Anesthesiologist Assistants: Good for California

  • Hertzberg, Linda, MD, FASA
| Feb 17, 2015

Editor's Note: The following blog post was written by members of the CSA Executive Committee. No specific author is attributed; this is CSA sponsored material.

When you need anesthesia for surgery or a diagnostic procedure, of course you want to know who’ll be giving you anesthesia.  If you live in some states, you may be lucky enough to have an anesthesia team taking care of you that includes a physician anesthesiologist and an anesthesiologist assistant, or “AA”.  If you live in other states — including our own state of California — care from an AA isn’t yet an option.

Many Americans have never heard of anesthesiologist assistants.  Even many physicians are unaware that the profession exists.  But for more than 45 years, AAs have worked alongside physician anesthesiologists in exactly the same way that physician assistants (PAs) work with a surgeon, internist, or pediatrician–using teamwork to deliver the best possible medical care to their patients.

Today, there are nearly 1700 certified AAs in the U.S.  Why are they limited to practicing only in certain states?  It’s a complicated question.  The answer involves the fierce opposition of nurse anesthetists to the very existence of the AA profession, our complex American system of state licensure, and the economics of healthcare.

Here’s the background

The AA profession came into being in the 1960s, when we had a serious shortage of anesthesia professionals in the U.S.  The goal was to create a new master’s level program which would enable graduates to deliver anesthesia care under the direction of a physician anesthesiologist.  The first AA programs were established at Emory University in Atlanta and Case Western Reserve University in Cleveland.

To become an AA, the first step is to get a bachelor’s degree with a strong basic science background, taking the same classes that premedical students take to prepare for medical school.  The next step is to take the GRE or MCAT examination and gain admission to one of the ten accredited university programs in the U.S. offering a Master of Science in Anesthesia degree. AA programs must be affiliated with a university that has a medical school and academic anesthesiology faculty, and each AA program must have at least one director who is a board-certified anesthesiologist. Training involves classroom time and hands-on experience in the operating room, with a minimum of 2000 clinical hours. After passing a certifying examination, graduate AAs administer anesthesia as clinical practitioners, always working under the supervision of a physician anesthesiologist.

AAs are recognized by the Centers for Medicare & Medicaid Services (CMS) as non-physician anesthetists with identical standing to nurse anesthetists, and the services of AAs and nurse anesthetists on a care team are paid for by CMS and by commercial insurers on an equal basis.  AAs are authorized to work in any VA hospital, and they work side by side with nurse anesthetists in many academic departments and private anesthesia practices. They practice in 17 states, the territory of Guam, and the District of Columbia.

AA practice requires state-by-state approval

In hindsight, it might have been easier if the AA profession had been launched as a subspecialty under the broader umbrella of PAs, who already can be licensed in all 50 states.  Physician anesthesiologists specialize in anesthesia, but practice in every state under a general license as physicians.  Since AAs are defined as a separate profession, however, each individual state must approve AA licensure (or another means of authority) in order for them to practice.  Getting this approval has been a battle, as nursing lobbies and unions have fought hard to defeat legislation authorizing AA licensure in every state where it has been proposed.

According to a 2010 Rand report, the U.S. is experiencing a shortage of anesthesia providers, including both physician anesthesiologists and nurse anesthetists. The obvious conclusion is that more anesthesia professionals are needed to care for our aging population.  In addition to training more physicians, we also need a system that extends physician care with the right set of appropriately trained physician extenders. AAs will help fill this gap. The addition of AAs to the patient care team model will increase efficiency and improve access to care because certain tasks can be delegated while protecting patient safety.

AAs work alongside physicians and nurses in the physician-led, patient-centered model of care. AAs do not practice independently; routine cases and emergencies alike are handled in a team format, which has been shown through substantiated research to lead to better patient outcomes.   A study by J.P. Abenstein and  Mark Warner demonstrated that there are fewer adverse events and anesthesia-related deaths when a physician or anesthesia care team cares for patients, as opposed to a nurse anesthetist acting alone.

Physician-led anesthesia care

There’s a difference in philosophy between AAs and nurse anesthetists as well.  In opt out states, some nurse anesthetists practice independently, which means that a nurse anesthetist may give anesthesia without the supervision of — or even consultation with — a physician.  In contrast, AAs work only under the supervision of a physician anesthesiologist.  That’s how they want it.  They believe strongly in the concept of the care team, where physician and non-physician practitioners work together.

Saral Patel, AA-C, a past president of the American Academy of Anesthesiologist Assistants (AAAA), points out that when AAs are on your anesthesia team, they “ensure an anesthesiologist presence in the care of every patient.” The overwhelming majority of patients automatically assume that a physician is in charge of their anesthesia care, and prefer to keep it that way.

The future of anesthesia practice

The market for anesthesia services continues to grow, as the number of surgeries and complex diagnostic procedures requiring anesthesia increases each year. With the advent of the PSH model, demand for physician expertise in supervision and coordination of care and for advanced practice anesthesia professionals is certain to grow.  The ASA and the CSA strongly believe in the anesthesia care team, and would like to see AAs gain the right to practice in every state. 

It’s a shame that any California student who wants to become an AA has to leave the state for training and can’t come back here to work.  Certified AAs deserve to practice in any state where they want to live and work.

“I’m a California native,” says Shane Angus, AA-C, an experienced AA on the teaching faculty of Case Western Reserve University.  “I’d come back to work here in a minute.”


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  1. Bliss | Apr 28, 2020
    no Alex. My husband and I are in the same shoes and unfortunately things are still the same. Its really sad when you cant practice in your own native state. 
  2. Alex | Dec 02, 2019



    i know it has been a few years since you wrote is article but i am hoping things might have changed im the last few years. My wife is an Anesthesia Assistant and we would love to move back to california to be near family but it isnt an option until she can work here. Has anything changed, or is there anything on the horizon that might open up this market to AAs in the next couple years? Thank you and look forward to hearing. 


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