AA vs. CRNA - Let's Discuss.

  1. Let's have a discussion/debate (although it will probably be one sided) about AA vs. CRNA. These are just some topics I thought of off the top of my head. Any input or 'playing devil's advocate' would be appreciated.

    - What is the difference in schooling/certification/academics?
    - What is the difference in their scope of practice or autonomy?
    - What economic factors are behind the push of AAs, if any?
    - Can we relate this situation to another in Healthcare? Possibly LPN vs. RN?
    - What are the best and worst case scenarios for CRNAs in the future, as it pertains to AAs vs. CRNAs?
    - Why should one become a CRNA, rather than an AA?
    - How does the MDA benefit from the increased use of AAs vs CRNAs?
    - How does all this factor into the level of care a patient receives?

    We need some AAs or MDAs to log on here to stir up the pot.

    This is probably an emotional subject for some, but let's keep it civil. Ultimately we are all on the same team...I guess everyone just wants to be the MVP.

    Who wants to cast the first stone?
    Last edit by warzone on Apr 29, '03
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  2. 43 Comments

  3. by   warzone
    Here is an AA's description:

    Anesthesiologist Assistants are highly educated allied heath professionals who work under the direction of licensed anesthesiologists to develop and implement anesthesia care plans. Anesthesiologist Assistants work exclusively within the Anesthesia Care Team environment as described by the American Society of Anesthesiologists (ASA). AA's are trained extensively in the delivery and maintenance of quality anesthesia care as well as advanced patient monitoring techniques.
    Anesthesiologist Assistants educational programs are based on the masters degree model and require at least two full academic years. Programs are required to be co-directed by board certified anesthesiologists. AA educational programs accept students who have prior education in the sciences that would qualify the student to pursue careers in medicine, dentistry, or one of the basic medical sciences. Students are taught course work that enhances their basic science knowledge in physiology, pharmacology, anatomy, and biochemistry with special emphasis on the cardiovascular, respiratory, renal, nervous, and neuromuscular systems. Clinical instruction educates students extensively in patient monitoring, anesthesia delivery systems, life support systems, and patient assessment as well and in the skills need to provide compassionate, quality care.
  4. by   warzone
    Here's a "FAQ" from a University with an AA program:

    Is the job description for the Anesthesiologist Assistant (AA) profession equivalent to that for a Certified Registered Nurse Anesthetist (CRNA)?
    Yes. When AAs are employed within the same organizations as CRNAs, the job description is usually identical. One fundamental difference is that AAs must work under the medical supervision of a licensed anesthesiologist. Conversely, in some unique clinical settings (usually not at tertiary care centers), a CRNA can practice under the medical supervision of any physician (not necessarily an anesthesiologist).
  5. by   SharonH, RN
    Isn't this comparable to the difference between a PA and APRN? Was the AA role developed by physicians, perhaps to compete with CRNAs? Why? AAs cannot work independent of anesthesiologist but CRNAs can, at least in some states. Am I on the right track?
  6. by   New CCU RN
    Originally posted by warzone
    Here's a "FAQ" from a University with an AA program:

    Is the job description for the Anesthesiologist Assistant (AA) profession equivalent to that for a Certified Registered Nurse Anesthetist (CRNA)?
    Yes. When AAs are employed within the same organizations as CRNAs, the job description is usually identical. One fundamental difference is that AAs must work under the medical supervision of a licensed anesthesiologist. Conversely, in some unique clinical settings (usually not at tertiary care centers), a CRNA can practice under the medical supervision of any physician (not necessarily an anesthesiologist).
    Actually there are many other differences b/n an AA and a CRNA

    1) CRNA's are employed in all 50 states, a growing number of those states are allowing CRNAs to practice independantly. AA's are only allowed to practice in less states than I can count on my hands.

    2) CRNA's have previous clinical experience in comparison to an AA where they are either bs or ms prepared with their only clinical experience being while in school.

    3) AA's are exactly what the word says.... anethesia assistants, they are assistants to the MD. CRNA's have their own scope of practice.

    4) CRNA's administer 65 % of the anesthesia in the US, there is no stastic that I could find out there for AA.

    5) CRNA's make about 100-150 thousand while AA's start off around 70-90

    6) AA's must have the MDA in the room, as they are under DIRECT supervision. Thus decreasing their effectiveness. EVen if a CRNA is practicing under an MDA as this occurs in some states, the MDA does not have to be present.

    7) Given the little autononmy that AA's possess, I do not see their role growing much more. They simply crowd the OR with another person, one who cannot make any decisions on their own. A person who may be educated but is NOT clinically educated and has very little hands on clinical experience.

    8) CRNA's must have BS or BSN's, competitive GPA's, competitive GRE's, and a minumum of at least one year ... most usually have about five years experience of Critical Care nursing (ICU), managing high acuity patients. They have dealt with Swan Ganz, balloon pumps, CVVH, a coding patient, a direct post op patient. While RN's are not autonomous, ICU nursing involves ALOT of decision making, seeing the whole scope of the picture, convincing the physicians (usually no offense but baby doctors who have very little ICU knowledge) of a medical plan of care, recovered a patient post op. ICU RN's now CRNA's have this under their belt before they even begin their education to become a CRNA. CRNA's undergo 27-36 months of full time school and clinical... which also puts an AA program to shame.

    9) If you look back into the history of CRNA's, they have been around for many years (over 100). I don't see them doing anything but expanding their current practice. Many studies are out there that find the same patient outcomes whether a CRNA or an MDA administered the anethesia. AA's... seem to be an MDA's handmaiden.
  7. by   EmeraldNYL
    Oh yea, this is going to be a fun thread!

    - What is the difference in schooling/certification/academics?
    Well, both are master's prepared but the CRNA has previous ICU experience, while the AA may or may not have any previous medical experience.
    - What is the difference in their scope of practice or autonomy?
    CRNA's obviously have a lot more autonomy because they have the capacity to practice independently, such as in a rural setting. However, in a tertiary care center in a city setting, there may not be a whole lot of difference in job description between AA's and CRNA's.
    - What economic factors are behind the push of AAs, if any?
    Duh, AA's are cheaper! MDA's have a lot more control over AA's while they may view CRNA's as a threat to their profession.
    - Can we relate this situation to another in Healthcare? Possibly LPN vs. RN?
    Sure, for example, some job ads advertise for either an LPN or an RN. In the future we may see some ads recruiting AA's or CRNAs, so the CRNA's will have to make sure they remain extra competitive to warrant their larger paychecks.
    - What are the best and worst case scenarios for CRNAs in the future, as it pertains to AAs vs. CRNAs?
    Best case scenario-- AAs never gain in popularity and the profession slowly dies. Worst case scenario-- AAs take CRNAs jobs because they are cheaper and threaten CRNAs job security.
    - Why should one become a CRNA, rather than an AA?
    Right now there are more opportunities for CRNA's and they can practice more independently.
    - How does the MDA benefit from the increased use of AAs vs CRNAs?
    More control over the AA and they are cheaper.
    - How does all this factor into the level of care a patient receives?
    Studies have shown that CRNA's are just as safe as MDAs. However, studies remain to be completed about the safety of AAs. So it may or may not affect patient safety.

    Really, I think this debate is extremely similar to the whole PA vs. NP argument. PA's have little medical experience prior to PA school and they have proven themselves to be competent care providers. In most situations the job description of the PA and NP are interchangeable. (Just trying to play devil's advocate a little bit, I really want to be a CRNA and it would really stink if an AA took my future job!)
  8. by   warzone
    I am wondering if MDA's will use their power to push AA's autonomy level up almost on par with CRNAs, while still keeping their leverage over them. MDAs are probably looking at CRNAs, similar to the way CRNAs view AAs. Will patient care suffer? I don't know, but I bet that is not a driving force in this.

    As far as economics goes. . . what kind of staffing ratios or staffing heirarchy can be achieved by using MDAs, CRNAs, and AAs that still allows for the same patient volume? Which ends up being the most cost effective?
  9. by   New CCU RN
    Originally posted by warzone
    I am wondering if MDA's will use their power to push AA's autonomy level up almost on par with CRNAs, while still keeping their leverage over them. MDAs are probably looking at CRNAs, similar to the way CRNAs view AAs. Will patient care suffer? I don't know, but I bet that is not a driving force in this.

    As far as economics goes. . . what kind of staffing ratios or staffing heirarchy can be achieved by using MDAs, CRNAs, and AAs that still allows for the same patient volume? Which ends up being the most cost effective?
    The CRNA was around before an MDA actually. Anethesia has always been a nursing specialty. Like I said earlier, it would benefit you to look into the history of nurse anethesia.

    Economically, MDA's make the most (at least twice that of a CRNA), CRNA's second, and AA's third.

    However, AA's cannot do anything without the MDA present. I don't see how this can be effective. The AA's scope of practice has already been defined, and these are the guidelines. CRNA's, it all depends on the state and facility, but they never have needed the MDA in the room. Economically, I don't see how the AA will benefit bc they are still tying up the MDA. The MDA cannot be doing another surgery simultaneously, unlike with the CRNA.

    I don't see the NP/PA being comparable to the CRNA/AA because the PA/NP can still see patients on their own, develop their own plan of care, implement, prescribe. AA's must have the OK with every move they make in the OR.... I see an AA as having even less autonomy as a nurse.
  10. by   warzone
    Originally posted by New CCU RN
    ... Economically, I don't see how the AA will benefit bc they are still tying up the MDA. The MDA cannot be doing another surgery simultaneously, unlike with the CRNA...
    Well then AAs are dead in the water, if it can't be marketed as a viable option. Would the AA profession have been 'created' if there was no viable way to market it? I highly doubt that the role of AAs, if given the right amount of time, will stay stagnant. If they are directly supervised by MDAs, and proven reliable, why would they not be afforded more autonomy?
  11. by   EmeraldNYL
    Originally posted by warzone
    I am wondering if MDA's will use their power to push AA's autonomy level up almost on par with CRNAs, while still keeping their leverage over them.
    This is an interesting point and a scary possibility, although I think it's unlikely anytime in the near future for all the reasons that CCU RN stated. I could definitely see how the job description of the AA could be stretched somewhat. I'm really not that worried though, especially considering there are only 2 AA schools. I don't think this is cause for panic but I'd be really interested to hear what the long-time CRNA's on this board think.
  12. by   CRNA, DNSc
    Of course the Anesthesiologist will push the use and education of the AA since the fundemental different is that the AA is complete under the control of the MDA. CRNAs can practice without the supervision of an MDA, that mean we are not under their direct control. Control is a great motivator that's why the MDA are looking for another provider that they have complete control over. Before anyone considering becoming a CRNA panics remember there are over 28,000 practicing CRNAs in the US and around 600 AA. Become a CRNA, it's a wonderful profession!!!!!:kiss
  13. by   loisane
    You guys are testing me, here (which I love, btw). I have been meaning to do some serious research on AAs. They are not an issue in my area, but that is no reason to ignore them. Many people feel this will be the next defining issue in anesthesia.

    Ok, here goes what I know off the top of my head. True, there are a limited number of AAs now. They started out being unlicensed providers, working only on the authority of the MDA. Now, some states are licensing them (Is this a good thing, or a bad thing. I don't know.)

    Recently some states have attempted to increase the supervision ratio from 1:2 to 1:4. Now, how immediately available is the MDA if he is supervising 4 AAs?

    "Immediately available" has been defined in different ways. Some places it means "in the building". So, as I understand it, the MDA does not have to be physically in the room to supervise the AA. (Again, I have no direct knowledge of AAs or how they function).

    These are just some of the issues. This is huge guys. I don't think we can afford to take the attitude that there is no way it will affect us.

    The most concerning thing to me is the ASA definition of the anesthesia care team. The ASA position is the anesthesia is the practice of medicine. According to them, the only thing that legitimizes CRNA practice is that they are carrying out delegated medical acts. So by their definition, there is no difference between CRNAs and AAs.

    Our position is that anesthesia is medicine when done by MDs and nursing when done by CRNAs. Thus, we hold that CRNAs have the legitimate right to practice anesthesia independent of MDA supervision. (You may need MD supervision depending on your state nurse practice act, but no state requires that the MD be an anesthesiologist.)

    Organized anesthesiologists/ASA tried very hard to gain complete control of CRNAs. In the past they have tried to regulate our practice through Boards of Medicine instead of Boards of Nursing. They have tried to gain control of our education programs, accrediting bodies and certification process. They have failed at all this.

    My personal opinion is that they have changed tactics. There is now a provider shortage. This would be a perfect time to push a (relatively) new provider, one that they could control. They wanted CRNAs to be their assistants, and to be completely dependent on them. They couldn't make CRNAs conform to their view, so they create another provider that fits the mold that they feel is appropriate.

    Obviously, I am biased in my opinions. I am a firm adherent to the AANA definition of the anesthesia care team. I am not in favor of AAs. But I am trying to present a fair assessment of things as I see them. In the interest of fairness, let me also say that:
    1) There may be some practice settings were AAs are just that, assistants to the process, and the MDA is always physically present.
    2) Not all individual anesthesiologists agree with the stated agenda of their professional organization.
    3) It is possible that MDAs who do agree with the stated agenda are motivated by an altruistic desire to give patients the best care possible, and they really believe that can only happen when all care is controlled by a physician
    4) There is a provider shortage now, and we do need more help. On the surface, what's to say that AAs couldn't help the mess we are in. Disagreeing with the AA concept just to "protect our turf" is not a honorable position to take.


    So, charting a course through this upcoming storm is going to be tough. CRNAs have their best minds working on it, and you are all smart to stay apprised of the situation. It is definitely not one to be dismissed lightly.

    loisane crna
  14. by   New CCU RN
    Originally posted by warzone
    Well then AAs are dead in the water, if it can't be marketed as a viable option. Would the AA profession have been 'created' if there was no viable way to market it? I highly doubt that the role of AAs, if given the right amount of time, will stay stagnant. If they are directly supervised by MDAs, and proven reliable, why would they not be afforded more autonomy?
    There is a shortage of all different health care positions, so I am sure that the AA will fall into place in some ways. Will the AA become anywhere equivalent to the scope of practice of a CRNA...I highly doubt it. Will the AA's be inserting Swan Ganz and A-lines, also highly doubtful. Will AA's be code blue responders like CRNA's often are... quite doubtful. Will they have an independant practice... as long as they have the title "assistant", they will be just that.... an assistant to the MDA.

    Are AA's a threat to CRNA's... also highly doubtful. CRNA;s administer over 65 % of the anethesia in the US. There are a growing number of anethesia positions that are becoming open for both CRNA's and MDA's. AA's can be an assistance... but no where near that of a CRNA. Do remember that AA's will always in every circumstance be practicing under the MDA's license....they will be limited and unable to make many decisions.. ie) type of anethesia, etc.

    Will AA's gain more autonomy. CRNA's like Louisane said are practicing nursing. They have their own organizations ie) the AANA that have been lobbying and advocating for the autonomy of CRNA's. AA's are still a part of the AMA thus controlled under doctors. Their autonomy will be limited as they have no voice. They are assistants and I honestly see their position staying that way... a handmaiden to the MDA.

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