AA professionals

[BeGr8]

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Hello All!! I was recently accepted and plan on beginning the AA program through Case Western here in Houston. I have looked at the various professional threads throughout the years and have seen little from actual AA's or Anesthesiologists view on AA's. I'm very excited to join this profession and just curious to hear from or about the other AA's out there!

 

[IlDestriero]

Just be aware going in that AAs are currently geographically limited as to where they can practice and expansion, which will likely be supported by Anesthesiologists, will be bitterly fought by the CRNA PAC in every state.
Also, future expansion of the ACT model from the usual 4:1 to 6 or 8:1 could also negatively affect your employability.
I don't want to rain on your parade, but forewarned is forearmed.
Good luck. Anesthesia is a great career.

 

[BeGr8]

Thank you so very much for your reply. I'm very aware of the geographical limitation and working with other public health and medical policy enthusiasts (my current background) to change that. I would love to know more about the expansion of the ACT model and why it would negatively affect my employabililty. Every career move has a risk.

 

[IlDestriero]

23. What is the anesthesiologist supervision ratio for AAs?

In addition to the practical issues that limit how many anesthetists may be supervised by an anesthesiologist at any one time, ratios are also often specified as contract requirements from payors. For instance in order to meet CMS requirements for medical direction, no more than 4 anesthetists (AAs or NAs) may be concurrently directed by an anesthesiologist.

The supervision ratio may also be defined in state law or Board of Medicine guidelines and is usually between 2:1 and 4:1. Check the regulations in your state for the applicable standard. It is important to note that in states where statutes specify a supervision ratio of AAs to anesthesiologists at less than 4:1, the anesthesiologist may also concurrently supervise NAs up to a total combined ratio of 4:1 for both non-physician.

It's not safe to assume your ratios will remain the same as CRNAs, who can practice completely outside of the ACT model.

 

[BeGr8]

Good information to know. Thanks again.

 

[HenryH]

IlDestriero, so you're saying that if the supervision ratio standard increases to 6:1 or 8:1, AA's wouldn't be allowed to work under these ratios?

I'm kind of confused, if that's the case -- can you explain why that would be? Are AA's only allowed to work according to a 4:1 ratio, even if more and more groups switch to a 6:1 or 8:1 ratio in the future?

 

[IlDestriero]

Your supervisory ratios may be determined by state law, the state board of medicine, and/or hospital policy. You have to see what the deal is in your state. It's not safe to assume the law or nursing board will treat CRNAs the same.
If they go 6:1 and you're stuck at 4:1, you will be at a disadvantage.

 

[BeGr8]

I could kind of see how this would be a small disadvantage but hopefully the laws will apply to AA's as well.

 

[HenryH]

Your supervisory ratios may be determined by state law, the state board of medicine, and/or hospital policy. You have to see what the deal is in your state. It's not safe to assume the law or nursing board will treat CRNAs the same.
If they go 6:1 and you're stuck at 4:1, you will be at a disadvantage.

Potential drawbacks to the profession such as the one you described are why I'm hesitant to go to AA school. I could spend a couple extra years becoming an RN and working in the ICU for a year and going to CRNA school, so it may be worth it to spend the extra time, especially since everyone in my area is always talking about how they know a CRNA here who works 30 hours a week in outpatient facilities and makes $160k, blah blah blah....

 

[pamac]

Potential drawbacks to the profession such as the one you described are why I'm hesitant to go to AA school. I could spend a couple extra years becoming an RN and working in the ICU for a year and going to CRNA school, so it may be worth it to spend the extra time, especially since everyone in my area is always talking about how they know a CRNA here who works 30 hours a week in outpatient facilities and makes $160k, blah blah blah....

With the medical industry about to enter a period of intense change, there's no way I'd take on a career that isn't entrenched into the healthcare environment in all 50 states. PAs and NPs have been expanding rapidly since the 60s, and even they are working hard to cement their footprint in the face of what's to come. (AAs have been around since the 60's as well, and have only about 2000 AAs practicing to show for it). I think the model for AA's is probably sound, but without a firm presence across the board, I'd be concerned they would go the way of specialized "physician assistants" of times past (like orthopedic physician assistants or radiologist assistants) that are a regional phenomena. It's bold to state that one plans to be a trailblazer.... Famous last words. I looked at AA school for a couple days before the notion of what they could be up against in the future settled things in my head. If AAs were found in all 50 states already, they'd be positioned to thrive, but they are in 17 states plus DC.. The vast majority of AAs practicing are in just a couple of those states. Spending what's got to be several tens of thousands of dollars and two years towards a career that limits me to specific states in the face of a national healthcare push? No way. Any kind of expansion of the profession into new territory pits them against entrenched interests that will be already fighting over resources that will be stretched. You have to remember that even in those places where AAs are restricted to, they still have to compete with CRNAs. Don't get fooled into thinking that because AAs are trained in the "medical model", and recruit from the same demographic as many PA schools, and are two years in length, that they carry as much clout as PAs (which to me seems that PAs in turn still have much less clout than NPs). AAs don't have nearly the penetration into markets that PAs do.

 

[BeGr8]

I understand it's a risk, especially in this political climate. However, every health profession had to start from somewhere and work it's way to it's current standing. From what I understand, the push for CRNAs to become fully independent in most states would push them to practicing in rural areas (NOTE: not all CRNAs) and that would lead to a gap needing to be filled in many hospitals and urban medical settings.

 

[IlDestriero]

False.
That's the line they use on the state government guys that don't know any better. Cheaper (false) and rural where no M.D. will go (false).
You'll find them taking over contracts at ASCs, offices, etc. in nice suburban locations and small cities. Who knows what's next. I've seen jobs for the "fireman" anesthesiologist. Working with "independent" CRNAs. Someone will take the job, and the liability, but not me. Didn't pay well either.

 

[BeGr8]

Wow. That's good to know. Well I'll keep praying for change and expansion on the AA front. I'm too excited and invested to turn back now.

 

[pamac]

False.
That's the line they use on the state government guys that don't know any better. Cheaper (false) and rural where no M.D. will go (false).
You'll find them taking over contracts at ASCs, offices, etc. in nice suburban locations and small cities. Who knows what's next. I've seen jobs for the "fireman" anesthesiologist. Working with "independent" CRNAs. Someone will take the job, and the liability, but not me. Didn't pay well either.

My hospital facility is basically at the edge of where urban ends and rural begins, and still has in house MDAs available to work with the CRNAs. What you are saying is true, though... They have the law in place to benefit the out of the way facilities, (which in some rare cases it does.... Since the rural facilities are often DR owned, doctors were reaping the profits), but now the law allows for CRNA expansion into the rest of the state. One of the reasons CRNAs get paid like family practice doctors is that they are reimbursed at the full rate, not some percentage formula like many other non physician providers. That's why you see CRNAs that are operating independently, or in CRNA groups taking home huge paychecks.

 

[pamac]

I understand it's a risk, especially in this political climate. However, every health profession had to start from somewhere and work it's way to it's current standing. From what I understand, the push for CRNAs to become fully independent in most states would push them to practicing in rural areas (NOTE: not all CRNAs) and that would lead to a gap needing to be filled in many hospitals and urban medical settings.

That push for independence is also what separates CRNAs from AAs.... AAs are not meant to have any kind of independence from the physician, and won't have any granted unless its in the interest of the physician. You are regulated by physicians, employed under them, and your ability to practice is dependent upon them entirely. Just visit PA forums to see how closely to their model you will function and how well they like that (AAs should probably start pushing to change the name to "associates" rather than "assistants" now while the profession is young if they are ever to do it).

Thats cool that you are in a program and excited to roll up your sleeves, and I'm not out to destroy your excitement, just go into it with your eyes open as to what you are paying so much for. Like i said, I was intrigued by the notion of beig an AA as well until I took a good look at the climate and what's comin down the pike. I can easily see a streamlining of healthcare that comes at the expense of less well established niches. You have over 100 NA programs vs 8 AA programs, and a toehold in just a few states. You have no ability to practice independently, which may sound safe, but restricts your bargaining ability and relocation. AA is appealing to the biology major that wants to tap into a cool career like they would with PA school (albeit without the traditional route of med school or CRNA school). The reality is that there are plenty of CRNAs being churned out, and by nature they almost always have significant HCE in very pertinent areas before they even show up to the first day of CRNA school. Running drips and managing patients on vents is often part and parcel of entire 3x12 workweeks for those of us who work in critical care. Being an NP is a different thought process than being an RN, so folks MIGHT have an arguement that on day one after graduation a PA is better prepared than an NP based on actual clinical hours as a student provider and heavy sciences of their program. I'm not sure the same holds true for AA vs CRNA.
Sitting back and hoping that the practice climate will change over time is a perilous approach to managing career prospects. Ask yourself what AA school offers you that CRNA school doesn't. I bet that like me, the only thing you will find is that it's the time and convenience factor that AA gives you.

 

[HenryH]

False.
That's the line they use on the state government guys that don't know any better. Cheaper (false) and rural where no M.D. will go (false).
You'll find them taking over contracts at ASCs, offices, etc. in nice suburban locations and small cities. Who knows what's next. I've seen jobs for the "fireman" anesthesiologist. Working with "independent" CRNAs. Someone will take the job, and the liability, but not me. Didn't pay well either.

The bolded part is exactly what happened in my area (at least 4 hospitals and a handful of surgery centers and GI clinics). And like you said -- there are anesthesiologists out there who are willing to essentially be paid to sit in the background and be consulted when needed. I know an anesthesiologist here who, when I told her that I heard her anesthesia group is no longer hiring AA's, simply said, "Oh, I think the CRNA's are in charge of all that." I think my area is an exception, though.

 

[pamac]

The bolded part is exactly what happened in my area (at least 4 hospitals and a handful of surgery centers and GI clinics). And like you said -- there are anesthesiologists out there who are willing to essentially be paid to sit in the background and be consulted when needed. I know an anesthesiologist here who, when I told her that I heard her anesthesia group is no longer hiring AA's, simply said, "Oh, I think the CRNA's are in charge of all that." I think my area is an exception, though.

Thats not surprising at all. I've never run across an AA, but I can see how having a third distinct category of provider, complete with their own practice guidelines and such, would complicate the picture for a group. And in the case of a CRNA coordinated practice, how do they even accommodate hiring an AA when the requirement is for them to practice in conjunction with a physician. It's not that call schedules and coverage can't be worked out, but why even bother when you can hire or partner with another CRNA and have an all weather anesthetist. That's not a skill issue I'm talking about, but one pertaining to regulation. As an AA, you might not even be able to do things like partner in a practice like a CRNA can.

That comment about AAs not being hired because CRNAs aren't advicating for them makes sense, not from a maliciousness on the part of NAs, but simply because they are familiar with nurses and want to stick to what they know.

 

[JoBreeze]

...managing patients on vents...

 

[pamac]

If every AA applicant were required to be an RT in a previous career, then that would be a good arguement that they are the ones doing the most "managing patients on vents". Since that's not the case, then I'd argue that an RN with a vented patient does more "managing" than your typical AA student did prior to school.... The OP that hails from public health, for instance. It's hard to go to a CRNA school website and not trip over a statement saying that critical care experience is necessary for applicants. Mention of HCE requirements are nowhere to be found on any of the AA school sites I looked at. Maybe I didn't look hard enough.

 

[deleted6669]

If every AA applicant were required to be an RT in a previous career, then that would be a good arguement that they are the ones doing the most "managing patients on vents". Since that's not the case, then I'd argue that an RN with a vented patient does more "managing" than your typical AA student did prior to school.... The OP that hails from public health, for instance. It's hard to go to a CRNA school website and not trip over a statement saying that critical care experience is necessary for applicants. Mention of HCE requirements are nowhere to be found on any of the AA school sites I looked at. Maybe I didn't look hard enough.

there are still a handful of programs that will accept er nurses without icu experience. I know a few who have gone this route.

 

[pamac]

there are still a handful of programs that will accept er nurses without icu experience. I know a few who have gone this route.

plenty of ER experiences mirror critical care. we float icu nurses to ER all the time, and often ahead of an admit on a critical patient.

 

[deleted6669]

plenty of ER experiences mirror critical care. we float icu nurses to ER all the time, and often ahead of an admit on a critical patient.

ICU nurses are great once the pt is stabilized, lines in, etc.
I find with the newly presenting acute pts that the er nurses are more on top of their game than the icu nurses floating to the er.
but yes, I agree. lots of critical care in the ER. we frequently have folks on multiple drips, vented, etc awaiting an icu bed as we board them for X hrs or days...in a hallway....

 

[pamac]

ICU nurses are great once the pt is stabilized, lines in, etc.
I find with the newly presenting acute pts that the er nurses are more on top of their game than the icu nurses floating to the er.
but yes, I agree. lots of critical care in the ER. we frequently have folks on multiple drips, vented, etc awaiting an icu bed as we board them for X hrs or days...in a hallway....

the reason we have ICU float down is because directors saw it the other way around... ER nurses used to dealing with folks that should be seen in the minute clinic don't have familiarity with the drugs and lines for the wait once stabilized.

but in any event, im not on a CRNA admissions board, so i can't say why they extend the olive branch out to ER nurses. even critical care complexity varies from facility to facilty, so i don't see how they wade through the applicants and see who was taking care of the rough patients at one facility vs the ones at the rural places that ship all but the easy ones.

 

[deleted6669]

the reason we have ICU float down is because directors saw it the other way around... ER nurses used to dealing with folks that should be seen in the minute clinic don't have familiarity with the drugs and lines for the wait once stabilized.
.

probably site specific. our er if very high acuity with lots of admits. regional stroke/trauma/cardiac referral center, etc, 80-100k pts/yr at our main facility and 30k or so at our satellite facility.
we have icu nurses who float to the er who won't start IV's because they expect the IV therapy team to do all of them (and it seems like they have forgotten how)
er nurses think more like medics: prioritize, and get pts stabilized.
icu nurses are great with the vents, weird drips, etc and are much more "academic" but less ready to jump on a coding pt who is not intubated and does not yet have any iv/io access.

 

[PrinceVersed]

probably site specific. our er if very high acuity with lots of admits. regional stroke/trauma/cardiac referral center, etc, 80-100k pts/yr at our main facility and 30k or so at our satellite facility.
we have icu nurses who float to the er who won't start IV's because they expect the IV therapy team to do all of them (and it seems like they have forgotten how)
er nurses think more like medics: prioritize, and get pts stabilized.
icu nurses are great with the vents, weird drips, etc and are much more "academic" but less ready to jump on a coding pt who is not intubated and does not yet have any iv/io access.

ER nurses and IV's...If would have gotten another pt that had a 20g in their AC that occluded every time they bent their arm... I probably would have killed everyone in that dept. Thankfully, I don't have to deal with that much anymore...pts spontaneously moving that is.

 

[deleted6669]

ER nurses and IV's...If would have gotten another pt that had a 20g in their AC that occluded every time they bent their arm... I probably would have killed everyone in that dept. Thankfully, I don't have to deal with that much anymore...pts spontaneously moving that is.

a friend of mine became a crna for the same reason. he was an er nurse for many years and one day decided he was tired of pts who could talk back....

 

[pamac]

probably site specific. our er if very high acuity with lots of admits. regional stroke/trauma/cardiac referral center, etc, 80-100k pts/yr at our main facility and 30k or so at our satellite facility.
we have icu nurses who float to the er who won't start IV's because they expect the IV therapy team to do all of them (and it seems like they have forgotten how)
er nurses think more like medics: prioritize, and get pts stabilized.
icu nurses are great with the vents, weird drips, etc and are much more "academic" but less ready to jump on a coding pt who is not intubated and does not yet have any iv/io access.

IV start team? We don't play ball that way, but i do hear icu nurses talk about how their skills in that realm are rusty just by the nature of not placing IVs every 30 minutes. I have skills with the needle due to my third tier lab experience. Realized the other day that I didn't need to spare the easy to hit veins for the nurse to use to place an IV because... I'm the nurse placing the IV.

But it doesnt surprise me that a nurse would take a step back to let someone more familiar with a process provide appropriate care. Sounds like if you have the luxury of an IV start team, then someone among the powers that be is/has been making the push to have people play to their strengths in the name of efficiency in some form or another. In other words, that's more of a tacit admission that admin wants icu to spend time worrying about X and Y rather than taking time placing IVs.

 

[steiner2]

Is there such a difference as a PA who specializes in anesthesia and an AA? Do they have the same pay and privileges? I don't know why AAs are considered beneath a CRNA.

 

[Denatured]

Is there such a difference as a PA who specializes in anesthesia and an AA? Do they have the same pay and privileges? I don't know why AAs are considered beneath a CRNA.

PAs can't do anesthesia. We are generalist and receive practically no training. However, I think there are something like 2 PAs in anesthesia in the VA system from before that was established.

Several reasons, whether good or not, are having ICU nursing experience which allows them to spend more time on advanced concepts rather than learning EKG/IVs/foleys/drug names, AA can take boards 180 days before graduation (I have not personally verified that but never have seen it disputed), and never being able to practice without an anesthesiologist in the building legally. In practices that employ both, however, they will be treated the same.