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The
Alabama Experience
In all states, a medical practice act and similar
legislation establish a state medical board with the
authority to regulate the practice of medicine. The
board is given, among other rights, the authority
to promulgate rules and guidelines for the practice
of medicine, the responsibility of licensing and credentialing
physicians, overseeing and regulating prescriptive
authority and disciplining physicians who violate
the established rules or state laws. In many jurisdictions,
the state’s medical board also has statutory
authority over the activity of physician extenders,
excluding nursing personnel who are usually regulated
by a state nursing board. Anesthesiologist assistants
(AAs) fall into this last category.
Physician extenders may function under either
delegatory or regulatory rules established
by the state medical board. Legislative language determines
whether the rules are delegatory or regulatory. Under
delegatory rules, a board may allow a physician to
utilize the services of a physician extender. The
duties of the extender are outlined and determined
by the physician and delegated based upon training
and experience. The duties (or scope of practice)
of the extender must usually be approved by the medical
board and also by the operating bylaws or rules of
any institution where the physician extender may work.
A physician assumes liability for the actions of the
physician extender. Under regulatory rules, the medical
board defines what minimal training and experience,
examination requirements and any other pertinent characteristics
the physician extender must possess in order to obtain
certification or licensure to function in that state.
The scope of practice is determined and detailed by
the state medical board. The license of the physician
extender is typically linked to a licensed physician
in that state. Alabama is an example of a regulatory
state.
In 1994, an AA student from Emory University in Atlanta,
Georgia, became engaged to marry a medical student
training in Birmingham, Alabama. He inquired about
potential employment opportunities in Alabama. An
anesthesiology group in Birmingham was willing to
hire him if he could obtain permission from the state
medical board to work in Alabama. Several anesthesiologists
wrote letters to the board on his behalf, and the
board decided to consider the request. The medical
board determined that an Alabama statute outlining
the classification and function of physician assistants
(PAs) allowed the potential new category of anesthesiologist
assistant. Under the requirements of the Alabama Administrative
Procedures Act, public testimony and comment must
be solicited whenever the medical board decides to
add, amend or delete a rule. Adding a category of
provider, in this instance an AA, required an amendment
of an existing rule that established PAs. There was
much opposition to the potential new physician extender
class. Nurse anesthetists opposed the rule change,
citing inadequate training and experience on the part
of AAs. General physician assistants opposed the rule
change on the grounds that AAs did not take their
national PA examination and might try to practice
as general PAs. Physical therapists were concerned
that an AA might perform physical therapy. Even the
cardiovascular perfusionists had concerns that bypass
pump operation might be something the AA would want
to perform. According to a senior medical board member,
the board received more comments and letters on this
issue than any other in its history. The board was
so intrigued that a special subcommittee was appointed
to investigate and make recommendations. They visited
practices in Georgia and spoke with faculty from the
Emory University training program. Their recommendation
was to approve the new class. The board approved AAs
as a new class of provider and promulgated rules and
a specific scope of practice utilizing the Georgia
regulations as a guide. AAs may now obtain a license
through the Alabama State Board of Medical Examiners
to function in the state. To date, there are approximately
a dozen of these providers working in three major
cities in Alabama.
The Texas Experience
In 1997, Greater Houston Anesthesiology, P.A. (GHA)
recognized the need for additional dependent anesthesia
providers. This need arose out of a shortage of qualified
anesthesiologists and nurse anesthetists that developed
in the mid-1990s. Adverse changes in the medicoeconomic
environment for anesthesiologists drove most qualified
medical graduates into other specialties. To date,
there continues to be limited availability of qualified
anesthesiologists and anesthetists.
During this personnel shortage, GHA faced a variety
of new obligations and opportunities in the Houston
area. After an appropriate period of due diligence,
a decision was made to augment GHA’s existing
anesthesia care team with AAs to optimize the delivery
of physician-directed anesthesia care.
Prior to their introduction into Texas, GHA sought
out the guidance and approval of the Texas State Board
of Medical Examiners (TSBME) to ensure that supervision
of AAs would be allowed under the Texas State Medical
Practice Act. After a presentation to the TSBME Standing
Orders Committee in September 1997, it was deemed
appropriate to utilize AAs as defined by the Medical
Practice Act, Section 3.06 (d)(1), (2), (3) and (4).
In a letter of confirmation from the president of
TSBME, he stated: “This Section of this Act
pertains not only to anesthesiologist assistants but
to any qualified and properly trained person or persons
acting under the physician’s supervision conducting
any medical act which a reasonable and prudent physician
would find is within the scope of sound medical judgment
to delegate if, in the opinion of the delegating physician,
the act can be properly and safely performed by the
person to whom the medical act is delegated and the
act is performed in its customary manner, not in violation
of any other statute, and the person does not hold
himself out to the public as being authorized to practice
medicine.”
Subsequent to this opinion, TSBME promulgated “Guidelines
for Anesthesiologist Assistants.” Though the
guidelines originally recommended a 1:2 supervision
ratio, this ratio has recently been changed to 1:4.
The guidelines also recommend that the supervising
anesthesiologist be board-certified. This document
can be accessed at <www.tsbme.state.tx.us/policy/anassist.htm>.
In both the hospital and ambulatory surgical setting,
AAs have proven to be valuable, highly qualified members
of the anesthesia care team in Texas. In addition
to the Houston area, AAs have worked in Dallas, San
Antonio and Galveston. All government and commercial
insurers recognize payment for anesthesia services
involving AAs.
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Arthur M. Boudreaux, M.D., is Professor and
Vice-Chair for Clinical Affairs, Department
of Anesthesiology, and Assistant Chief of Staff,
University of Alabama-Birmingham. |
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John
M. Zerwas, M.D., is Past President of Greater
Houston Anesthesiology, P.A., Houston, Texas. |
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