Updated Fact Sheet Regarding
Anesthesiologist Assistants (AAs)

July 2003

• Two educational programs for AAs: One program is located at Emory University in Atlanta, Georgia; the other program is located at Case Western Reserve University in Cleveland, Ohio.

• Admission to AA programs: An applicant must possess a bachelor's degree. Many types of majors are acceptable for admission, although traditional premedical courses such as biology, chemistry, physics, and math are essential.

• Applicants to Emory must take the GRE; taking the MCAT (Medical College Admission Test) examination is optional. Case Western requires applicants to take the MCAT examination; it won’t accept any other test. Case Western requires a minimum GPA of 2.75; it claims entering average GPAs range from 3.2 to 3.4.

• Emory program: This program consists of seven consecutive semesters, i.e., 2.2 years. Case Western: This program is two years long, consisting of six semesters of classroom and clinical instruction.

• Emory program: The first semester is composed of classroom and laboratory-based teaching. Each successive semester incorporates escalating clinical duties and responsibilities until semesters five through seven, which are mainly clinical rotations in several areas of anesthesia practice. Students learn to administer all types of anesthesia, except regional anesthesia. Although the program provides the anatomic and physiologic basis of regional anesthesia and students gain clinical experience managing patients who have received regional anesthesia, the program does not provide clinical instruction in the administration of regional anesthesia. Emory program materials state that if an employer wants an Emory graduate to administer regional anesthesia, the anesthesiologist may train the graduate in regional techniques and request that privileges be granted, as necessary, based upon the anesthesiologist's documentation of "competence." This is presumably a reference to the AA's competence, rather than the anesthesiologist's. Case Western’s program materials say clinical training focuses on all types of anesthesia, including general, epidural, spinal and peripheral nerve blockade.

• Case Western materials state that during their last three semesters, students complete month-long rotations in all subspecialties of anesthesiology, including ambulatory surgery, burns and trauma, cardiothoracic surgery, general surgery, neurosurgery, obstetrics, pediatrics, surgical intensive care unit, and pain service. Emory also states that it has students go through clinical rotations in all subspecialty areas of anesthesia practice, such as pediatrics and obstetrics.

• Both the Case Western and Emory programs graduate AAs with a master's degree.

• AA educational programs are accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP), located in Chicago, Illinois.

• The Association for Anesthesiologist Assistant Education (AAAE) is a sponsoring organization of the CAAHEP. Its Web site is: www.aaaehq.org. This organization, consisting of anesthesiologists, participates in the AA program accreditation process. It states that it has a “three-fold vision,” including: (1)“Increased capacity for AA Education”; (2) “Anesthesiologist-Directed Patient Care when given by Non-physician Providers”; and (3) “Favorable National and State Regulations Which Enable Practice Groups to Employ AAs.”

• Case Western and Emory graduates may take a national certification examination sponsored by the National Commission for Certification of Anesthesiologist Assistants (NCCAA), located in Atlanta. Graduates who pass the exam are designated Anesthesiologist Assistant -- Certified (AA-C). Certified AAs must submit continuing education credits biennially (every two years) for certification renewal and must successfully complete a “Continued Demonstration of Qualifications” examination every six years.

• Case Western and Emory students may also take the NCCAA certification examination up to 180 days before graduation. The current NCCAA rules and regulations state, "The candidate must be a student in good standing in a formal educational program … who will be graduated from that educational program within 180 days immediately following the date of the Certifying Examination." Scores can be released immediately after the NCCAA has received documentation of the student's graduation.

Number of AAs

• Emory: In 1999, the Emory Web site said that as of August 1996, there were 370 graduates from Emory from 26 classes, with the first class graduating in 1971. In 2003, the Web site said that, in the past five years, there were about 24 to 32 students in each Emory class.

• Emory: In 1999, the Emory Web site said about 10 to 15 percent of its graduates have gone on to medical school, most as anesthesiology residents.

• Case Western: This program began in 1969. For many years, the program only graduated a handful of students every year. It now reports that it has 20 to 26 students enrolled in the program at any given time, with each class having from 12 to 14 students.

• The 2003 Emory Web site said that there are approximately 545 AA "graduates delivering anesthesia under the direction of a qualified anesthesiologist." It is unclear whether the Web site is referring to Emory graduates only, or to all practicing AAs.

• The March 2003 ASA Newsletter reported that there are fewer than 600 practicing AAs.

Distinguishing Between AAs and PAs

• Most AAs are not educated, trained, or certified as Physician Assistants (PAs).

• PAs have a generalist education and often move among specialties; AAs don’t have a generalist education and are only trained to deliver anesthesia care as part of the "anesthesia care team" under anesthesiologist direction. PAs attend one of over 130 accredited PA educational programs. AAs attend either Case Western or Emory.

• PAs and AAs sit for different national certification examinations. PA exam: This exam was developed by the National Commission on Certification of Physician Assistants (NCCPA). AA exam: This exam was developed by the National Commission for Certification of Anesthesiologist Assistants (NCCAA).

• PAs have explicit statutory and/or regulatory recognition in every state. AAs have explicit recognition in fewer than 10 states.

• See the American Academy of Physician Assistants (AAPA) document: "Physician Assistants and Anesthesiologists Assistants: The Distinctions." The Academy’s Web site address is: www.aapa.org.

• The national organization for AAs is the American Academy of Anesthesiologist Assistants (AAAA); its Web site is: www.anesthetist.org. This Web site has links to Web sites for the Case Western and Emory AA educational programs.

• Approximately 40 AAs have also been trained as PAs, and it’s estimated that those 40 AA/PAs practice in about 17 states.

• The Emory Web site now refers to its program as the "Anesthesiology Physicians Assistants Program." Emory explains that although the original term for graduates was “Anesthesiologist Assistant,” “[g]raduates function in a role more commonly described as physician extenders or anesthesiology physician assistants. . . .” However, Emory notes that confusion may arise from the term “Anesthesiologist Physician Assistant,” and the term “Physician Assistant” is frequently associated with primary care medicine physician assistants in the minds of state boards of medicine, practicing physicians, the AAPA, and some of the public. Consequently, the Emory program refers to its graduates as "AAs/APAs" (Anesthesiologist Assistants/Anesthesiology Physician Assistants).

• The AAPA is opposed to states characterizing AAs as a kind of PA.

Status In The States

• AAs are explicitly mentioned in laws in Alabama, Kentucky, Missouri, New Mexico, Ohio, South Carolina, and Vermont. (Missouri’s recently enacted law will go into effect on August 28, 2003.) AAs are mentioned in board of medicine rules or regulations in Alabama, Florida, Georgia, Kentucky, New Mexico, and Ohio. In addition, the Texas State Board of Medical Examiners has guidelines for AA practice.

• A March 2001 ASA Newsletter article by a member of the ASA's Committee on Governmental Affairs stated that AAs "are able to practice in" Alabama, Georgia, Michigan, New Mexico, Ohio, Texas, Vermont, and Wisconsin. The article also stated that Colorado, Illinois, Kentucky, New York, and Oklahoma "are considering the role of AAs in their state, but acceptance of this form of physician extender is not guaranteed." Since the ASA article appeared, the laws in Missouri and South Carolina recognizing AAs were enacted. In addition, varying sources have contended that some AAs are practicing in New Hampshire, Washington state, and West Virginia as well.

• To the best of our knowledge and research, AAs are not explicitly recognized by statute or regulation in Colorado, Illinois, Michigan, New Hampshire, New York, Oklahoma, West Virginia, and Wisconsin. That would mean that, to legally practice, AAs would need to practice pursuant to physician delegation provisions in these states' laws and/or regulations. The AANA has not confirmed whether AAs may legally practice in these states pursuant to physician delegation.

• In sum, it appears that AAs are practicing in no more than 14 to 18 states. In some of those states, though, the AAs are also PAs and practicing via PA laws and/or regulations rather than legal authority explicitly recognizing AAs by name. There are clearly still only about nine states that mention AAs by name in laws or regulations (plus Texas, which mentions AAs in medical board guidelines). The legality of practice in additional states may be questionable.

• In Alabama, AAs are categorized as one of two types of “assistants to physicians”; PAs are the second category of “assistants to physicians.” AAs are not required to possess PA educational and certification qualifications, and they must graduate from an AA program and pass the AA certification examination.

• In Florida and Kentucky, AAs are classified as a kind of PA; AAs must meet the educational and certification requirements for PAs and graduate from an AA educational program.

• In Georgia, AAs are classified under the Board of Medical Examiners’ rules as one of “three general categories of job descriptions for certification of Physician’s Assistants.”

• Unlike Florida and Kentucky, Georgia AAs don’t have to meet the educational or certification requirements that PAs possess. Georgia AAs graduate from an AA educational program and pass the AA certification examination.

• In Missouri, AAs are not classified as a kind of PA; they are not required to possess PA educational and certification requirements, and they must graduate from an AA program and pass the AA certification examination.

• In New Mexico, AAs are not classified as a kind of PA; they are not required to possess PA educational and certification requirements, and they must graduate from an AA program and pass the AA certification examination. However, the AA must be employed by a New Mexico university with a medical school.

• In Ohio, AAs are not classified as a kind of PA; they are not required to possess PA educational and certification qualifications, and they must graduate from an AA program and pass the AA certification examination.

• In South Carolina, AAs are not classified as a kind of PA; they are not required to possess PA educational and certification qualifications, and they must graduate from an AA program and pass the AA certification examination.

• In Vermont, AAs are not classified as a kind of PA; they are not required to possess PA educational and certification qualifications, and they must graduate from an AA program and pass the AA certification examination.

• In Texas, the State Board of Medical Examiners has issued "Guidelines for Anesthesiologist Assistant." The guidelines "suggest" that AAs have successfully completed an accredited AA educational program and pass the AA certification examination.

Supervision/Registration Ratios

• In Alabama, AAs are required to be registered to a supervising anesthesiologist approved by the Board of Medical Examiners. Alabama’s Board of Medical Examiners’ rules for AAs state: “An anesthesiologist may have registered to him or her not more than four (4) anesthesiologist assistants.” In addition, the rules provide, among other things, the following requirements for the “supervised practice” of an AA: (1) “a direct, continuing and close supervisory relationship” between the AA and the supervising anesthesiologist; (2) “[s]upervision does not, necessarily, require the constant physical presence of the supervising anesthesiologist . . . however, the anesthesiologist must remain readily available in the facility”; and (3) “[e]xcept in life-threatening situations,” the supervising anesthesiologist must be “readily available for personal supervision” and must be “responsible for pre-operative, intra-operative and post-operative care.” The rules also provide that an AA must administer anesthesia under the supervision of an anesthesiologist, and the supervising anesthesiologist must, at all times, be responsible for the AA’s activities.

• In Florida, the statute governing PAs states that a "physician may not supervise more than four currently licensed physician assistants at any one time." Florida PAs who administer general, spinal, and epidural anesthetics may only do so "under direct supervision," according to the Florida PA regulations. "Direct supervision" is defined as "the physical presence of the supervising physician on the premises so that the supervising physician is immediately available to the physician assistant when needed."

• In Georgia, the statute governing PAs provides, “No primary supervising physician shall have more than four physician’s assistants licensed to him or her at a time; provided, however, that no physician may supervise more than two physician’s assistants at any one time except as provided in paragraph (2) of this subsection.” Paragraph (2)(A) states, “A physician may supervise as many as four physician’s assistants at any one time while practicing in a group practice in which other physician members of such group practice are primary supervising physicians.” Paragraph (2)(B) allows a physician to supervise as many as four PAs at one time while acting as an “alternate supervising physician” in the following circumstances: “In an institutional setting such as a hospital or clinic;” “On call for a primary supervising physician or a group practice;” or “If otherwise approved by the board to act as an alternate supervising physician.” “Alternate supervising physician” essentially means a physician to whom the primary supervising physician has delegated the responsibility of supervising the PA.

• In Kentucky, the statute governing PAs provides that a supervising physician cannot supervise more than two PAs at any one time.

• In Missouri, the law recognizing AAs provides, “A supervising anesthesiologist shall be allowed to supervise up to four anesthesiologist assistants consistent with federal rules or regulations for reimbursement for anesthesia services.” The term “supervision” means “medical direction by an anesthesiologist of an anesthesiologist assistant as defined in conditions of 42 CFR 415.110 [Medicare conditions for payment for medically directed anesthesia services] which limits supervision to no more than four anesthesiologist assistants concurrently.”

Under 42 CFR 415.110, Medicare pays for an anesthesiologist’s medical direction of anesthesia services only if the anesthesiologist: (1) performs a preanesthetic examination and evaluation; (2) prescribes the anesthesia plan; (3) personally participates in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence; (4) ensures than any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual as defined in operating instructions; (5) monitors the course of anesthesia administration at frequent intervals; (6) remains physically present and available for immediate diagnosis and treatment of emergencies; and (7) provides indicated post-anesthesia care. In addition, the anesthesiologist must not perform any other services while he or she is directing the anesthesia service or concurrent anesthesia services. The anesthesiologist also must document in the patient’s medical record that the conditions set forth above have been satisfied, “specifically documenting that he or she performed the pre-anesthetic exam and evaluation, provided the indicated post-anesthesia care, and was present during the most demanding procedures, including induction and emergence where applicable.”

The Missouri law also states that AA program faculty members cannot concurrently supervise more than two AA students who are delivering anesthesia and that CRNAs “will be excluded from clinical education of anesthesiologist assistants.”

• In New Mexico, the law recognizing AAs states that the medical board shall adopt rules “establishing the number of anesthesiologist assistants a supervising anesthesiologist may supervise at one time, which number, except in emergency cases, shall not exceed three.” The medical board rules currently require that a supervising anesthesiologist shall not supervise more than two AAs at one time, except in emergencies. In addition, the law provides, “An anesthesiologist shall not supervise, except in emergency cases, more than four anesthesia providers if at least one anesthesia provider is an [AA].” The law and medical board rules also require enhanced supervision at the commencement of an AA’s practice. Finally, the law states that AA students providing anesthesia “shall be supervised on a one-to-one basis by an anesthesiologist who is continuously present in the operating room.”

• In Ohio, the law recognizing AAs does not include a supervision ratio, although it requires "enhanced supervision" of AAs during the first four years of practice. ("Enhanced supervision" is not defined in the law.) The medical board has adopted rules defining “enhanced supervision.”

• In South Carolina, “[a]n anesthesiologist may not supervise more than two anesthesiologist’s assistants at any one time.” The law also provides that two years after its effective date, the Board of Medical Examiners must evaluate the prohibition against an anesthesiologist supervising more than two AAs, and report its findings, including any recommendations for statutory revisions, to the Senate and House committees that deal with health issues.

• In Vermont, the law recognizing AAs does not include a supervision ratio. The law states that the “number of [AAs] permitted to practice under the direction and supervision of a physician shall be determined by the [medical] board after review of the system of care delivery in which the supervising anesthesiologist and [AAs] propose to practice.”

• In Texas, the “Guidelines for Anesthesiologist Assistant” state, “Except under emergency circumstances, the supervising anesthesiologist may not concurrently direct more than four anesthesia services or simultaneously supervise more than a combination of four (4) certified registered nurse anesthetists, AAs, or anesthesiology residents.”

Analyzing the Legality of AA Practice

• Conceptual framework: The analysis of whether an AA may legally practice in a state must take into account several factors. First, does the state have statutory or regulatory language that explicitly authorizes AAs to practice? If so, what are the parameters of that language, e.g., does the language restrict AA practice in some fashion?

• Secondly, is the AA also a PA by education and certification? (As noted previously, only about 40 AAs have reportedly also been trained as PAs.) If the AA is also a PA by education and certification, the analysis of the legality of the AA's practice in a particular state would have to take into account the PA statutory and/or regulatory provisions for that state; PA scope of practice provisions would be especially pertinent.

• What about an AA who is not a PA and wants to practice in a state where AAs are not explicitly mentioned in statutes or regulations? Unless there is a statutory or regulatory provision (such as physician delegation language) that could allow the AA to practice, he or she would arguably be engaging in the illegal practice of nursing or medicine.

• Delegatory powers of physicians vary from state to state. In some states, delegatory authority is barely mentioned, if at all. In other states, delegatory authority is quite broad; in others, it is quite narrow. To determine physician delegatory authority, one must carefully examine the state's medical practice act and board of medicine regulations. Delegation provisions may well appear in statutory or regulatory sections apart from those that deal with physician assistants.

• Texas is an example of a state that gives broad delegatory authority to physicians.

• The Texas Medical Practice Act allows physicians to delegate tasks to "qualified and properly trained" individuals acting under a physician's supervision. A delegated medical act must be one which a "reasonable and prudent physician would find is within the scope of sound medical judgment to delegate if, in the opinion of the delegating physician, the act can be properly and safely performed by the person to whom the medical act is delegated and the act is performed in its customary manner, not in violation of any other statute, and the person does not hold himself out to the public as being authorized to practice medicine.”

• In contrast, the following is an example of language that would give narrow delegatory authority to physicians.

• A state’s Medical Practice Act says that nothing in that act shall be construed “[t]o prohibit a licensed physician from delegating tasks to unlicensed personnel in his employ and on his premises if…the task is of a routine nature involving neither the special skill of a licensed person nor significant risk to the patient if improperly done….”

ASA Actions

• In August 2000, subject to ASA House of Delegates ratification, the ASA's Board of Directors approved a resolution that the ASA endorse efforts to obtain licensure and reimbursement for AAs. In October 2000, the House of Delegates adopted and it appears modified the resolution as follows: "That the American Society of Anesthesiologists endorse efforts to obtain licensure and reimbursement for anesthesiologists’ assistants practicing under the on-site medical direction of an anesthesiologist.” (ASA Newsletter, January 2001, Vol. 65, No. 1, and ASA Newsletter, October 2000, Volume 64, No. 10)

• A May 2003 ASA position paper concerning AAs reported: “In 2000 the ASA House of Delegates approved recommendations to endorse efforts to educate, train and allow for the practice of AAs in as many states as anesthesiologists request their services. That House of Delegates also approved a recommendation that ASA formally state its recognition of and support of AAs as a member of the Anesthesia Care Team and a resolution that ASA endorse efforts to obtain licensure and reimbursement for AAs. The 2001 House of Delegates approved a category of educational membership for AAs.” These ASA actions clearly signal the ASA’s desire to actively promote both licensure and education of AAs.

AA Salaries

• The Case Western Web site states that salaries "vary depending on the experience of the individual and the regional cost of living." The Web site says that the average starting salary for a newly graduated AA "is approximately $75,000 to $85,000 for a 40-hour work week plus benefits and consideration of on-call activity." The site also says that an increase of "approximately 10 to 20% should be expected after the first 1 to 2 years post graduation." (A 20 percent increase in salary would mean that AAs with one to two years of experience would be earning an average of $90,000 to $102,000.) Finally, the Web site states that AA salaries "are comparable to compensation paid to Certified Registered Nurse Anesthetists (CRNA) nationally."

Reimbursement

• Medicare: AAs are paid on the same basis as CRNAs, except that AAs must be anesthesiologist supervised. The Medicare conditions for hospitals require that AAs be under the supervision of an anesthesiologist who is immediately available if needed; the ambulatory surgical center conditions merely require AAs to be under anesthesiologist supervision.