Could the 800 anesthesiologist assistants (AA) practicing in the United States help ease the anesthesia shortage? Without question, say an increasing number of anesthesia care team practices that have been recruiting this third category of anesthesia provider to augment the dwindling supply of anesthesiologists and nurse anesthetists. As you well know, today's surgical demand far outpaces the more than 35,000 MD anesthesiologists and 30,000 CRNAs.

Although AAs have been around for more than 20 years, they've only recently gained a foothold at the national level. Here's what you need to know about their qualifications and some insights into how they could fit in to your facility.

AA training
About 50 new AAs graduate each year from the two AA education programs in the United States, Emory University and Case Western Reserve University, according to the American Academy of Anesthesiologists Assistants (AAAA). Students seeking admission must a have a bachelor's degree. Some licensed AAs had formal medical education and critical care experience before seeking AA training, but this is not required. Upon the successful completion of the full-time two-year program, students receive a master's degree. About 10 percent of each graduating class goes on to medical school (among those more than 90 percent complete anesthesiology residences).

The AA programs at Emory and Case Western are part of the medical schools at the colleges. Anesthesiologists conduct all of the classroom education and clinical training of AA students. The Case Western program requires a total of 59 course credits and 2,000 clinical hours for graduation. Upon graduation, students take the NCCAA (National Commission for the Certification of Anesthesiologist Assistants) exam, which certifies that they have passed the minimal qualifications to participate in an anesthesia care team. Most state medical boards that license AA practice require this certification. AAs must be re-certified every two years.

"There's a real need for more AA training schools, because there's just so much that two schools can do to meet the growing demand," says John Neeld, MD, the chair of the Department of Anesthesiology at Northside Hospital and Northside Anesthesia Consultants in Atlanta.

Recruiting AAs
Dr. Neeld, who directs 34 physician providers, 34 CRNAs and 33 AAs in his department, offers these suggestions for recruiting AAs to fill vacancies in your care team.

• Network. Establish contact with the faculty at the training programs. Perhaps a hospital HR department may want to set up a booth at the annual AAAA conference.
• Train AAs. Became a clinical training site for AA students, taking in one or two students at a time.

Once word of mouth spreads, Dr. Neeld says, the recruitment challenge becomes much less daunting. "They'll tell their colleagues and help bring them to you." he says.

AAs are less expensive than MD anesthesiologists or CRNAs. AAAA says that starting salaries for AAs are in the $70,000-to-$80,000 range for a 40-hour workweek plus benefits and consideration for on-call activity. Case Western says that salaries generally increase about 10 to 20 percent after the first year or two of anesthesia team experience. The average CRNA salary at an ambulatory surgery center was $101,825, according to FASA's 2002 Employee Salary and Benefits Survey. The average MD provider now costs upwards of $200,000.

"There are only so many dollars and providers to go around in anesthesia," says Alan Marco, MD, MMM, of Toledo, Ohio. "Care teams are one way potential solution and the practice, in general, have been shown to be safe and effective." Dr. Marco works with several AAs at the Medical College of Ohio. He says, "I find that since they tend to be younger graduates, they are happy for the opportunity to have jobs and are eager to work and make money."

So, what can they do?
AAs work only within the care team setting. Unlike CRNAs, there are no states that allow independent AA practice (by virtue of removing the requirement for an anesthesiologist to "medically direct" the case). As a result, if your facility has AAs, there must be an anesthesiologist working over them. In some care settings with the most dire anesthesia provider shortages, such as rural communities, AAs are simply not an option, even if they are recognized at the state level. "AAs are not a cure-all for staffing problems," says Dr. Neeld.

Additionally, while no U.S. states expressly forbid AAs to practice, only 17 states currently recognize their practice in one form or another (see "Does Your State Recognize AAs?"). Without practice recognition from the state medical board, AAs can theoretically work as unlicensed providers but Medicare and most third-party payers do not recognize their services for reimbursement, nor can they obtain liability insurance policies.

Lastly, there are conflicting reports as to whether AAs possess the training to perform regional anesthesia techniques. Emory, for example, teaches it students "the anatomic and physiologic basis" of regional anesthesia, but students do not receive clinical training. Case Western's program teaches "techniques for spinal, epidural, caudal and peripheral nerve blockade ? throughout the 2-year program of study."

Dr. Neeld says that he does not assign AAs (or CRNAs) to perform regional anesthesia at his facility.

Integration and retention
The key to a successful anesthesia team, says Dr. Marco, is to make the practice a place that all providers- MDs, CRNAs and AAs alike - want to work.

Says Dr. Neeld, "Why do people remain loyal to a practice? Based on my 17 years as department chair, I would suggest that anesthesiologists need to give each category of anesthetist the same support and the same respect for their professionalism. You need to assign the same range of duties for all anesthetists. There should be the same salary base. Lastly, there needs to be good communications on quality review and improvement and everyone's voices should carry weight."

Both Dr. Marco and Dr. Neeld say that care teams are designed on the principle of anesthesiologists providing medical direction to the CRNAs and AAs and not merely "supervision" (which can be as little as a "breakroom sign-off"). This is a recipe for resentment by personnel, presents the image of a cavalier attitude toward the team, and eliminates any clinical benefits that may be gained by using a care team.

Dr. Neeld (a former ASA president) says that even though the CRNAs at his facility initially balked at adding AAs to the program, none carried out on threats to resign. The turnover ratio for CRNAs has been less than 3 percent for more than five years.

"No one abandons an otherwise desirable practice because of the title of the anesthesia provider working in the next room," says Dr. Neeld.