Let me first say that I am not, nor have I ever been, in favor of independent practice for CRNAs. I know a lot of my detractors think I am. Thus I come to the MD vs CRNA argument with the general understanding that physician anesthesiologists should, in general, oversee the work of their “midlevels”. The problem is that I suspect that even if the independent practice issue, which is mostly coming from the CRNA governing societies, not individual CRNAs, were off the table, the battle would still rage. And now I think I know why. In the world of anesthesia politics something odd is going on. While opposition to CRNAs among physicians is vocal and strident in the upper echelons of the high mucky-mucks in the American Society of Anesthesiologists (ASA), state societies of anesthesia are being encouraged to welcome another group of “midlevels”: Anesthesia Assistants.
What is an AA, exactly?
Here is what the AAAA (American Academy of Anesthesiologist Assistants, of course) says in their career flyer:
Anesthesiologist Assistants are highly educated allied health professionals who work under the direction of licensed anesthesiologists to develop and implement anesthesia care plans. AAs work exclusively within the Anesthesia Care Team environment as described by the ASA. AAs are trained extensively in the delivery and maintenance of quality anesthesia care as well as advanced patient monitoring techniques.
Ah. So, they’re like CRNAs. What’s the difference? AA programs are based on a masters degree model. So are CRNA programs. AA programs require two full academic years and accepts students who have prior education in the sciences. So do CRNA programs. Let’s see, what else… physiology, pharmacology, anatomy, biochemistry, patient monitoring, life support, patient assessment… Yup. All the same. However, there is a significant difference: AA programs typically require a bachelor’s degree with all the premed requirements, and the MCAT (or GRE, for the faint of heart). CRNA programs require a background in critical care nursing and a bachelor’s degree in nursing or related field.
Anesthesia Assistants are trained under the prevailing medical model, while CRNAs are trained from the nursing side. AAs, therefore, are under the umbrella of medical certification, and indeed the certifying exam for AAs is administered and scored by the National Board of Medical Examiners. CRNAs are certified by their own organization, and as such are separate from the dictates of medical societies.
AAs and CRNAs do the same work. Yet no one is yelling about AAs taking over physician anesthesiologist jobs. You see, AA societies are much more controllable by state medical societies, and AAAA would never, ever, suggest independent practice. AAs are firmly on the doctors’ side, since sides are being taken. According to the most recent issue of the ASA newsletter, the Ohio Society of Anesthesiologists voted in September of 2012 to include AAs as members. Here’s what Dr. Basem Abdelmalak, OSA president, said:
“When we met with the Ohio AAs, we found that we share the same passion for excellent care.”
(OK, but CRNAs have the same passion for excellent care.) He continues:
“We have the same understanding and expectations of the anesthesia care team model and the roles of different members of the team under the direction of the physician anesthesiologist.”
Bingo. Those Anesthesia Assistants are speaking Dr. Abdelmalak’s language. CRNAs are not. That’s the problem. That’s why the fight continues. That’s why sides are being taken and barricades built.
I call on the ASA and the AANA (American Association of Nurse Anesthetists) to sit down with each other and create a common language. Medicine and Nursing should not be on opposite sides of anything. We should all be working together.