House bill to license anesthesia assistants causes debate

A proposal to license a new kind of anesthesia provider in Missouri has ignited a turf war between area doctors and nurses, and a key point of contention is whether it would make surgery patients less safe.

Citing a shortage of nurses, doctors who specialize in anesthesia say Missouri needs to create an alternative to nurse anesthetists: anesthesiologist assistants.

But nurse anesthetists say that AAs are not nearly as trained as they are and would greatly diminish the quality of health care if allowed to work in Missouri.

The House of Representatives passed the bill 136 to 22 and sent it to the Senate, which is holding a committee hearing today on its version of the bill. At least one Cape Girardeau doctor will be testifying at the hearing.

State Rep. Jason Crowell, R-Cape Girardeau, is a co-sponsor of the House bill. He said that nurse anesthetists' concerns are unjustified.

"The bottom line is there is a need in the field to help make sure that we have quality anesthesiology care," he said. "That is the primary goal of the bill. It has nothing to do with the nurses. AAs are highly trained to do their jobs."

'Reservations immediately'

But nurse anesthetist Melanie Dillard and others in her field disagree. Dillard has been a certified registered nurse anesthetist for eight years and has been at Southeast Missouri Hospital since 2000.

She noted that most nurse anesthetists have years of critical care nursing experience before they enter a 30- to 36-month nurse anesthesia program. By contrast, AAs are not required to have any health care training or experience before they begin their anesthesia training.

"When I first heard about the bill, I had reservations immediately," she said. "My reaction became more negative after I found out they had no training whatsoever."

According to medical literature, nurse anesthetists must first become a registered nurse and then have a minimum of one year of in-depth, hands-on nursing and patient acute care, such as in an intensive care unit, before entering a nursing anesthesia graduate program.

AAs must have a bachelor's degree that can be in a nonmedical field, but must take specific premed science courses, such as biology, chemistry, physics and math. Then they must receive two years of training in anesthesia with 2,000 hours of supervised experience.

Local anesthesiologist Dr. Jeff Steele, who works at St. Francis Medical Center, said allowing AAs to practice in Missouri would help address nursing shortages, as well as shortages in the anesthesiology field.

Besides, he said, AAs are qualified to do the job.

"They don't start off as nurses, that's true," Steele said. "But they have to do something the nurses don't: They have to take the same type of courses that you would have to take as someone about to enter medical school. Four-year nursing degrees don't include those courses."

Quality not the issue

He compares the AAs to physician's assistants, who also don't have to become nurses first.

Steele also said that the quality of health care isn't the main reason nurse anesthetists oppose allowing AAs in Missouri.

"They don't want the competition," he said.

Steele said that nurse anesthetists are well paid -- many make more than $150,000 -- and that they fear competition may drive down their salaries.

"We have nothing against the nurse anesthetists," Steele said. "They are well-trained, competent providers. We work beside them every day. At the same time, we have this class of people who are also well-trained, competent providers who are excluded from practicing in Missouri."

Fourteen other states allow AAs, Steele said, and there has been no increase in death rates attributed to anesthesia in those states.

Dillard says that there are only about 600 anesthesiologist assistants in the entire United States, so a higher death rate associated with AAs would not initially be obvious.

The current anesthesia safety statistics in each state is the result of the 28,000 nurse anesthetists and 32,000 anesthesiologists nationwide. As the number of AAs in a state increase, the real anesthesia death rate associated with AAs may gradually become more apparent, Dillard said.

Dillard and other nurses say that the licensing AAs in Missouri wouldn't address the shortage anyway. There are only two AA schools in the country, which aren't generating AAs fast enough to offer relief. Nurse anesthetist schools are producing more graduates, too, she said.

One local doctor agrees with the nurses.

Dr. Scot Pringle, who specializes in obstetrics and gynecology, is testifying at today's Senate hearing. He said that the nurses' claims that AAs aren't as qualified is accurate.

"Most patients don't know the difference between doctors, nurses and orderlies, let alone whether someone is nurse anesthetist or an AA," he said. "But they do know they want the best. That's what I'd want if I was going to sleep."

Good, not cheap

Pringle also doesn't like that the bill doesn't put a ratio on how many AAs can work under one anesthesiologist, as in the case of nurses who work under a 4:1 ratio, meaning one doctor can supervise four nurses. The anesthesiologists, however, say they don't have a problem if that is worked into the final version of the bill.

But Pringle thinks the anesthesiologists want AAs because they can pay them less and put the savings into their own pocket.

"We want good, we don't want cheap," Pringle said.

Steele points to another doctor, Michael Lasecki, who works with AAs in Alabama, which already licenses AAs. Lasecki has been an instructor of both AA students and nurse anesthetists.

"My AAs and CRNAs do exactly the same work, thus their pay and benefits are the same," Lasecki said. "I have found AAs to be competent to do even the most challenging cases."

The debate continues, but, in the end, the Missouri Legislature will have the final say.

State Sen. Peter Kinder, R-Cape Girardeau, met with about 30 nurse anesthetist from the area recently, who voiced their opposition. He's still undecided and said he has no idea how the bill will do in the Senate, though he noted that it sailed through the House.

"I think it will be amended to address many of the concerns they have," Kinder said. "Whether that will soften the opposition, I can't guess."

smoyers@semissourian.com

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