ASA March 2003 Newsletter

The most important contribution that anesthesiologists (and ASA) can make toward providing an adequate supply of high-quality AAs is to continue to take an active leadership role in AA education — in the design and administration of AA educational programs as well as in the classroom and in their clinical practice settings. Such “leadership by participation” will grow to mirror anesthesiologist-led accomplishments in clinical care, research and resident/fellow education.

As experts in the development of the medical specialty of anesthesiology, anesthesiologists have stepped forward during the last century to exert leadership in many areas. Particularly, as the number of anesthesiologists has increased, this leadership has been manifested by new and refined medical and technical aspects of clinical care that parallel our accomplishments in clinical and basic research. As evident by the growing number of anesthesiologists today, a priority has been placed on both the quantity of programs and the quality of education of the next generation.

What seems clear is that there will be a continuing need to meet part of the clinical staffing needs across the country by the utilization of the anesthesiologist-directed anesthesia care team. This means there also must be continued attention to the nature of anesthetist education. Several questions arise concerning the recruitment pool (e.g., level of relevant aptitudes, previous education, etc.), what training should entail and, of course, how anesthetists will be utilized in daily practice to optimize the quality of anesthetic care affordable to the public. Answers to these questions in AA education have been sought using a “top down” approach. It is most important to first delineate the spectrum of practice conditions (e.g., what tasks are delegated to anesthetists and what educational elements are needed to support an adequate knowledge base and set of technical skills). The origin and definition of such a “performance standard/specification” is described by J. S. Gravenstein, M.D., and John E. Steinhaus, M.D., in this edition of the NEWSLETTER (page 5). The wisdom of the original choices made 30 years ago with the founding of the two existing anesthesiologist assistant (AA) programs is an outstanding example of professional foresight and physician leadership. It has been established since then that recruiting at a high level from candidates with a solid college education in premedical sciences can provide qualified AAs. This is accomplished by selecting top applicants who are qualified to do graduate work in clinical medical science within AA programs that are founded in an academic medical community and are under the direction of well-trained anesthesiologists.

In a very practical way, anesthesiologists play a vital role in this process. We could have conceivably taken an “arm’s length” role, i.e., help a program get started and then turn over most of the administration and teaching to the anesthetists themselves. Or we could allow AAs to design and run their own programs, producing graduates that we then hire and manage after having little input into admission criteria and curriculum design. In our opinion, the outcome of the AA educational process has been successful because anesthesiologists are directly involved in the curriculum design, admissions criteria/process, classroom education and clinical training. This could be likened to the military training model whereby the top military staff not only take responsibility for the military academies (West Point, Annapolis, etc.) but also for setting up the entire training chain, from privates, corporals, sergeants (our anesthesia technical personnel), through the lieutenants and captains (our anesthetists), on up to the higher officer levels (the physician level). It is much more likely that the quality of the AA thus educated will meet the needs defined by practicing anesthesiologists. Furthermore, it is much more likely that the attitude and spirit of cooperation at the bedside in the operating room will be more conducive to a cooperative “team effort” if there is a bond of mutual respect forged in the total educational process. This bond would gain strength not only due to those fully trained anesthesiologists directing the AA education but also by the constructive relationship between AA students and residents who “grow up” together in training rather than first meeting each other in a later postgraduate clinical setting. As summarized by Helmut Cascorbi, M.D., director of the Case Western Reserve AA program for many years, this can be an “imprinting” relationship of considerable educational and managerial benefit in later years.

As an additional positive feature of the goals originally set by Dr. Gravenstein and Dr. Steinhaus, the educational process modeled in the two existing AA programs has allowed up to 10 percent of AA graduates to proceed on to medical school (without having to double back to acquire premedical courses) with the recommendation and support of physicians with whom they have trained and worked. Experience has shown that the large majority of AAs entering medical school choose anesthesiology as a specialty.

The physician’s role in AA practice does not end with the graduation of the AA but continues into the clinical arena where anesthesiologists provide medical direction as defined by the “ASA Guidelines for the Ethical Practice of Anesthesiology.” There is no rule in any jurisdiction allowing the independent practice of AAs or of practice of AAs under the supervision of a nonanesthesiologist physician. The AA works under the rules of the medical examining board of each state either as defined in administrative statute or under rules defining delegated care by physicians. Individual AAs must obtain Medicare and Medicaid provider numbers so that billing may be submitted for their portion of the defined service under Medicare Part B and the Medicaid rules of the state where they are practicing. In addition, Medicare rules specify that AAs must work under the medical direction of an anesthesiologist. The actual practice conditions of AAs are dependent on the specific policies of the anesthesiology department where they are employed. Use of anesthetic techniques, including the monitoring of regional anesthesia and the insertion of monitoring lines, is determined by the practice and judgment of the medically directing anesthesiologist and applicable departmental, hospital and state regulatory rules. Depending on local hospital rules, AAs may or may not be specifically credentialed by the hospital. In all instances, however, their pattern of practice is specified by the department of anesthesiology’s policies and procedures, which are often approved by the hospital’s physician medical board. Usually the department determines the accuracy of the certification status of AAs and keeps documentation of the education completed on site as well as certification and recertification by the National Commission for Certification of Anesthesiologist Assistants (NCCAA). Recertification requires completion of the NCCAA recertification examination every six years.

The practice of medicine and anesthesiology is changing rapidly. It is essential that the physicians whose education is grounded in the knowledge of the pathophysiology, assessment and treatment of disease guide the graduate AA in the future practice of the anesthesia care team. ASA has responded to this need not only by inclusion of AAs in its care team policy statement for many years but also by recently (2002) providing AAs with the opportunity to obtain sponsored educational membership in the Society. In addition, physicians who practice with AAs or who have an interest in the education of AAs should consider membership in the Association for Anesthesiologist Assistant Education (AAAE).

In Summary:
Anesthesiologists are involved in the design of the AA curriculum and, in particular, the criteria for admission (level of educational background and at what level of performance). These quality standards are critical in determining the level at which the anesthesia basic sciences can be taught as well as the breadth and depth of clinical education (and ultimately the quality of the AA contribution to the anesthesia care team at the beside).

Anesthesiologists are involved in classroom experiences (alongside qualified AA faculty and other medical school faculty) in order to ensure the quality of the basic science education. Of particular relevance is involvement to ensure a complementary integration of the basic AA knowledge base with the more extensive medical education of anesthesiologists.

Anesthesiologists are involved directly in the clinical education of AA students not only in terms of the content of the facts and principles being conveyed and emphasized but, perhaps more importantly, in establishing the “mindset” of both student and teacher as a model for future cooperation expected in later clinical practice.

Anesthesiologists are involved directly in establishing specific policies and protocols for the clinical practice of AAs in an anesthesiology department. Only credentialed anesthesiologists prescribe the specific anesthesia care plan and provide the personal medical direction of an AA in its implementation.

Anesthesiologists are involved in the continuing on-site postgraduate guidance of AAs and sponsorship of their access to ASA-developed medical educational materials and conferences.

Anesthesiologists are involved in the continuing support of the education and practice of AAs through the work of AAAE <www.aaaehq.org>.

Given the long history and demonstrated success of the AA profession in several states, the availability of AAs will continue to expand. The key factor will be to engage a growing number of anesthesiologists in the ongoing support and utilization of AAs. Anesthesiologists must contribute their LEADERSHIP THROUGH PARTICIPATION in all aspects of AA education and practice.

John F. Kreul, M.D., is Professor of Anesthesiology and Associate Chair for Clinical Administration, University of Wisconsin Medical School, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin. He is a member of the Board of Directors of AAAE.

Wesley T. Frazier, M.D., is Associate Professor of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.

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