Player |
Scott B. Groudine,
M.D.
Committee on Governmental Affairs
Over the last 40 years, medicine has seen a growth in nonphysician
providers or extenders. In virtually every field of medicine,
there are nurse practitioners and/or physician assistants in the
office and operating room environment. Although the scope of practice
of these two types of extenders often differ with regard to prescriptive
authority and the degree of supervision required (depending on
state law or regulation), there is significant overlap in their
ability to provide care for patients. Therefore, competition among
nonphysician providers and patients is beneficial because it often
leads to a larger supply of practitioners and lower costs.
Many anesthesiologists are familiar with only one type of anesthesia
nonphysician extender: nurse anesthetists. Another group of nonphysician
anesthesia providers also exists but remains unknown to many anesthesiologists
because of state laws that restrict their ability to practice
widely. This prevents anesthesia practices and their patients
from enjoying the benefits of competition experienced by most
other medical and surgical specialties. These practitioners are
known as anesthesiologists' assistants (AAs) or anesthesiology
physicians' assistants. A brief review of their training and qualifications
is provided.
In the late 1960s, due to significant changes in anesthesia
care, personnel shortages and the increasing complexity of monitoring
equipment, a need for a differently trained participant in the
anesthesia care team was identified. The physicians' assistant
(PA) model was investigated. The Board of Medicine of the National
Academy of Sciences described generalist (type A) and specialist
(type B) physician assistants. AA training is modeled after the
specialist type B PA description: The type B assistant, while
not equipped with general knowledge and skills relative to the
whole range of medical care, possesses exceptional skill in one
clinical subspecialty or, more commonly, in certain procedures
within such specialty. In this area of specialty, a degree of
skill beyond that normally possessed by a type A assistant and
perhaps beyond that normally possessed by physicians who are not
engaged in the specialty. Because his/her knowledge and skills
are limited to a particular specialty, the AA specialist is less
qualified for independent action.
Rather than condensing a generalized overview of medicine within
a relatively short training period, AA training focuses on anesthesia
care. This is possible because AA teaching programs, the American
Academy of Anesthesiologists' Assistants and state laws require
anesthesiologists to direct AAs whenever they care for patients.
As a leader of the anesthesia care team, it is expected that the
physician will supply most of the required medical background.
AAs, however, receive extensive training in the administration
of anesthesia and monitoring and bring to the care team additional
expertise in testing and calibrating anesthesia delivery systems
that many anesthesiologists do not possess. Coursework on electric
circuits, biophysics of life-support and monitoring systems are
just a few of the classes and labs that AAs take but which are
often missing from anesthesiology residency training programs.
This makes for a care team where the AA can add to the anesthesiologist's
fund of knowledge and experiences, benefiting the patient and
practice.
AA training programs in the United States exist at two locations:
Emory University in Atlanta, Georgia and Case Western Reserve
University (CWRU) in Cleveland, Ohio. Both are accredited by the
Commission on Accreditation of Allied Health Education Programs
(CAAHEP) that succeeded the American Medical Association's (AMA's)
Committee on Allied Health Education and Accreditation. It is
the same body that accredits the nation's PA programs. Emory offers
graduates of its AA program a Master in Medical Science in Anesthesiology
and Patient Monitoring Systems (M.M.Sc.), while CWRU offers its
graduates a Master of Science in Anesthesiology (M.S.A.).
Both programs are approximately two to two-and-one-half years
in duration and have strict requirements for admission. All applicants
for these training programs must have a bachelor's degree from
an accredited college that contained coursework very similar to
those required by medical schools, i.e., at least one year of
coursework in college-level biology, chemistry, physics and mathematics.
Organic chemistry is also required as is the Medical College Admission
Test (for CWRU) or the Graduate Record Examination (for Emory).
A minimum grade point average of 3.0 is suggested for the successful
applicant. As long as these prerequisite courses are taken, no
specific major is required. Recent graduates have had business,
engineering and liberal arts backgrounds as well as more health
science-oriented majors, including nursing, respiratory therapy
and medical technology.
Graduates of AA schools are often hired in practices that have
nurse anesthetists. In many cases, their job descriptions are
identical. However, they must work under the supervision of an
anesthesiologist, and some states such as Texas limit the anesthesiologist/AA
ratio at 1:2. An example of some of these issues can be seen in
the “Suggested Job Description of the Guidelines for Anesthesiologists’
Assistants from Texas:
1. Anesthesiology is the practice of medicine; AAs administer
anesthesia under the medical direction of an anesthesiologist.
2. AAs may introduce themselves as Anesthesiologists' Assistant
but may not refer to themselves as a physician or physician assistant.
3. AAs perform initial cardiopulmonary resuscitation/ advanced
cardiac life support in emergency situations until the supervising
anesthesiologist is summoned.
4. AAs establish a comprehensive patient database (by chart/medical
record review and patient examination and interview) to assist
in anesthetic planning. AAs may order appropriate preoperative
evaluations and premedications after consultation with the anesthesiologist,
who is then responsible for these orders.
5. AAs initiate multiparameter monitoring prior to anesthesia
or in other acute care settings. Modalities include but are not
limited to ASA Standard Monitors and arterial and venous catheters.
AAs may manipulate and interpret data from central venous, pulmonary
artery and intracranial catheters and other monitors or devices
that are indicated.
6. AAs administer the prescribed anesthetic with particular care
to the cardiovascular, respiratory and metabolic health of the
patient.
7. AAs utilize advanced treatment modalities to effect Section
6, including but not limited to advanced airway interventions
and intubation of the trachea, starting and adjusting doses of
vasoactive infusions, administering vasoactive and anesthetic
drugs, administering blood and any other treatment modalities
that are prescribed by the supervising anesthesiologist.
8. AAs will summon the supervising anesthesiologist for the induction
of anesthesia, for extubation of the trachea, for consultation
during unexpected or adverse perioperative events or at any other
time when the prescribed anesthetic deviates significantly from
its expected course.
9. AAs assist in the postoperative management of patients by
managing ventilatory support and acute pain management in conjunction
with existing protocols or the attending anesthesiologist.
10. AAs recognize that the choice of anesthetic drugs and techniques
are prescribed by the attending anesthesiologist preoperatively.
Exceptions exist when standard orders for a given situation exist
or when life-threatening situations arise requiring the use of
standard therapeutic or resuscitation techniques until the attending
anesthesiologist arrives or is consulted by telephone.
11. The anesthetic prescription may consist of a verbal discussion
between the AA and the supervising anesthesiologist; in this instance,
the anesthetic record is considered to reflect the anesthetic
prescription in the absence of other notations in the medical
record.
12. The supervising anesthesiologist will remain at all times
immediately available in the operating area and is reachable by
beeper or overhead page.
13. The AA may engage in teaching and research functions as deemed
appropriate by the supervising anesthesiologist.
A newly trained AA can expect to earn between $60,000-$80,000
his or her first year. Unlike nurse anesthetists, not every state
allows AAs to practice. AAs are able to practice in Vermont, Michigan,
Wisconsin, Texas, New Mexico, Alabama and, of course, Georgia
and Ohio. Colorado, Oklahoma, Illinois, Kentucky and New York
currently are considering the role of AAs in their state, but
acceptance of this form of physician extender is not guaranteed.
Nurse anesthetist groups have mounted strong lobbying efforts
to prevent the acceptance of AAs in states where they are not
currently practicing. In many cases, they have been successful
in maintaining their monopoly with nonphysician-provided anesthesia
care. Medicare will pay for a medically directed AA in the same
manner it pays for medically directed nurse anesthetists.
After graduation, an AA is expected to become AA-certified.
This test is sponsored by the National Commission for Certification
of Anesthesiologist Assistants. Certification is maintained by
submitting continuing education credits every two years and taking
a Continued Demonstration of Quality examination every six years.
The American Academy of Anesthesiologists' Assistants (AAAA),
based in Atlanta, Georgia, is the professional organization that
represents and provides continuing education to most AAs.
It is my hope that anesthesiologists unfamiliar with AAs will
now have a greater understanding of the other nonphysician anesthesia
provider.
Additional information can be obtained from the American Academy
of Anesthesiologists' Assistants at (800) 757-5858 or at www.anesthetist.org.
| Another
group of nonphysician anesthesia providers also exists but
remains unknown to many anesthesiologists because of state
laws that restrict their ability to practice widely. This
prevents anesthesia practices and their patients from enjoying
the benefits of competition experienced by most other medical
and surgical specialties. These practitioners are known as
anesthesiologists' assistants (AAs) or anesthesiology physicians’
assistants. |
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Scott
B. Groudine, M.D., is Associate Professor of Anesthesiology,
Albany Medical Center, Albany, New York. |
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