Experience with AAs

[neuroride]

My state of practice is considering licensing of AA's. I don't know if it will pass but I was wondering if anyone has experience working with AA's? We have about 12 CRNA's right now and 4 docs. Do you find anything experience or knowledge that lacks in AA's? We are all for it and have sent out letters to our state legislators so fingers crossed.

---

Members don't see this ad.

 

[jwk]

Thank you for your support! AA's can pretty much do anything you need them to do in your practice. We believe that the local anesthesiologists at the local level are in the best position to decide how they want to use the AA's in their practice. That means if you want your AA's doing any invasive line placement or blocks, or one or the other, or neither, that is best decided at the local level. Remember that in any state in which we practice, medical direction at no more than 1:4 is required, but that is really pretty easy to do. About the only thing we don't do is take call by ourselves, but if you believe that every patient should be able to have an anesthesiologist involved in every anesthetic, then that's not an issue. AA's do all types of cases, again depending on the local practice. We do every type of case in our very large practice - the only thing we don't do is transplants and open heart because we don't offer those services. However, many AA's are doing those types of cases in the centers that have those as part of their practice. And although not a requirement to enter anesthesia school, many AA's have significant healthcare experience in other fields. All AA's are trained in a medical school environment, not a nursing school.

Feel free to PM me if you have any specific questions.

 

[Gaseous Clay]

They do a good job overall and in my practice, I honestly can't tell the difference between them and our CRNA's. Just as an FYI, I trained at a program with an AA school and we employ about 15% AAs.

 

[btbam]

I'm also an AA and can answer questions if you have them neuro. I work in a level 1 peds hospital...we do everything. Hearts, transplants, cath lab, neurosurg, trauma, you name it. We are probably 70/30 AA:CRNA. Everyone gets along and respects each other both on the MD and anesthetist level. But I do work in Atlanta which is very AA friendly. It's great to hear you are so supportive of hiring AAs!

 

[bashwell]

Slightly off topic, but wouldn't it be better for anesthesiologists to hire AAs instead of CRNAs, if they have the choice in making the decision about who is hired? If so, then why not refuse to hire CRNAs and hire AAs every time, assuming equal competence etc., and hopefully over time the CRNA problem would be radically minimized. Although maybe it's because there aren't enough AAs available to be hired (supply/demand). Just thinking out loud.

 

[Baller MD]

I think more groups would hire AAs if it was legal in their respective state.

 

[PianoMedic]

From my understanding, an AA needs to have an anesthesiologist as their medical direction while a CRNA just needs a physician, any physician (and in some states they can be independent now too? Not as sure about that part). In a rural state, this allows surgeries to be performed at smaller hospitals where an anesthesiologist wouldn't be employed. And then there is the limited licensure of AAs to less than half the states while CRNAs are licensed in all states. I don't think we will see a significant decrease in CRNA population due to AAs for awhile.

 

[Mad Jack]

From my understanding, an AA needs to have an anesthesiologist as their medical direction while a CRNA just needs a physician, any physician (and in some states they can be independent now too? Not as sure about that part). In a rural state, this allows surgeries to be performed at smaller hospitals where an anesthesiologist wouldn't be employed. And then there is the limited licensure of AAs to less than half the states while CRNAs are licensed in all states. I don't think we will see a significant decrease in CRNA population due to AAs for awhile.

What's messed up about that is that the only reason CRNAs can work there but anesthesiologists can't afford to is the passthrough legislation that allows bonus subsidies to be given to CRNAs but not anesthesiologists, because that makes sense. It has basically made it impossible for anesthesiologists to compete in rural areas, since CRNAs cost less at baseline and get a subsidy to boot.

 

[PreAA]

I'm not in AA school yet, but honestly it seems like the biggest issue is the medical direction/1:4 requirement, at least that's what I can tell from getting in touch with the practices that post CRNA jobs on Gasworks (at least for FL). Of course I'm still just a pre-AA at this point (as my screenname gives away), but it does seem like changing ratios to 1:8 might help AAs get employed by more practices.

 

[urge]

There is not much difference in practice between a nurse and an AA.

The AAs tend to behave as senior residents while CRNAs think they are independent and can police all physicians.

 

[jwk]

I'm not in AA school yet, but honestly it seems like the biggest issue is the medical direction/1:4 requirement, at least that's what I can tell from getting in touch with the practices that post CRNA jobs on Gasworks (at least for FL). Of course I'm still just a pre-AA at this point (as my screenname gives away), but it does seem like changing ratios to 1:8 might help AAs get employed by more practices.

You're listening to CRNA's too much. And stay off GasWorks - it is most definitely NOT the real world.

 

[jwk]

What's messed up about that is that the only reason CRNAs can work there but anesthesiologists can't afford to is the passthrough legislation that allows bonus subsidies to be given to CRNAs but not anesthesiologists, because that makes sense. It has basically made it impossible for anesthesiologists to compete in rural areas, since CRNAs cost less at baseline and get a subsidy to boot.

And what's really weird is that the pass-through legislation DOES apply to AA's - but without an anesthesiologist, it's a little bit of a moot point.

 

[cleansocks]

There is not much difference in practice between a nurse and an AA.

The AAs tend to behave as senior residents while CRNAs think they are independent and can police all physicians.

I completely agree. I had to assign someone who normally works in our preop clinic to one of my ORs for a simple crani as 2 crnas "called in sick" one day. It was such a nice experience - very competent but also conscientious, respectful, and willing to work with a standard, safe neuro anesthetic plan that we decided on together. I felt safer leaving her alone as I knew she would follow a plan we came up with together and call if needed rather than trying to be a hero. The next day I heard the CRNAs were upset that she was assigned to work in the OR at all. When I asked my colleagues about it I found out she was an AA. What an immense difference.

 

[psychbender]

Is there a realistic way to get more AAs working for anesthesiologists and less CRNAs so that we can someday drastically reduce CRNA presence, influence, power, etc.?

Get more states to recognize them, and train more to try and keep up with the demand.

 

[drmwvr]

How about not working with either one? Not having trained or worked a significant amount of time in the US, non physician anesthetists have always been a head scratcher. If the problem is your 'mid levels', trading one for another helps how? Kind of rearranging deck furniture on the Titanic as she lists to one side. Why wouldn't the replacements just end up wanting more once endorsed and empowered?

There is a critical mass of surgeons and anesthesiologists who apparently just don't care who gives the anesthetic as much as the group here does. Pretending that another group will solve that problem is quite at best naïve and at worst, delusional.

 

[bashwell]

How about not working with either one? Not having trained or worked a significant amount of time in the US, non physician anesthetists have always been a head scratcher. If the problem is your 'mid levels', trading one for another helps how? Kind of rearranging deck furniture on the Titanic as she lists to one side. Why wouldn't the replacements just end up wanting more once endorsed and empowered?

There is a critical mass of surgeons and anesthesiologists who apparently just don't care who gives the anesthetic as much as the group here does. Pretending that another group will solve that problem is quite at best naïve and at worst, delusional.

Sure, I suppose that'd be ideal. I greatly appreciate how UK/Commonwealth nations respect their anesthesiologists/anaesthetists. But the problem is (at least from what I understand) the fact that CRNAs are deeply embedded within the US healthcare system. Maybe what you say could be the ultimate end game, but even if so I would think we'd need incremental strategies for it to realistically work out?

 

[jwk]

How about not working with either one? Not having trained or worked a significant amount of time in the US, non physician anesthetists have always been a head scratcher. If the problem is your 'mid levels', trading one for another helps how? Kind of rearranging deck furniture on the Titanic as she lists to one side. Why wouldn't the replacements just end up wanting more once endorsed and empowered?

There is a critical mass of surgeons and anesthesiologists who apparently just don't care who gives the anesthetic as much as the group here does. Pretending that another group will solve that problem is quite at best naïve and at worst, delusional.

Given that there aren't near enough anesthesiologists to personally perform each and every anesthetic in this country - would you rather work with someone who wants to work WITH you, or would you rather attempt to work with someone who would just as soon stab you in the back? If you want to work in an all-MD practice, you can certainly do that, but on a nationwide level, it's not possible.

 

[jwk]

I completely agree. I had to assign someone who normally works in our preop clinic to one of my ORs for a simple crani as 2 crnas "called in sick" one day. It was such a nice experience - very competent but also conscientious, respectful, and willing to work with a standard, safe neuro anesthetic plan that we decided on together. I felt safer leaving her alone as I knew she would follow a plan we came up with together and call if needed rather than trying to be a hero. The next day I heard the CRNAs were upset that she was assigned to work in the OR at all. When I asked my colleagues about it I found out she was an AA. What an immense difference.

You normally just use your AA's in pre-op?

 

[HenryH]

I'm not in AA school yet, but honestly it seems like the biggest issue is the medical direction/1:4 requirement, at least that's what I can tell from getting in touch with the practices that post CRNA jobs on Gasworks (at least for FL). Of course I'm still just a pre-AA at this point (as my screenname gives away), but it does seem like changing ratios to 1:8 might help AAs get employed by more practices.

Actually, the AMC that took over the contract at the local hospital group in my area has implemented 1:6 and 1:8 ratios at several of their facilities (as well as the "collaboration" model at another), but based on the favorable responses I received from a number of Georgia groups who have posted CRNA openings on Gaswork (most of them express a willingess to hire AA's), it seems like most groups and practices are content with the 1:4 ratio.

I don't know how good of a chance he has of actually getting elected, but I'm thinking that a Jeb Bush presidency could be a boon to the AA profession; in the past, he has been vocally supportive of AA practice rights and signed the legislation back in 2004 that granted AA's licensure in Florida.

 

[drmwvr]

Given that there aren't near enough anesthesiologists to personally perform each and every anesthetic in this country - would you rather work with someone who wants to work WITH you, or would you rather attempt to work with someone who would just as soon stab you in the back? If you want to work in an all-MD practice, you can certainly do that, but on a nationwide level, it's not possible.

Spare me... doctors would "stab (me) in the back". That isn't the question. Your 'AA's'...they possess some supernatural virtue heretofore unknown on earth? Ye gods...

 

[bashwell]

Spare me... doctors would "stab (me) in the back". That isn't the question. Your 'AA's'...they possess some supernatural virtue heretofore unknown on earth? Ye gods...

Yes, it's true doctors, CRNAs, AAs, and almost any human being can behave immorally or unethically. But legally speaking CRNAs are for example given independence from physician supervision in many states whereas AAs are not (at least as far as I'm aware). I believe there are other not so insignificant legal differences between CRNAs and AAs, but I'm sure others know better than I do. In any case, this can foster a very different work environment to say the least. I could be wrong, but I suspect this is what jwk was alluding to.

 

[deleted171991]

As I said before: we shouldn't trust AAs any more than CRNAs. It's just a matter of time till they develop the same bad habits, starting with using anesthetist.org as the domain for their national organization (which speaks volumes to me).

We should concentrate on long-term solutions involving nurses, not midlevels.

 

[HenryH]

FFP, what's wrong with using anesthetist.org as the domain name for the AAAA? Groups that hire both CRNAs and AAs utilize them interchangeably as, literally, anesthetists, but just out of curiosity, what part of AAs referring to themselves as anesthetists do you take issue with?

 

[deleted171991]

FFP, what's wrong with using anesthetist.org as the domain name for the AAAA? Groups that hire both CRNAs and AAs utilize them interchangeably as, literally, anesthetists, but just out of curiosity, what part of AAs referring to themselves as anesthetists do you take issue with?

Anesthetist is the equivalent name for anesthesiologist outside the US. It implies a physician. I am pretty sure the wise people from AAAA knew that very well when they reserved the domain.

Stop confusing terms. That's what midlevels want. They are NOT anesthetists. They are either NURSE anesthetists or anesthesiology ASSISTANTS.

 

[bashwell]

As I said before: we shouldn't trust AAs any more than CRNAs. It's just a matter of time till they develop the same bad habits, starting with using anesthetist.org as the domain for their national organization (which speaks volumes to me).

We should concentrate on long-term solutions involving nurses, not midlevels.

This is helpful! Thanks, FFP! I know in Australia and New Zealand there are anaesthetists (aka anesthesiologists) and "anaesthetic nurses" who are nurses working in the anaesthetics dept. They do help anaesthetists/anesthesiologists get the job done (e.g. helping sedate the patient in the anaesthetic bay). But otherwise their roles are nothing like CRNAs. I'm guessing something like this would be ideal? Although I don't know how realistic it would be to happen in the US someday, even if we wish it were so.

 

[deleted171991]

An experienced ICU/ER nurse doesn't need more than a few months of teaching to be able to do sedation or simple cases under medical supervision. Recipe or protocol-based medicine; you set the parameters and s/he actually follows them. Anything complicated can be done by anesthesiologists with or without midlevels. If anesthesiologists are overqualified and too expensive for stool sitting easy cases, then so are CRNAs.

It's just a matter of time till an AMC figures it out.

 

[jwk]

Anesthetist is the equivalent name for anesthesiologist outside the US. It implies a physician. I am pretty sure the wise people from AAAA knew that very well when they reserved the domain.

Stop confusing terms. That's what midlevels want. They are NOT anesthetists. They are either NURSE anesthetists or anesthesiology ASSISTANTS.

There was no intent to confuse anyone. Many years ago, before the AAAA had a web presence, some clever individual, not an AA, bought up all the domain names that were close to what the AAAA might have used - anesthesiologistassistant.com/org, anesthesiaassistant.com/org, anesthesiologist-assistant.com/org, etc. - you get the picture. Unfortunately for us, aaaa.com and aaaa.org are domain names for other companies or organizations and beat us to the punch, and, interestingly, if you go to aana.org, you'll get something totally unrelated to anesthesia. And lastly, aa.com and aa.org are also very well known websites, neither one remotely connected to anesthesia.

Since an anesthetist in the US is NOT a physician, and since we don't spell it anaesthetist, and since I could care less if it irritates the CRNA's, which it most certainly does, and absent a better alternative, I have no problem with it.

And please remember - we fully support the concept that only a physician should be referred to as "Doctor" in a healthcare setting as well as fully support the various Healthcare Truth and Transparency bills proposed over the last several years on both the federal and state levels.

And lastly, to drmwvr - not sure where you currently practice, but both Canada and Great Britain are developing AA-type options, and at least one of the AA training programs in the US has a clinical rotation in Great Britain.

 

[deleted171991]

Sorry, but an anesthetist is a physician, all around the world. Anaesthetist is just the British spelling (from the original Latin), the same way they write oesophagus or oedema.

That's why they we make the emphasis "nurse anesthetist" in CRNA. AAs and CRNAs are NOT and should NOT be referred to as anesthetists, except by people who want to muddy the waters.

 

[Mad Jack]

How about not working with either one? Not having trained or worked a significant amount of time in the US, non physician anesthetists have always been a head scratcher. If the problem is your 'mid levels', trading one for another helps how? Kind of rearranging deck furniture on the Titanic as she lists to one side. Why wouldn't the replacements just end up wanting more once endorsed and empowered?

There is a critical mass of surgeons and anesthesiologists who apparently just don't care who gives the anesthetic as much as the group here does. Pretending that another group will solve that problem is quite at best naïve and at worst, delusional.

Probably because it's impossible to ever train enough anesthesiologists to provide all anesthesia care in the United States. We'd have to more than double the number of anesthesiologists currently in practice in order to not utilize midlevel providers.

 

[deleted171991]

Probably because it's impossible to ever train enough anesthesiologists to provide all anesthesia care in the United States. We'd have to more than double the number of anesthesiologists currently in practice in order to not utilize midlevel providers.

Any European, Canadian or Australian would probably have two words for this legend: the first begins with bull and the second ends with ****.

In a free market, where there is demand, there will be supply.

 

[Mad Jack]

Any European, Canadian or Australian would probably have two words for this legend: the first begins with bull and the second ends with ****.

In a free market, where there is demand, there will be supply.

We don't have a free market. We've got a cap on residency positions and no way to train the number of anesthesiologists we'd need if all the CRNAs were to disappear tomorrow.

If we could go back in time, certainly, we could have done things differently. But replacing every CRNA with an anesthesiologist is now impossible due to the training bottleneck.

 

[btbam]

We staff something like 20 sites every day...I don't even think we have 20 attendings on staff so you do the math. There simply aren't enough attendings (peds fellowship trained) to offer 24/7 coverage at a hospital like ours.

 

[drmwvr]

And lastly, to drmwvr - not sure where you currently practice, but both Canada and Great Britain are developing AA-type options, and at least one of the AA training programs in the US has a clinical rotation in Great Britain.

And just where do you think the vast majority of the pool of potential candidates will come from? The laboratory? Of course not. The critical care units in the UK haven't been poached of nurses to anesthesia for the last 80 years and are ripe for the picking. They may be given the title of PA' A', but rest assured, most of them will be nurses.

 

[cleansocks]

You normally just use your AA's in pre-op?

She's our only AA I believe and chooses to use her PA license mostly (in clinic) which unfortunately pays better at this facility than AA work.

 

[jwk]

She's our only AA I believe and chooses to use her PA license mostly (in clinic) which unfortunately pays better at this facility than AA work.

bummer

 

[HenryH]

She's our only AA I believe and chooses to use her PA license mostly (in clinic) which unfortunately pays better at this facility than AA work.

Just out of curiosity, can I ask why clinic work pays better than AA work at your facility? Does clinic work also pay better than what the CRNAs make to do anesthesia?

 

[IlDestriero]

We don't overpay ours either. You may make more elsewhere, and you can go there if you want. We treat the CRNAs pretty well, they have nice hours and no call, and there's no shortage of people wanting to work here.

 

[IHatePikeys]

In my experience, I've seen a stark difference between AAs and CRNAs. My AAs in general seem to have a a firm grasp on the science behind our practice. I can have intelligent discussions on pertinent topics, and the back and forth is worthwhile. CRNAs tend to have a lesser understanding of the nuances, as, for example, simple comments about acid/base physiology and pharmacokinetics have been met with blank stares, by more than a few.

This really isn't meant as a slight, but there is a major difference in education between the two groups. Our group employs many of each, and clinically, most of our AAs and CRNAs are very good (bread and butter practice).

Can anyone comment on the educational differences?

 

[jwk]

In my experience, I've seen a stark difference between AAs and CRNAs. My AAs in general seem to have a a firm grasp on the science behind our practice. I can have intelligent discussions on pertinent topics, and the back and forth is worthwhile. CRNAs tend to have a lesser understanding of the nuances, as, for example, simple comments about acid/base physiology and pharmacokinetics have been met with blank stares, by more than a few.

This really isn't meant as a slight, but there is a major difference in education between the two groups. Our group employs many of each, and clinically, most of our AAs and CRNAs are very good (bread and butter practice).

Can anyone comment on the educational differences?

AA programs are all in concert with a university medical school, with a board-certified anesthesiologist serving as the medical director for each program. They do their clinical time with anesthesiologists and other AA's. Depending on the school, they may take a few classes with medical students (physiology for example) or with other PA students. AA students are exposed to all subspecialty areas in the OR, including peds, neuro, and cardiac. Their first year is primarily didactic, with some OR time. The senior year is mainly OR time, with a few conferences to attend each week either in person or via web chat if at a remote clinical site.

CRNA programs are generally tied in with a nursing school, and with two exceptions that I'm aware of in Florida, have a university affiliation that allows them to grant an accredited master's degree (or DNP). The bulk of their training is generally done by other CRNA's, but there is a lot of variability from program to program. Military CRNA training is generally recognized as one of the better programs. Interestingly, the move to the DNP increases actual clinical training very little, if at all.

 

[criticalelement]

Military CRNA training is generally recognized as one of the better programs. .

That is scary because i know a few military CRNAs who consistently miss the boat. This whole independent CRNA thing is going to end very badly. I cant see why any clear thinking individual would buy into it.

 

[deleted126335]

That is scary because i know a few military CRNAs who consistently miss the boat. This whole independent CRNA thing is going to end very badly. I cant see why any clear thinking individual would buy into it.

No it won't. The new normal will be a higher acceptable complication rate that will be whitewashed over.

 

[Baller MD]

AA programs are all in concert with a university medical school, with a board-certified anesthesiologist serving as the medical director for each program. They do their clinical time with anesthesiologists and other AA's. Depending on the school, they may take a few classes with medical students (physiology for example) or with other PA students. AA students are exposed to all subspecialty areas in the OR, including peds, neuro, and cardiac. Their first year is primarily didactic, with some OR time. The senior year is mainly OR time, with a few conferences to attend each week either in person or via web chat if at a remote clinical site.

CRNA programs are generally tied in with a nursing school, and with two exceptions that I'm aware of in Florida, have a university affiliation that allows them to grant an accredited master's degree (or DNP). The bulk of their training is generally done by other CRNA's, but there is a lot of variability from program to program. Military CRNA training is generally recognized as one of the better programs. Interestingly, the move to the DNP increases actual clinical training very little, if at all.

Hey JWK, do you foresee more states allowing AAs to practice in said state in the near future? What has the trend been like?

 

[jwk]

Hey JWK, do you foresee more states allowing AAs to practice in said state in the near future? What has the trend been like?

Absolutely. Indiana has come on board within the last year, and there are a number of states in play this year with legislation at various stages in the process.

 

[Baller MD]

Absolutely. Indiana has come on board within the last year, and there are a number of states in play this year with legislation at various stages in the process.

I'm assuming the crnas aren't taking it very well?

 

[Matty44]

I'm assuming the crnas aren't taking it very well?

Nope. I've been involved in a few states legislative sessions regarding AA licensure, and the push back from CRNAs is nothing short of nasty.

But it's only a matter of time

 

[HenryH]

Nope. I've been involved in a few states legislative sessions regarding AA licensure, and the push back from CRNAs is nothing short of nasty.

But it's only a matter of time

Just out of curiosity, are you referring to recent legislative sessions for states that don't yet offer AA licensure? Or are you referring to past sessions in states that AAs have already gained licensure in?

 

[Matty44]

Just out of curiosity, are you referring to recent legislative sessions for states that don't yet offer AA licensure? Or are you referring to past sessions in states that AAs have already gained licensure in?

Previous states that have succeeded in gaining licensure. Haven't been super involved politically in recent years...

 

[jwk]

Previous states that have succeeded in gaining licensure. Haven't been super involved politically in recent years...

You need to change that.

 

[jwk]

It's unfortunate that CRNA's are more than willing to simply lie through their teeth to attempt to stop expansion of AA practice. Such is the case in NM at the moment, where AA's currently are licensed, but restricted by current legislation to working only at UNM hospitals. Sooner or later it comes back to haunt them. Practices that were once exclusively or majority CRNA have flipped to AA's. I don't know if that's because CRNA's don't want to work with AA's (their ego problem, not mine) or that the "if you don't practice independently as a CRNA you're lower than pond scum" mentality that's pervasive in the AANA and nurse anesthesia training programs, or because those groups where physicians do the hiring are preferentially hiring professionals who would prefer to work with them rather than against them. Actually, I do know - it's all of the above. AA's do not attempt to take positions away from CRNA's (the converse is certainly not true), but we are more than happy to step in and fill their positions when they choose to go elsewhere.

 

[sevoflurane]

It's unfortunate that CRNA's are more than willing to simply lie through their teeth to attempt to stop expansion of AA practice. Such is the case in NM at the moment, where AA's currently are licensed, but restricted by current legislation to working only at UNM hospitals. Sooner or later it comes back to haunt them. Practices that were once exclusively or majority CRNA have flipped to AA's. I don't know if that's because CRNA's don't want to work with AA's (their ego problem, not mine) or that the "if you don't practice independently as a CRNA you're lower than pond scum" mentality that's pervasive in the AANA and nurse anesthesia training programs, or because those groups where physicians do the hiring are preferentially hiring professionals who would prefer to work with them rather than against them. Actually, I do know - it's all of the above. AA's do not attempt to take positions away from CRNA's (the converse is certainly not true), but we are more than happy to step in and fill their positions when they choose to go elsewhere.

We are winning this battle. I can't say more... but the past couple of months have been good for AA's in my region.