PAs interested in Anesthesiology

[DelusionalEnthusiasm]

Any general comments are welcome, however I’d really like to ask that this post not turn into a AA vs CRNA vs PA post and focus the discussion more on how this could move forward. There’s been enough of those in the past and in general yes there will be fights if the below happens, but progress is never made easily.

 

From time to time the question comes up if PAs are able to practice intraoperative anesthesia.  Since this is an interest of mine I have happened to do a fair amount of research and discussed the subject with enough people that I feel its time for me to write a summative post for those in the future who wish to further push the subject and may be in the position to further the PA profession.

 

For some time now PAs have been involved in the “anesthesia area.”  If you search job postings enough you will occasionally see roles for PAs in anesthesia, although you will quickly discover these roles are targeted towards preoperative evaluations to clear / optimize patients prior to anesthesia provided by a physician / crna / AA.  The only area that PAs come close to providing true anesthesia services is in the realm of conscious sedation.  Depending on state laws, and largely more so on the hospital administrations views, PAs can perform conscious sedation in the hospital.  Usually these providers will be in an ED or ICU role, and the hospital can chose what drugs can be utilized in a prescribed manner.  These providers will have to go through education and supervised administration of agents prior to being credentialed to do this at the hospital.

 

Turning to intraoperative anesthesia, the question is can PAs really provide intraopeartive anesthesia?  The answer is yes.  The law is written such that a PA can perform the services of their supervising physicians.  Will this happen in real life? The answer is no.  The real question is what are the obstacles barring us from entering into this practice, and the answer is there are several.

 

In the 80s, a PA named Shepard Stone noticed that a Yale anesthesia residency slot had been abandoned by a physician who was supposed to take the seat. PA Stone approached them about taking this open seat and was allowed to fill it. PA Stone finished the complete anesthesia residency and remained at Yale administering anesthesia for many years and just recently retired. My argument is that we’ve dropped the baton as a profession at this point, and someone in the right position needs to pick it up and push forward.

 

Shepards story highlights the first and largest obstacle to PAs practicing anesthesia, namely the lack of professional training and experience in what is viewed as a high risk procedure that PAs were not trained in.  The easiest way for PAs to become appropriately trained in anesthesia would be to attend an Anesthesiology Assistant program.  At that point one could practice as an AA, however you’d quickly find that jobs are slim, and the number of states that license AAs are limited.  One could argue that a PA could now practice intraoperative anesthesia as a Physician Assistant because they had received adequate training and instruction through the AA program.  Some have argued that we should try to combine the two professions with bridge programs.  I feel this is completely unnecessary.  If an 18 month PA anesthesiology residency were created we would almost immediately be able to practice across the US, with the exception of several states that have specific laws written that exclude PAs from the practice of anesthesia.  However, with appropriate training and physician backing I can’t see how these laws couldn’t be overturned by state societies.  Will there be resistance? Of course, but that doesn’t mean we should hang up the towel… thats how our profession has already ended up where it is, while NPs are where they are.  Which leads me to the next obstacle PAs have, reimbursement.

 

 

The CMS law (Centers for Medicare and Medicaid Services) do not list PAs as an approved provider of anesthesia services for billing purposes.  See law here:

42 CFR § 482.52 - Condition of participation: Anesthesia services.

(a) Standard: Organization and staffing. The organization of anesthesia services must be appropriate to the scope of the services offered. Anesthesia must be administered only by - 

(1) A qualified anesthesiologist; 

(2) A doctor of medicine or osteopathy (other than an anesthesiologist); 

(3) A dentist, oral surgeon, or podiatrist who is qualified to administer anesthesia under State law; 

(4) A certified registered nurse anesthetist (CRNA), as defined in § 410.69(b) of this chapter, who, unless exempted in accordance with paragraph (c)of this section, is under the supervision of the operating practitioner or of an anesthesiologist who is immediately available if needed; or 

(5) An anesthesiologist's assistant, as defined in § 410.69(b) of this chapter, who is under the supervision of an anesthesiologist who is immediately available if needed.

 

In PA Stones case this was overcome by the anesthesiologists billing for the anesthesia administration, unfortunately as a dependent provider (as AAs are).  I did reach out to AAPA advocacy about addressing this law and received the following response:

 

“Preliminary past discussions with CMS' Department of Clinical Standards and Quality indicate that the agency is not favorable to a policy change to broaden which health professionals are authorized to deliver the full range of anesthesia services. It is likely that CMS would require that PAs who want to provide such services receive substantial additional training, education, and certification as a condition for any new authorization. AAPA would also likely encounter severe opposition from both physicians and CRNAs. As AAPA is pursuing a significant number of other Medicare policy changes, this is not a policy change we can prioritize at this time.”

 

In essence, there’s no point to pursue modification of the law without PAs who are trained and practicing anesthesia that could take advantage of this change.

 

Is it possible for PAs to develop a residency program that is of sufficient duration to train providers in Anesthesia care?  If a person wanted to pursue this it would likely need to be at an academic medical center with an already established AA program or anesthesiology residency.  It would take the work of someone connected and who is interested enough in the field to set this up. Ideal candidates for this program would be ICU PAs who already have established experience with intubation, lines, ventilators, and management of critically ill patients. If providers could make it through this program they could adequately demonstrate to the hospital and state medical board that they are sufficiently trained to provide anesthesia services.  The PA could then practice intraoperative anesthesia with an anesthesiologist.  The services could be billed under the anesthesiologist, as Shepard Stone did, until the AAPA could lobby for a change to CMS law.

 

I took some time and spoke with Shepard Stone about the PA residency idea and he agreed it would be possible with a 2 year residency. I’ve reached out to people I know but was unsuccessful in getting any interested parties. For those who are interested or stumble across this in the future I wanted to leave this as a guidepost that it can be done. It will take the right person with the right connection with an anesthesiologist to make it happen, or someone who makes it to executive leadership in a hospital to pitch the idea.

[newton9686]

Good post. Yeah it is unfortunate that Anesthesia is really the one area where PAs are excluded, which is sad for me because I really loved shadowing our anesthesiologist.  It is largely the reason why I went back to medical school as it is arguably still the best path for a PA given that AAs scope is still very limited and state dependent, plus, I could not see getting RN degree after already being a PA. I do believe a PA, especially one with a background working in an ICU could be trained to do intraoperative anesthesia with an 18 to 24 month residency, as this is essentially what we are doing training ICU nurses who become CRNAs (who upon until a few years ago only had to have a 2 year degree). People forget that the technical side of anesthesia is the easy part, the challenge is knowing the medicine and physiology. But if don't have strong technical skills, especially for a field like anesthesia where you really are working as the nurse, physician and pharmacist, no one cares about your knowledge of physiology and medicine. And the truth is ICU nurses are prepared very well for the technical side. Daily they are putting in IVs, setting up A lines, working the IV pumps, titrating drips, putting patients on the monitor, etc. I was joking as a PA I dont even know how where to place the leads of an EKG. I have an idea, but my role is to read EKGs, not to place. My wife even as an RN (now accepted to CRNA school) was able to be very helpful while shadowing both CRNAs and anesthesiologists because of how well her technical skills in the ICU translate to the OR.  As a PA I may have a better knowledge of the meds and physiology than my RN wife after PA school and spending some time in the open ICU, but it would be hard for me to be helpful in a more tangible way as a trainee until I too learned all these skills that nurses practice on a daily basis, which is party why PAs havent gained traction performing intraoperative anesthesia because you do need the technical skills that all ICU nurses are taught prior to CRNA school.

 

I say all this is that we do need anesthesia residencies for PA as this would give us that technical knowledge and allow us to take advantage of our medical knowledge and training. I would perhaps start with a one year anesthesia residency for a PA with significant ICU/surgical experience (preferably one that has done a surgical or ICU 1 year PA fellowship already). Basically treat this as their intern year,  then bring them in as essentially a CA1 and then allow them to practice at the level of a CA2-CA3 once they graduate, which would put them on par with AAs and many CRNAs. The challenging part would be getting them credentialed in the OR after graduation and recognized by Medicare (which is why I think you do a 1 year residency since you cannot promise them a role doing intraoperative anesthesia once they graduate.) You could also connect with the AA profession and see if they could sit for the AA boards once they have completed a 1 year PA surgical/icu residency and 1 year PA anesthesia residency. Although AAs are unforuntately still limited in scope, they can practice in 12 or 13 states I believe which would give Anesthesia PAs an ability to practice until you could provide proof of concept. Hopefully as someone looking to do an Anesthesia residency after I graduate medical school I will have an opportunity to build such a program because we as PAs, especially those who have been working in the hospital for a while largely could make the transition to the OR if given a year or two of intense training and become a valuable part of the anesthesia team. The problem is you are fighting the bureaucracy of Medicare and hospitals not to mention powerful societies with lots of lobbying power. It would undoubtedly be a huge uphill battle to get PAs into the OR doing intraoperative anesthesia. But I do think the push to get anesthesia out of the OR does provide an opportunity for more PAs looking to get into the wonderful world of anesthesia.