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    Anesthesiologist Assistants Alluding to Independent Practice

    In the recent second quarter Anesthesiologist Assistant (AA) newsletter a very interesting article appeared by AA program director of the Quinnipiac program William Paulsen entitled “Are Anesthesiologist Assistants really equivalent to Nurse Anesthetists (CRNAs)?”. He had a lot to say about Nurse Anesthetists and AAs in this article.

    Some of the most interesting quotes from him as pasted below with my commentary afterward:

    “Why would anyone hire an AA if they were only equivalent to a nurse anesthetist in the operating room during the day? Nurses offer billing advantages, call advantages and the ability to provide services to a broader range of patients if you include plastic surgery of*fices and dental offi*ces to name a few. Why would physician anesthesiologists raise the money to enter a legislative battle to have AAs licensed or registered in their state?”

    In this quote Mr Paulsen makes it clear that the advantages of CRNAs in providing expansion of care to rural areas as well as urban areas are significant whereas AAs cannot work in these areas without an Anesthesiologist which becomes cost prohibitive. He relates how CRNAs can take call independently and that even in a practice with Anesthesiologists CRNAs provide greater value and flexibility. Obviously there is a significant disincentive to hiring and advocating for AAs in any practice and in many they cannot exist at all as they limit the service to surgeons, hospitals and patients by their very nature.

    It does not take a genius to see what the solution to this conundrum would be for AAs. After all, they are told (as this article states) that they are “as good as Nurse Anesthetists” at every turn. They tell each other that, indoctrinate their students with the idea and the American Society of Anesthesiologists also advocates this statement. It does not take a leap of faith to see that if a CRNA can do all these things that AAs cannot due to being shackled by the requirement to work directly with an Anesthesiologist so too can an AA? Right? This is not complicated logic at all.

    Although Mr Paulsen falls just short of stating that AAs should also be able to work the way a CRNA can, he clearly alludes to this injustice. Of course he cannot say anything which would suggest an AA could work without an Anesthesiologist as it would likely result in professional suicide. Why is this? Simple. AAs would then also become competitors for anesthesia dollars against Anesthesiologists as well. Since AAs were created to be dependent providers working only under an anesthesiologist (including the word ‘assistant’ within their professional title) anything which would eliminate the financial and professional protection benefits which AAs confer to the Anesthesiologists they work for would be blasphemy. Mr Paulsen explains the sole reason why Anesthesiologist would hire an AA over a CRNA in the quote below:

    “The answer could be that they (Anesthesiologist) are looking for who will maintain the profession of anesthesiology rather than letting the profession fall to nurse anesthesia.”

    This statement is the crux of the article and in it Mr Paulsen makes it clear that the reason Anesthesiologists seek to bring AAs into a state and hire them is entirely for political gain and guild protectionism. He clearly shows that AAs cannot expand access to care, are not a fiscally responsible option and are not as flexible even within a practice with Anesthesiologists as a CRNA is.

    Well, unless of course they are independent as well. Right?

    The ASA will eventually experience a revolution from their dependent assistants. It is coming and this is not the first time we are hearing it (AA who sued in Ohio to expand their practice or the bill in NM to allow them to work without an MDA present). They have created their own Trojan horse, brought it into their homes and perpetually equate them to Nurse Anesthetists. Will they really be surprised when they fight to have the same rights as CRNAs?
    Comments 22 Comments
    1. Anesthesinator's Avatar
      Anesthesinator -
      Great post.


      Sent from my iPhone using Tapatalk
    1. jwk's Avatar
      jwk -
      That depends on your perspective. The author (Mike?) reads a lot into this article that simply isn't there - especially the title of the thread.
    1. gaspass3's Avatar
      gaspass3 -
      Quote Originally Posted by jwk View Post
      That depends on your perspective. The author (Mike?) reads a lot into this article that simply isn't there - especially the title of the thread.

      Well, if you don't buy Mike's position and perspective, than the only reasonable conclusion is the AA interviewed for the original article knows and admits AAs are simply not interchangeable with CRNAs. Makes sense.
    1. jwk's Avatar
      jwk -
      You know I never buy Mike's position and perspective - but he feels the same way about me so it's OK.

      Bill Paulsen, the author of this op-ed piece, is a PhD and AA program director and is one of the original AA's from more than 40 years ago. He's raising questions intended to be the subject of discussion in our profession. Nowhere does it allude to independent practice. I think it's interesting that that tidbit was fabricated out of the article by Mike or whoever wrote it, yet the comments about us being better trained than nurse anesthetists went untouched - you would think that would be much more thought provoking on your end. And as I've noted in the past, the original intent behind those who authored the AA concept in the 70's was to develop a professional that would function at a level in between the level of CRNA and anesthesiologist at a time when anesthesia technology was evolving so fast that few could keep up. The instrumentation and monitoring coursework continues to this day. Along the way, the profession moved from a specialty PA (as envisioned by the IOM) to a wholly separate professional, the AA.
    1. subee's Avatar
      subee -
      Oooooh. Can't wait to see ASA reaction to this.
    1. MmacFN's Avatar
      MmacFN -
      This is true but i still love yah :P


      It is the undertone of his writing. Clearly he posits that in order to be equal to a CRNA AAs must move forward from where they are. I didnt comment on the "better training" because frankly its laughable. It is clear that AAs do not get "better training". How do i know?

      - Regional not taught in most schools
      - Independent practice not taught at all.
      - Focus is on "assistant" and always to call an MDA for everything untoward
      - AAs count hours by the hour not by the face to face time doing actual anesthesia as CRNAs do. Due to this CRNAs get MANY MANY more anesthesia hours than AAs and the quotes of AA clinical time (same as MDAs) are highly bloated because they include more than actual anesthesia time.
      - Critical thinking not focused on in AA school as their are considered "technicians" and "extenders" of the MDA. No need to critically think just dial the MDA. Afterall an MDA who worked with AAs told me that when it comes to AAs "independent thinking hurts the team".

      Quote Originally Posted by jwk View Post
      You know I never buy Mike's position and perspective - but he feels the same way about me so it's OK.

      Bill Paulsen, the author of this op-ed piece, is a PhD and AA program director and is one of the original AA's from more than 40 years ago. He's raising questions intended to be the subject of discussion in our profession. Nowhere does it allude to independent practice. I think it's interesting that that tidbit was fabricated out of the article by Mike or whoever wrote it, yet the comments about us being better trained than nurse anesthetists went untouched - you would think that would be much more thought provoking on your end. And as I've noted in the past, the original intent behind those who authored the AA concept in the 70's was to develop a professional that would function at a level in between the level of CRNA and anesthesiologist at a time when anesthesia technology was evolving so fast that few could keep up. The instrumentation and monitoring coursework continues to this day. Along the way, the profession moved from a specialty PA (as envisioned by the IOM) to a wholly separate professional, the AA.
    1. acnp-crna's Avatar
      acnp-crna -
      I'll be glad to comment on the article. What I read was a call to his colleagues to scheme up this plan to pretend AAs are some kind of class of anesthesia providers that are somewhere in the middle of the road between CRNA and MDA. That is laughable. He kept alluding to better training and more hours. Ha. I completed my CRNA training with 4200 clinical hours and 3200 anesthesia hours with over 1600 cases (low when compared to most programs). This clinical time being spread out across a multitude of clinical sites. Including rural independent CRNA sites, 4:1 ACT, supervision, and some sites where crnas and Mdas do their own cases and bill indy. Over 200 blocks, chronic pain, perioperative, ER, and acute ICU management. I've done everything from colonoscopies to heart transplants including placing and interpreting TEEs (only allowed at one site).

      So don't tell me you are equal or better trained when you're spending time in your 27 month program learning medical terminology and medical word formation (Anes 505 at Emory). Or that you have better clinical training which at all times must be performed under the thumb of an MDA. The worst clinical rotation I experienced was in an academic setting (where AAs are mainly employed) because there is zero critical thinking and zero autonomy. I was nothing more than a body in the OR following the every instruction of an MDA.

      I met an AA 3 weeks ago who was in town visiting family. I was wearing scrubs and she came up to talk to me at Restaurant. She introduced herself as a CRNA. After inquiring, she said she was actually an AA but "they're basically the same" and how she wished she could be licensed in my state to work. Now why would she say she was a Crna? Because it holds a higher position of respect than an assistant? Most likely. But if AAs are better like Paulsen says then why not own it?

      I'll get off my soap box. Bill Paulsen can circle jerk the AAAA and blow smoke all he wants. At the end of the day, AAs are just bodies in the OR waiting for someone to tell them what to do.
    1. jwk's Avatar
      jwk -
      Quote Originally Posted by MmacFN View Post
      This is true but i still love yah :P


      It is the undertone of his writing. Clearly he posits that in order to be equal to a CRNA AAs must move forward from where they are. I didnt comment on the "better training" because frankly its laughable. It is clear that AAs do not get "better training". How do i know?

      - Regional not taught in most schools
      - Independent practice not taught at all.
      - Focus is on "assistant" and always to call an MDA for everything untoward
      - AAs count hours by the hour not by the face to face time doing actual anesthesia as CRNAs do. Due to this CRNAs get MANY MANY more anesthesia hours than AAs and the quotes of AA clinical time (same as MDAs) are highly bloated because they include more than actual anesthesia time.
      - Critical thinking not focused on in AA school as their are considered "technicians" and "extenders" of the MDA. No need to critically think just dial the MDA. Afterall an MDA who worked with AAs told me that when it comes to AAs "independent thinking hurts the team".
      We'll never agree on the above - your points are as laughable to me as you think the "better training" comments are in Bill's article.
    1. jwk's Avatar
      jwk -
      Quote Originally Posted by acnp-srna View Post

      I met an AA 3 weeks ago who was in town visiting family. I was wearing scrubs and she came up to talk to me at Restaurant. She introduced herself as a CRNA. After inquiring, she said she was actually an AA but "they're basically the same" and how she wished she could be licensed in my state to work. Now why would she say she was a Crna? Because it holds a higher position of respect than an assistant? Most likely. But if AAs are better like Paulsen says then why not own it?

      I'll get off my soap box. Bill Paulsen can circle jerk the AAAA and blow smoke all he wants.
      Ah, such a professional adult perspective.

      And I'll call BS on the AA saying they were a CRNA.

      You wear scrubs out to eat? Seriously?
    1. ethernaut's Avatar
      ethernaut -
      Quote Originally Posted by jwk View Post

      You wear scrubs out to eat? Seriously?
      Clean or dirty, I'm with ya here.
    1. My_brain_hurts's Avatar
      My_brain_hurts -
      I would like to say that any time anyone is left alone in the OR, there is some level of critical thinking that has to take place. Sure, you can call the 'ologist for this or that, but how long does that take? how many rooms are they "supervising"?

      I think saying that AAs are warm bodies in the OR, waiting to be told what to do is just a tad harsh and uncalled for. Remember your first time alone in the OR? I remember mine. I didn't know a whole lot, but I damn well sure was using all the critical thinking skills I had at the time. Sure you can call for assistance/guidance/help, and it will maybe be there in 5 to 10mins, which is an eternity when the pt needs your attention AT THAT MOMENT. To say they are simply standing around waiting to be told what to do is kind of ridiculous to me.

      Let the harsh comments telling me how wrong I am begin! (I'm logging off and may just not ready any of them. . . so there!)
    1. MmacFN's Avatar
      MmacFN -
      You may consider them laughable and you are entitled to your own opinion but NOT your own facts. These are facts.

      Quote Originally Posted by jwk View Post
      We'll never agree on the above - your points are as laughable to me as you think the "better training" comments are in Bill's article.
    1. Bad Apple's Avatar
      Bad Apple -
      I once knew a CRNA who wore scrubs nearly everywhere, including on his days off. He explained that it is a way to avoid buying clothes and having to decide what to wear, "ha ha ha". I thought it was positively bizarre. Imagine getting up on Saturday morning and putting on scrubs -- not to go to work, but to go to the grocery store, the post office, and the car wash. I'm not sure if it was due to his pathological cheapness or a play for attention in public. Probably both.
    1. acnp-crna's Avatar
      acnp-crna -
      Probably both. Personally I love scrubs because they are free and comfy. If I wore pajamas to the grocery store then people would assume I'm a poor slob. But if I wear scrub bottoms, then people assume I'm important. I mean...it's a win-win.
    1. jwk's Avatar
      jwk -
      Quote Originally Posted by MmacFN View Post
      You may consider them laughable and you are entitled to your own opinion but NOT your own facts. These are facts.
      You're simply wrong Mike - just because it's YOUR opinion doesn't mean they are factual.

      AA's get far more training and exposure to regional anesthesia than in the past. I've done enough spinals to last a lifetime. Procedures are largely practice dependent. Just like in CRNA programs, much of what is taught depends on where a student has their clinical rotations. We have some that are block/regional heavy, some that aren't. In the end, if a given practice wants their anesthetists to do blocks, regionals, or central lines, they can do it - like any other practitioner, MD, AA, or CRNA, they are going to have to demonstrate that they are proficient in a given technique before they're allowed to do it without someone watching over them.

      Independent practice - I know that's your personal favorite - but in the end, I practice just the same as tens of thousands of CRNA's working in anesthesia care team practices every day. Are there CRNA's in independent or "collaborative" (cool word y'all love) practices? Of course. Are they the majority? No. You beat that independent practice drum constantly, but reality is a different animal. By all means - practice independently, because AA's are ready to step into the vacancies created by those leaving to be on their own.

      Our educational model is not focused on being an assistant. It's focused on being an anesthetist. You, perhaps better informed than many, understand the seven rules of TEFRA, as do I. Last I checked, it doesn't specify "call the anesthesiologist" for each deviation from baseline. During the case, as you know, the anesthesiologist is to be present for induction, emergence, and check in at intervals during the case. The regs aren't really any more specific than that. I will indeed call when the need arises. I know you are and always have been hung up on and ridiculed the "assistant" part of our title. That's really your problem to deal with - but again, reality is a little different (actually a lot) than what you imagine. Oh, I know, you've met someone who claims their sister's best friends husband was an AA dying to be a CRNA. Spare me.

      I don't keep up with the latest numbers on clinical hours and cases, but clearly we don't obsess about it quite to the extent you do. I'm sure the programs could give you numbers - feel free to contact them. I know the students keep a case log. Their rotations can be adjusted or emphasis at a given clinical site can be changed if they need more cases or procedures in a given area. Students will get several hundred hours of clinical time during their first year, and are full-time in the OR the senior year. Full time generally implies at least a 40hr work week, if not more, and depending on the rotation, students may be on call. I know in my practice, where we may have as many as 15 AA and CRNA students on a given day, students are assigned to a room with an anesthetist and are in that room for the day doing whatever case comes in that room. If the room finishes early, they go work with someone else. Students fortunate enough to be at my facility benefit from a fast-paced private practice, so they might do more cases in a day or two than others do in a week in an academic locale - I suspect the situation is similar for CRNA students.

      Critical thinking is a given - for you to think otherwise, once again, is your fantasy, not reality. Just because someone has an anesthesiologist backing them up doesn't mean they're not capable of critical thinking.

      We agree to disagree - at least some on here are capable of some semblance of independent thought rather than simply toeing the party line - and others wear their scrubs out to dinner. (sorry, ya gotta admit that's pretty lame )
    1. stanman1968's Avatar
      stanman1968 -
      The article is quite clear, there is no benifit to using aa services, none. The only benifit is a workforce that will ensure the survival of "medical anesthesia", or to put it another way, "to keep things the way they have always been."
      Hardly a foundation for any profession.
    1. MmacFN's Avatar
      MmacFN -
      Well i could go line by line here are rebut but that isnt going to change your mind

      We can always agree to disagree and at the end of the day I enjoy our conversations and would drink beer with you anyday!


      Quote Originally Posted by jwk View Post
      You're simply wrong Mike - just because it's YOUR opinion doesn't mean they are factual.

      AA's get far more training and exposure to regional anesthesia than in the past. I've done enough spinals to last a lifetime. Procedures are largely practice dependent. Just like in CRNA programs, much of what is taught depends on where a student has their clinical rotations. We have some that are block/regional heavy, some that aren't. In the end, if a given practice wants their anesthetists to do blocks, regionals, or central lines, they can do it - like any other practitioner, MD, AA, or CRNA, they are going to have to demonstrate that they are proficient in a given technique before they're allowed to do it without someone watching over them.

      Independent practice - I know that's your personal favorite - but in the end, I practice just the same as tens of thousands of CRNA's working in anesthesia care team practices every day. Are there CRNA's in independent or "collaborative" (cool word y'all love) practices? Of course. Are they the majority? No. You beat that independent practice drum constantly, but reality is a different animal. By all means - practice independently, because AA's are ready to step into the vacancies created by those leaving to be on their own.

      Our educational model is not focused on being an assistant. It's focused on being an anesthetist. You, perhaps better informed than many, understand the seven rules of TEFRA, as do I. Last I checked, it doesn't specify "call the anesthesiologist" for each deviation from baseline. During the case, as you know, the anesthesiologist is to be present for induction, emergence, and check in at intervals during the case. The regs aren't really any more specific than that. I will indeed call when the need arises. I know you are and always have been hung up on and ridiculed the "assistant" part of our title. That's really your problem to deal with - but again, reality is a little different (actually a lot) than what you imagine. Oh, I know, you've met someone who claims their sister's best friends husband was an AA dying to be a CRNA. Spare me.

      I don't keep up with the latest numbers on clinical hours and cases, but clearly we don't obsess about it quite to the extent you do. I'm sure the programs could give you numbers - feel free to contact them. I know the students keep a case log. Their rotations can be adjusted or emphasis at a given clinical site can be changed if they need more cases or procedures in a given area. Students will get several hundred hours of clinical time during their first year, and are full-time in the OR the senior year. Full time generally implies at least a 40hr work week, if not more, and depending on the rotation, students may be on call. I know in my practice, where we may have as many as 15 AA and CRNA students on a given day, students are assigned to a room with an anesthetist and are in that room for the day doing whatever case comes in that room. If the room finishes early, they go work with someone else. Students fortunate enough to be at my facility benefit from a fast-paced private practice, so they might do more cases in a day or two than others do in a week in an academic locale - I suspect the situation is similar for CRNA students.

      Critical thinking is a given - for you to think otherwise, once again, is your fantasy, not reality. Just because someone has an anesthesiologist backing them up doesn't mean they're not capable of critical thinking.

      We agree to disagree - at least some on here are capable of some semblance of independent thought rather than simply toeing the party line - and others wear their scrubs out to dinner. (sorry, ya gotta admit that's pretty lame )
    1. jwk's Avatar
      jwk -
      Quote Originally Posted by MmacFN View Post
      Well i could go line by line here are rebut but that isnt going to change your mind

      We can always agree to disagree and at the end of the day I enjoy our conversations and would drink beer with you anyday!
      C'mon man, you at least have to give me an AMEN on the scrubs at a restaurant for dinner.
    1. MmacFN's Avatar
      MmacFN -
      AMEN brothah!!

      Quote Originally Posted by jwk View Post
      C'mon man, you at least have to give me an AMEN on the scrubs at a restaurant for dinner.
    1. acnp-crna's Avatar
      acnp-crna -
      Oh come on fellas. It was Subway on the way home from work. Not like it was Ruth's Chris.