November 29, 2024 • 35 mins
Curious about what it truly means to be a Certified Anesthesiologist Assistant (CAA)? You're in the right place! From nearly two decades of experience, I share a clear and comprehensive breakdown of the CAA profession. Think of me as your older sister or best friend, guiding you step-by-step through the essentials—from what CAAs actually do to how much money we make, no topic is off limits. Whether you're an aspiring AA student or simply exploring a career in medicine, this guide equips you with the insights you need to understand the CAA profession.
In Part 3 I break down some universally misunderstood concepts pertaining to CAA practice regulations such as licensure vs. delegatory authority, medical direction vs. medical supervision, and why CAA state licensure does not automatically guarantee state practice. This is a critical episode no matter where you are in your CAA journey, and one that helped me answer some long considered questions.
Resources Mentioned:
- S3 E46 Transatlantic Tales of a Certified Anesthesiologist Assistant ft. Mark Leonard, CAA
- S3 E36 [PROCESS] Lindsey Diaz, CAA on fear, anger and her right to practice in New Mexico
- S3 E35 [PROCESS] The Stars Align in Nevada ft. CAAs Stephanie Zunini, Jada Wabanimkee and Joey Parrish
- S4 E56 [PROCESS] Breaking Barriers in The Evergreen State ft. Sarah Brown, CAA
- States Can CAA's Work @anesthesiasal
- ASA statement on medical direction vs. supervision
- ASA statement on anesthesia care team
- AAAA statement on licensure vs. delegatory authority
- Michigan's delegatory authority statute
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:04):
Welcome to the Awakened Anesthetist podcast,
the first podcast to highlightthe CAA experience.
I'm your host, mary Jean, andI've been a certified
anesthesiologist assistant forclose to two decades.
Throughout my journey andstruggles, I've searched for
guidance that includes my uniqueperspective as a CAA, at one of
(00:42):
my lowest one.
I encourage you to stick aroundand experience the power of
being in a community filled withvoices who sound like yours,
sharing experiences you neverbelieved possible.
I know you will find yourselfhere at the Awakend Anesthetist
podcast.
Welcome in, welcome backAwakend Anesthetist community.
(01:06):
This is your host, mary jean,and welcome back to this mini
series in season four that I'mcalling your complete guide to
understanding certifiedanesthesiologist assistants.
You have tuned in to part three, which is answering the
question where can caas work?
And I just want to note thateach of these episodes in this
(01:27):
mini-series do build on oneanother, so if you're really not
familiar with certifiedanesthesiologist assistants at
all, hearing this episode as astandalone is going to be a
little bit confusing.
So I really recommend goingback and listening to part one,
which is defining what a CAA is,and then part two, which is me
(01:49):
giving you some behind thescenes of why you should not and
why you also should become aCAA.
And just the lingo, theverbiage, the acronyms, the sort
of medical ease speak that Iwill use in this episode isn't
going to make a lot of senseunless you've listened to those
episodes or you have somebaseline familiarity with being
(02:12):
a CAA, whether that means you'rea current AA student or a
practicing CAA or a prospectiveAA student.
These episodes are really meantto make more clear what a CAA
is and where we are in themedical hierarchy and what we do
, and just really be aconversation between a big
(02:34):
sister or best friend to you all, the listener.
That really is going to keep itreal and cut it to you straight
on what a CAA is.
So again, in this episode we'regoing to be answering the
question where can CAAs work?
And as a longtime practicingCAA, I found a lot of answers to
(02:54):
questions that I've had since Istarted or since before I
started being a CAA.
So really this episode is goingto be interesting to everyone
listening, even if you'repracticing CAA and you feel
pretty familiar with the basics.
I learned a lot and so I reallyencourage you to stay tuned and
, you know, just be a moreinformed CAA so that you can
(03:15):
advocate for our profession moregracefully, so that you have
some more places and resourcesto turn to If you have a
question you are not knowing theanswer to.
I'm going to put a bunch ofresources in the show notes, so
check that out.
And yeah, this might be alittle bit of a longer episode.
We're going to see how long ittakes me to feel like I explain
everything well enough, but I'mreally hoping that it's helpful
(03:39):
and that it's a resource you cankeep going back to over and
over again.
So let me lay out the frameworkfor how I'm going to tackle
this really important questionwhere can CAAs work?
I'm going to start on the mostmacro level and then move, you
know, step by step down into amicro level and we're going to
get to really specificconversation on where in a
(04:01):
hospital a CAA could work, wherein an anesthetizing location do
CAAs work, and what types ofanesthetizing locations, and so
we're going to be talking aboutthis question in several
different levels.
So let's start with the biggest, most sort of duh macro level
on where CAAs can work.
(04:22):
Let's talk a little bit aboutwhere in the world we can work.
So CAAs were first establishedwithin the United States of
America in about the 1960s.
So this profession originatedin the United States and I
thought that was the only placea CAA has ever or could have
(04:44):
ever worked.
But recently in season three ofthis podcast, which is episode
46, it's called TransatlanticTales of a CAA I interviewed a
CAA who is currently working inthe state of Florida in the
United States.
His name is Mark Leonard, buthe actually began his anesthesia
career in the United Kingdom,specifically in England, and he
(05:08):
details the association betweenUnited States CAA and the United
Kingdom equivalent, which iscalled an anesthesia associate.
And he has been both, and so Ijust wanted to reference that
episode because I really in thatepisode learned a lot myself on
(05:29):
how a CAA could work outside ofthe United States.
And the overall theme to how aCAA gets to use their license
outside of the United States isthat they have to find an
equivalent leveled anesthesiaprovider in the country that
they're in.
So as far as I know, this hasonly happened in the United
Kingdom, specifically England,and in Canada.
(05:51):
So you find our equivalent inthat country and then you
petition their agency, theirmedical board, their health
services association, whateverregulates their equivalent
anesthesia provider.
You basically petition them andask them to convert your
license your United States CAAlicense into their equivalent,
(06:14):
and how you would go about thatis something that they would
determine, and so then you havethe option of jumping through
their hoops in order to giveanesthesia in their country.
Jumping through their hoops inorder to give anesthesia in
their country.
So that's the most macro level.
Dropping down one level closer.
(06:34):
Let's focus on the United Statesand let's focus on the how and
the why behind CAAs being ableto work in certain states but
not in others.
And I was able to find a littlebit of specific legislative
lingo about where a CAA can workon the Quad A website, so I'm
just going to read that reallyquickly, because it brings up
(06:55):
two important points that I'mgoing to talk about further.
So, from the Quad A quote, thelegal ability for CAA practice
is created by legislation thatis enacted and codified into
state law or through regulationthat is adopted by the Board of
Medicine in each state.
Caas can practice within theanesthesia care team under two
(07:20):
models licensure authority ordelegatory authority.
Both state licensure and statedelegatory authority require
oversight by a state medicalboard, and both delegatory
authority and licensure can varyby state, depending upon how
the statute, rule or legislationreads, end quote.
(07:44):
Okay, that was kind of dense andI want to come back to the
difference between licensureauthority and delegatory
authority.
But first I want to tell youwhat actual states and
territories CAAs can work in asof the recording of this podcast
episode, which is November of2024.
And I am going to tell you theyear that the legislation was
(08:07):
passed and whether it was alicensure legislation or a
delegatory authority legislation, and then, of course, I'm going
to get into that.
So let's start off with Georgia.
The first state where CAAs werecreated, educated and licensed
was in 1971.
That was licensure authority,quickly followed by the state of
(08:27):
Ohio.
In 1973, we were licensedthrough delegatory authority and
then in 2000, the legislationwas changed to licensure
authority.
Michigan in 1978 has delegatoryauthority.
Wisconsin in 1980 haddelegatory authority and then in
2012, it was changed tolicensure.
(08:49):
Alabama in 1998 has licensureauthority.
Texas in 1999 has delegatoryauthority.
New Mexico in 2001 hadlicensure authority that was
limited to specific counties andthen in 2023, there is still
licensure authority but CAAs canwork in more counties, or at
(09:13):
least it's guaranteed for longerthat CAAs can work in more
counties.
There's an episode on this.
I will put it in the show notesso that you can understand some
of the nuance.
In New Mexico, south Carolina,was passed in 2001 with
licensure.
Kentucky in 2002 with licensure.
Missouri in 2003 with licensurethat's where I work.
(09:34):
Vermont in 2003 with licensure.
The District of Columbia in2004 with licensure.
Florida, 2004 licensure.
North Carolina, 2007 licensure.
Oklahoma, 2008 licensure.
Colorado, 2012 licensure.
Guam, 2015 delegatory authority.
(09:55):
Indiana, 2015 licensure.
Kansas in 2021 with delegatoryauthority.
Utah in 2022, we have licensureauthority.
Pennsylvania in 2022, we havedelegatory authority.
Nevada in 2023, we havelicensure.
There's an episode I'll linkwith the Nevada state president
(10:20):
and that is going to explain alot more of that.
And, of course, washington in2024, we have licensure
authority and I interviewedSarah Brown in the season
opening for season four that Iwill link in the show notes for
you to learn more aboutWashington's process.
Okay, so those are all theplaces that CAAs can currently
work within the United States,and then, of course, in Guam.
(10:43):
Okay, this is Mary Jean from theFuture in the Edits and I did
not mention that CAAs are alsolicensed to work in any VA
hospital.
So even a VA hospital in astate where CAAs are not
statewide legislatively allowedto work.
We can work within a VAhospital.
(11:05):
It has to do with billing andyou know the governance of a VA
hospital versus the otherhospitals in that state.
I did not fully research this.
I do not fully understand this.
I actually am currentlysearching for a CAA who is
working within the VA system whois willing to come on the
podcast and share their journey.
So if you are a CAA or knowsomeone who is a CAA working in
(11:29):
the VA hospital, email me atawakenesthetist at gmailcom, dm
me on Instagram you can find meat awakenesthetist or just chat
me in the show notes.
I would love to tell your storyso we can all learn from you.
Okay, let's get back to theoriginal episode.
So let's break down exactlywhat licensure authority means
(11:51):
versus delegatory authority,because now you know the states
and how their legislation iswritten, but I did not really
understand the differencebetween those two types of
legislation until like last weekwhen I was doing all the
research for this.
Okay, so let me give a littlebit more of a statement that I
(12:11):
found on the ASA so the AmericanSociety of Anesthesiologists
those are the physicians aboutCAAs and where we can practice,
because they had some specificlanguage around delegatory
authority.
Let me read that and then I'llgive you my own understanding
and interpretation.
So this is a little bit of anexplanation of what delegatory
(12:33):
authority is.
From the ASA's website, quotecertain common law principles
inherent to a physician'sauthority and licensure may be
delegated to an unlicensedperson if there is a statutory
grant of authority to delegatemedical acts to unlicensed
persons and there is not astatement in the Medical
(12:55):
Practice Acts which precludesunlicensed persons from
performing any medical act.
A prohibition on unlicensedpersons performing an injection
or a prohibition on unlicensedpersons administering anesthesia
end quote persons administeringanesthesia end quote.
(13:16):
Okay, so here is my big sisterinterpretation of all of that
specific language.
So CAAs still have to havelegislation passed in the state
or district saying that we canwork, but that legislation can
either be through an actuallicense so being a licensed
profession in the state orthrough delegatory authority.
(13:36):
Delegatory authority is the moreconfusing one.
So let me start there.
Basically, within the statelegislation for each state,
there is language talking aboutwho can deliver medical care and
again, this is my very basicunderstanding, said in very
basic words that we can all havea grasp on this and there will
(13:57):
be more detailed notes in theshow notes.
But if in the state legislationthere is some language that a
physician can delegate theirresponsibilities to a
professional that they deemqualified, that language can
then be sort of pulled from thestate legislation and applied to
(14:21):
our situation where a physiciananesthesiologist delegates the
authority for a CAA to deliveranesthesia.
So it is a sort of blanketstatement that can be found in
state legislation.
It's not in every state'slegislation, so you have to go
state by state and read thelegislation to see how that
(14:41):
state says a physician candeliver care.
And if there is sort of thisgeneral blanket statement that a
licensed and qualifiedphysician can delegate their own
authority to deliver medicalcare to another professional
that is deemed qualified, ifthat language is there in a way
(15:02):
that doesn't prohibit a CAA fromworking, we can take that
language out of the legislation,like you know, make an example
of it and say here in your statelegislation there is language
that says physiciananesthesiologists can do this
for a CAA here.
See how your language can beapplied to our specific
situation and we can be granteddelegatory authority to work in
(15:27):
that specific state.
If the regulating authorities,which usually are the medical
boards, like the people who arelicensing the physicians, if
they accept that as what thestate legislation says, an
appropriate interpretation of it, and that executing it from a
physician anesthesiologistdelegating to a CAA is a proper
(15:49):
execution of that statelegislation.
So in some states thislegislation has been used.
So they've looked through.
Let's take an example Texas.
No, no, let's take Michigan,because I actually have
Michigan's actual statelegislation, the statement of
this that was kind of pulled outand then applied to physician
(16:12):
anesthesiologists delegatingauthority to CAAs.
So let's read just a little bitof that statute.
It's from the Public HealthCode, it is Act 368 of 1978, and
it is titled Delegation of Acts, tasks or Functions to Licensed
(16:33):
or Unlicensed IndividualSupervision Rules, immunity,
third-party Reimbursement orWorkers' Compensation Benefits.
So within this act there's alot of things addressed and the
delegatory authority is just oneof those things addressed.
So basically putting it alltogether, this act is saying
(16:54):
that an MD or a DO can quotedelegate to a licensed or
unlicensed individual who isotherwise qualified by education
, training or experience, theperformance of selected tasks,
training or experience, theperformance of selected tasks,
acts or functions where the acts, tasks or functions fall within
(17:16):
the scope of practice of thelicensees the doctor's
profession and will be performedunder the licensees'
supervision, end quote.
And then it goes on to justgive a lot more specifics and it
even calls out some of theprofessions that this pertains
to.
I didn't specifically see CAAsnoted in this section.
(17:38):
I'm not sure if this wascreated before or after CAAs
were licensed through delegatoryauthority in the state of
Michigan, but you can see howthat sort of general statement
can then be pulled out by ourprofessional body and say hey
look, you say that this is OK inyour state legislation if a
(17:58):
physician does this.
And hey look, ananesthesiologist is a physician
who could delegate this to a CAA.
So that is an example of thelanguage that can be utilized
for delegatory authority.
And you might be asking why inthe world would we want to do
this?
Like, why would there belanguage that an unlicensed
person could deliver any sort ofmedical care?
(18:18):
And I guess on one end it cansound a little bit, I don't know
, maybe like avant-garde orcareless, like, oh, anyone can
do this, but it's just a way toensure that health care can be
delivered in this country,because there are not enough
physician providers to givedirect care to every person who
(18:40):
needs health care, and so therehas to be ways to extend
physician care.
And because there are so manytypes of physicians and so many
type of physician extenders ormid-level providers In health
care, there's some generalizedlanguage that says how a
physician can delegate theirresponsibilities, their licensed
(19:02):
act to give health care toanother provider that is a
non-physician.
And remember also I want to saythat you can't just delegate it
to some person off the street.
You have to delegate theauthority to deliver health care
and, in our specific case, todeliver anesthesia, to a
professional who has metstandards that have been set by
(19:23):
our governing body as well as,oftentimes, hospitals' governing
bodies.
You know we have to meetcertain qualifications and so
it's not just like, oh well, aphysician can do this for anyone
.
It's very specific.
Now, delegatory authority isnot even possible in every state
, and as I'm sort of trying toexplain it, you can see how it
(19:45):
is a bit cumbersome Licensureauthority.
So passing an actual specificlicensure for CAAs within a
state is harder to do.
It takes more money, it cantake more time.
It oftentimes because we areintroducing completely new
legislation.
It allows for the people whodon't want us to be working in
(20:10):
states to sort of like stand upand speak out and say no and
hear all the reasons why CAAshouldn't come to this state, so
it kind of makes a bigger fussabout it.
Then delegatory can sometimesbe more of like a slide under
the radar because the authorityfor physicians to delegate their
medical care to qualifiedprofessionals already exists in
(20:31):
the legislation, and so that'swhy some states would choose to
try to pass delegatory authorityinstead of licensure.
But truly we as a professionwould benefit more from having
licensure authority in all 50states, because it's just more
sort of ironclad than thisdelegatory authority.
(20:53):
But a state like Texas has beenhaving delegatory authority
since 1999, and there's a lot ofCAAs who are happily working in
Texas under delegatoryauthority, and you know who's to
say if that will one day betried to move into licensure
authority.
Okay, hopefully that is clear.
Please use the chat tool, thetext message tool in the show
(21:17):
notes, or DM me at my Instagramat awakenedanesthetist, if you
have more specific questions oryou feel like I misspoke or, you
know, said something that needsclarification, because this is
tricky, which is why a lot ofCAAs don't really understand
this and why I had to work sohard for myself to even find
people who could educate me.
Okay, let's keep moving downlevels here to get smaller and
(21:42):
smaller, and let's talk not onthe state level now, but let's
talk about working and givinganesthesia as part of, like, an
anesthesia community.
So, in the culture of medicine,how is anesthesia delivered and
, specifically, how can CAAsdeliver anesthesia Like?
(22:03):
What could be said is that aCAA can work wherever
legislation has been passed thatallows CAAs to work in state or
district and, number two, thatwithin those states and
districts, caas can workwherever anesthesia care is
delivered via the anesthesiacare team model.
(22:23):
But the anesthesia care teammodel can have several different
methods of function.
One is medical direction andone of the others is called
medical supervision.
So within the anesthesia careteam model, caas can, again,
only work when medical directionis being used, nothing else.
(22:45):
So that begs the questionwhat's medical direction and how
is it different from the otherways the anesthesia care team
model can be presented?
Okay, so here's a statement onthe anesthesia care team by the
ASA.
This was again updated in 2023.
It says, quote in theanesthesia care team, the
physician anesthesiologistinvolvement in the care varies
(23:09):
when the physiciananesthesiologist directs versus
supervises care.
Again, we can only work inmedical direction when the
anesthesiologist is directingthe care.
When he or she directs care,the physician anesthesiologist
has substantially more directinvolvement with the care than
(23:29):
when he or she is supervising.
At a minimum, to meet the ASAguidelines for the ethical
practice of anesthesiology, inboth situations a physician
anesthesiologist must performthe following the pre-anesthesia
evaluation, medicaldetermination for patient to
proceed with procedure,prescribing of anesthetic plan
(23:52):
for periprocedural care andmanage post-anesthesia care.
End quote.
Okay, so that's sort ofdescribing what a physician
anesthesiologist or how theydefine an anesthesia care team
and they're highlighting thedifference between directing
care within the anesthesia careteam versus supervising care.
(24:14):
And directing care, againthrough their own statement, has
substantially more directinvolvement.
Okay, what does that mean?
So here's my like big sisterspeak coming in.
So in medical direction, thestates have said how many
mid-level providers sonon-physician anesthesia
(24:34):
providers the physiciananesthesiologist can supervise
at any one time.
And in states where CAAs canwork, we can work no more than a
four to one ratio, meaning fourCAAs are directed by one
anesthesiologist, so they aremore able to be involved with
(24:55):
the care because they're notdirecting care of seven CAAs
with only one anesthesiologist.
So seven CAAs working in sevendifferent rooms.
It's four, and so when you callthem and say hey, I need some
help, they can be there quickeror with more immediacy than if
they were, you know, fieldingcalls from seven CAAs.
(25:17):
So that's a little bit more ofthe specifics there.
Let me see what else I want totell you.
You can see how that everydefinition sort of brings up
more questions.
I just sort of danced aroundthe terminology of a physician
anesthesiologist beingimmediately available, but under
(25:41):
medical direction.
So medical direction is a waythat a physician
anesthesiologist works withinthe anesthesia care team model.
The main point is that theanesthesiologist must be
immediately available.
And then there's a definitionof what immediately available
means and the main point is thatthey can not be outside of the
(26:06):
hospital.
They cannot be personallyperforming another anesthetic by
themselves, so they can't bebilling for the care I'm doing
and then also billing for thecare they're doing like a
completely other anesthetic,other anesthetic, and they can
(26:28):
be putting in an epidural, theycan be giving a quick break to
another fellow provider in adifferent room and they can be
immediately available by phoneand then if they can't come,
they can have someone else come.
So basically, their immediateavailability means that an
anesthesiologist has to be ableto come when I call for one.
Basically, it doesn't have tobe Susan.
(26:50):
If you know, dr Susan is theone that I have supervising me
directly.
Hey, you know, I need John tocome help you because I'm stuck
in the middle of doing what elsethat would still be considered
(27:11):
immediately available in termsof the definition of what
immediately available means bythe ASA.
Okay, are we all confused?
Yet how are we doing?
Because this is why a lot ofCAAs don't understand all of
this, because it's confusing.
You have to understand theentire big picture on a macro
and micro level in order to makesense of it.
And so we're getting smallerand smaller now and we're going
(27:32):
closer and closer to like, anindividual CAA sitting in an
anesthetizing location.
So let's take it down a notchand talk about hospitals, like
what types of hospitals a CAAcan work in.
Again, we could use thatframework of CAAs can work in
any hospital that is located ina state where CAAs have legal
(27:54):
authority to work and we areperforming anesthesia within the
anesthesia care team model,within the anesthesia care team
model, and the hospital bylawshave been changed to allow CAAs
to be one of the approvedproviders within their walls and
we've been hired by thathospital to work, or their
(28:15):
anesthesia group that is maybecontracted with the hospital to
work there.
So again, if all the other abovethings are true, caas can work
in non-operating roomanesthetizing locations.
So that means in interventionalradiology, in the cath lab, in
(28:35):
satellite operating rooms.
We can work in procedure roomsthat don't have anesthesia
machines, so, for example, giprocedure rooms,
gastrointestinal procedure rooms.
We can work in pain clinics.
We can work in injectionclinics, surgery centers,
specialty surgery centers, likeones that only do bariatrics or
(28:56):
ones that only do pediatrics orplastics or ENT.
We can work in level one, big,huge city hospitals.
We can work in teeny, tiny,small regional hospitals.
We can work in any specialty,any specialty location cardiac
peds, neuro, ob, gi we can doany of that.
We can deliver anesthesia inany place, anytime, anywhere.
(29:19):
But all the other things have tobe true.
So again, let's start from thebottom and go up so we can work
in any of those places I justlisted, so long as we're working
in an anesthesia care teammodel under medical direction,
so that sort of talks to howmany anesthesiologists are there
per CAA, then we have to beworking in a hospital, in the
(29:42):
institution, so under the roofand the four walls.
That institution has to havehad CAAs placed into their
bylaws, which is generally somesort of procedural thing that
has to be approved and writtenin.
So that has to have happened.
Then, on the state level, wehave to have some sort of
legislative authority topractice whether it's delegatory
(30:04):
or licensure.
And then at the state level,the CAA.
You can't just graduate from aCAA school and be like OK, I'm a
CAA.
You have to meet the state'srequirements for what a CAA is.
And these are things.
Like you know, a CAA has tohave graduated from an
accredited AA school.
We have to have passed ournational board exam.
We have to meet a continuingeducation credit hour per year
(30:29):
or every two years.
There has to be like ongoingcontinuing education.
We have to be certified incertain specific types of CPR,
like BLS, acls and PALS CPR.
Like BLS, acls and PALS.
We have to not have any sort ofholds on our licensure, meaning
(30:49):
that we've been arrested orother things that would preclude
us from having a license ingood standing.
I can't think of anything elseright now, but I'm sure there's
other things.
So all of those things have tobe true in order for us to work
in the types of settings wherewe can work, we can deliver
anesthesia.
That's not the problem.
It's sort of all the otherthings that have to be put into
place that would allow a CAA towork.
(31:13):
I think that sort of wraps upthe highlights and the lowlights
and the intense lights of whatI wanted to tell you.
I'm going to listen back tothis and just make sure it's
clear-ish, and I suspect there'sgoing to be some follow-up
questions.
I suspect if you're not supercomfortable with what a CAA is,
you might feel a little confusedor lost Again.
Go back and listen to part oneand part two in this complete
(31:36):
guide to understanding certifiedanesthesiologist assistance.
My goal here is really to beclear and sort of plain language
, pull in some facts and sometruths so that you can start
understanding the framework ofwhat it means to be a CAA, so
that you can make the mostinformed decision if you're
trying to enter into thisprofession or if you're already
(31:59):
a CAA, so that you can be themost informed advocate for our
profession, because we needpeople who have a deep and clear
knowledge of what theirprofession is, where they can
work, what we can do, what we'relicensed to do and all of the
other things.
So, again, I hope this takes usall one step closer to
understanding where CAAs canwork.
(32:21):
I will be back with part four inthis mini series, which is
going to be a good fun one.
It's going to be how much doCAAs make?
I know this is a hot topic.
I know a lot of people are sortof drawn in by the money and
unfortunately and fortunately itis true we do make a good
salary and there's a lot ofstipulations around how that
(32:42):
money is made, where you canmake it and what it looks like
and what you have to do for it.
You can't just get it becauseyou're a CAA.
You have to do some really hardwork to get it, and so I'm just
going to take the conversationin a little bit of a new
direction, give some more behindthe scenes.
I hope it's a really good oneafter listening to this and yeah
, I'm recording this a weekbefore Thanksgiving.
(33:03):
This episode comes out the dayafter Thanksgiving 2024.
I hope everyone had at least alittle bit of time off, maybe a
good meal.
They got to see their family ortalk to their family.
I know that if you're in thehospital right now on call, it's
a really hard weekend.
It's a hard holiday Anyholidays are hard when you're at
the hospital and not withpeople you love.
(33:24):
So we're thinking of you and weappreciate you working today so
that the rest of us could behome and your patients truly
appreciate you as well whenthey're in the hospital on
Thanksgiving.
So let me know what questionsyou have, let's talk soon, y'all
.
Amelia, you want to say HappyThanksgiving into the mic?
(33:44):
Happy Thanksgiving.
Welcome to the Awakened Anesthetist podcast,
the first podcast to highlightthe CAA experience.
I'm your host, mary Jean, andI've been a certified
anesthesiologist assistant forclose to two decades.
Throughout my journey andstruggles, I've searched for
guidance that includes my uniqueperspective as a CAA, at one of
(00:42):
my lowest one.
I encourage you to stick aroundand experience the power of
being in a community filled withvoices who sound like yours,
sharing experiences you neverbelieved possible.
I know you will find yourselfhere at the Awakend Anesthetist
podcast.
Welcome in, welcome backAwakend Anesthetist community.
(01:06):
This is your host, mary jean,and welcome back to this mini
series in season four that I'mcalling your complete guide to
understanding certifiedanesthesiologist assistants.
You have tuned in to part three, which is answering the
question where can caas work?
And I just want to note thateach of these episodes in this
(01:27):
mini-series do build on oneanother, so if you're really not
familiar with certifiedanesthesiologist assistants at
all, hearing this episode as astandalone is going to be a
little bit confusing.
So I really recommend goingback and listening to part one,
which is defining what a CAA is,and then part two, which is me
(01:49):
giving you some behind thescenes of why you should not and
why you also should become aCAA.
And just the lingo, theverbiage, the acronyms, the sort
of medical ease speak that Iwill use in this episode isn't
going to make a lot of senseunless you've listened to those
episodes or you have somebaseline familiarity with being
(02:12):
a CAA, whether that means you'rea current AA student or a
practicing CAA or a prospectiveAA student.
These episodes are really meantto make more clear what a CAA
is and where we are in themedical hierarchy and what we do
, and just really be aconversation between a big
(02:34):
sister or best friend to you all, the listener.
That really is going to keep itreal and cut it to you straight
on what a CAA is.
So again, in this episode we'regoing to be answering the
question where can CAAs work?
And as a longtime practicingCAA, I found a lot of answers to
(02:54):
questions that I've had since Istarted or since before I
started being a CAA.
So really this episode is goingto be interesting to everyone
listening, even if you'repracticing CAA and you feel
pretty familiar with the basics.
I learned a lot and so I reallyencourage you to stay tuned and
, you know, just be a moreinformed CAA so that you can
(03:15):
advocate for our profession moregracefully, so that you have
some more places and resourcesto turn to If you have a
question you are not knowing theanswer to.
I'm going to put a bunch ofresources in the show notes, so
check that out.
And yeah, this might be alittle bit of a longer episode.
We're going to see how long ittakes me to feel like I explain
everything well enough, but I'mreally hoping that it's helpful
(03:39):
and that it's a resource you cankeep going back to over and
over again.
So let me lay out the frameworkfor how I'm going to tackle
this really important questionwhere can CAAs work?
I'm going to start on the mostmacro level and then move, you
know, step by step down into amicro level and we're going to
get to really specificconversation on where in a
(04:01):
hospital a CAA could work, wherein an anesthetizing location do
CAAs work, and what types ofanesthetizing locations, and so
we're going to be talking aboutthis question in several
different levels.
So let's start with the biggest, most sort of duh macro level
on where CAAs can work.
(04:22):
Let's talk a little bit aboutwhere in the world we can work.
So CAAs were first establishedwithin the United States of
America in about the 1960s.
So this profession originatedin the United States and I
thought that was the only placea CAA has ever or could have
(04:44):
ever worked.
But recently in season three ofthis podcast, which is episode
46, it's called TransatlanticTales of a CAA I interviewed a
CAA who is currently working inthe state of Florida in the
United States.
His name is Mark Leonard, buthe actually began his anesthesia
career in the United Kingdom,specifically in England, and he
(05:08):
details the association betweenUnited States CAA and the United
Kingdom equivalent, which iscalled an anesthesia associate.
And he has been both, and so Ijust wanted to reference that
episode because I really in thatepisode learned a lot myself on
(05:29):
how a CAA could work outside ofthe United States.
And the overall theme to how aCAA gets to use their license
outside of the United States isthat they have to find an
equivalent leveled anesthesiaprovider in the country that
they're in.
So as far as I know, this hasonly happened in the United
Kingdom, specifically England,and in Canada.
(05:51):
So you find our equivalent inthat country and then you
petition their agency, theirmedical board, their health
services association, whateverregulates their equivalent
anesthesia provider.
You basically petition them andask them to convert your
license your United States CAAlicense into their equivalent,
(06:14):
and how you would go about thatis something that they would
determine, and so then you havethe option of jumping through
their hoops in order to giveanesthesia in their country.
Jumping through their hoops inorder to give anesthesia in
their country.
So that's the most macro level.
Dropping down one level closer.
(06:34):
Let's focus on the United Statesand let's focus on the how and
the why behind CAAs being ableto work in certain states but
not in others.
And I was able to find a littlebit of specific legislative
lingo about where a CAA can workon the Quad A website, so I'm
just going to read that reallyquickly, because it brings up
(06:55):
two important points that I'mgoing to talk about further.
So, from the Quad A quote, thelegal ability for CAA practice
is created by legislation thatis enacted and codified into
state law or through regulationthat is adopted by the Board of
Medicine in each state.
Caas can practice within theanesthesia care team under two
(07:20):
models licensure authority ordelegatory authority.
Both state licensure and statedelegatory authority require
oversight by a state medicalboard, and both delegatory
authority and licensure can varyby state, depending upon how
the statute, rule or legislationreads, end quote.
(07:44):
Okay, that was kind of dense andI want to come back to the
difference between licensureauthority and delegatory
authority.
But first I want to tell youwhat actual states and
territories CAAs can work in asof the recording of this podcast
episode, which is November of2024.
And I am going to tell you theyear that the legislation was
(08:07):
passed and whether it was alicensure legislation or a
delegatory authority legislation, and then, of course, I'm going
to get into that.
So let's start off with Georgia.
The first state where CAAs werecreated, educated and licensed
was in 1971.
That was licensure authority,quickly followed by the state of
(08:27):
Ohio.
In 1973, we were licensedthrough delegatory authority and
then in 2000, the legislationwas changed to licensure
authority.
Michigan in 1978 has delegatoryauthority.
Wisconsin in 1980 haddelegatory authority and then in
2012, it was changed tolicensure.
(08:49):
Alabama in 1998 has licensureauthority.
Texas in 1999 has delegatoryauthority.
New Mexico in 2001 hadlicensure authority that was
limited to specific counties andthen in 2023, there is still
licensure authority but CAAs canwork in more counties, or at
(09:13):
least it's guaranteed for longerthat CAAs can work in more
counties.
There's an episode on this.
I will put it in the show notesso that you can understand some
of the nuance.
In New Mexico, south Carolina,was passed in 2001 with
licensure.
Kentucky in 2002 with licensure.
Missouri in 2003 with licensurethat's where I work.
(09:34):
Vermont in 2003 with licensure.
The District of Columbia in2004 with licensure.
Florida, 2004 licensure.
North Carolina, 2007 licensure.
Oklahoma, 2008 licensure.
Colorado, 2012 licensure.
Guam, 2015 delegatory authority.
(09:55):
Indiana, 2015 licensure.
Kansas in 2021 with delegatoryauthority.
Utah in 2022, we have licensureauthority.
Pennsylvania in 2022, we havedelegatory authority.
Nevada in 2023, we havelicensure.
There's an episode I'll linkwith the Nevada state president
(10:20):
and that is going to explain alot more of that.
And, of course, washington in2024, we have licensure
authority and I interviewedSarah Brown in the season
opening for season four that Iwill link in the show notes for
you to learn more aboutWashington's process.
Okay, so those are all theplaces that CAAs can currently
work within the United States,and then, of course, in Guam.
(10:43):
Okay, this is Mary Jean from theFuture in the Edits and I did
not mention that CAAs are alsolicensed to work in any VA
hospital.
So even a VA hospital in astate where CAAs are not
statewide legislatively allowedto work.
We can work within a VAhospital.
(11:05):
It has to do with billing andyou know the governance of a VA
hospital versus the otherhospitals in that state.
I did not fully research this.
I do not fully understand this.
I actually am currentlysearching for a CAA who is
working within the VA system whois willing to come on the
podcast and share their journey.
So if you are a CAA or knowsomeone who is a CAA working in
(11:29):
the VA hospital, email me atawakenesthetist at gmailcom, dm
me on Instagram you can find meat awakenesthetist or just chat
me in the show notes.
I would love to tell your storyso we can all learn from you.
Okay, let's get back to theoriginal episode.
So let's break down exactlywhat licensure authority means
(11:51):
versus delegatory authority,because now you know the states
and how their legislation iswritten, but I did not really
understand the differencebetween those two types of
legislation until like last weekwhen I was doing all the
research for this.
Okay, so let me give a littlebit more of a statement that I
(12:11):
found on the ASA so the AmericanSociety of Anesthesiologists
those are the physicians aboutCAAs and where we can practice,
because they had some specificlanguage around delegatory
authority.
Let me read that and then I'llgive you my own understanding
and interpretation.
So this is a little bit of anexplanation of what delegatory
(12:33):
authority is.
From the ASA's website, quotecertain common law principles
inherent to a physician'sauthority and licensure may be
delegated to an unlicensedperson if there is a statutory
grant of authority to delegatemedical acts to unlicensed
persons and there is not astatement in the Medical
(12:55):
Practice Acts which precludesunlicensed persons from
performing any medical act.
A prohibition on unlicensedpersons performing an injection
or a prohibition on unlicensedpersons administering anesthesia
end quote persons administeringanesthesia end quote.
(13:16):
Okay, so here is my big sisterinterpretation of all of that
specific language.
So CAAs still have to havelegislation passed in the state
or district saying that we canwork, but that legislation can
either be through an actuallicense so being a licensed
profession in the state orthrough delegatory authority.
(13:36):
Delegatory authority is the moreconfusing one.
So let me start there.
Basically, within the statelegislation for each state,
there is language talking aboutwho can deliver medical care and
again, this is my very basicunderstanding, said in very
basic words that we can all havea grasp on this and there will
(13:57):
be more detailed notes in theshow notes.
But if in the state legislationthere is some language that a
physician can delegate theirresponsibilities to a
professional that they deemqualified, that language can
then be sort of pulled from thestate legislation and applied to
(14:21):
our situation where a physiciananesthesiologist delegates the
authority for a CAA to deliveranesthesia.
So it is a sort of blanketstatement that can be found in
state legislation.
It's not in every state'slegislation, so you have to go
state by state and read thelegislation to see how that
(14:41):
state says a physician candeliver care.
And if there is sort of thisgeneral blanket statement that a
licensed and qualifiedphysician can delegate their own
authority to deliver medicalcare to another professional
that is deemed qualified, ifthat language is there in a way
(15:02):
that doesn't prohibit a CAA fromworking, we can take that
language out of the legislation,like you know, make an example
of it and say here in your statelegislation there is language
that says physiciananesthesiologists can do this
for a CAA here.
See how your language can beapplied to our specific
situation and we can be granteddelegatory authority to work in
(15:27):
that specific state.
If the regulating authorities,which usually are the medical
boards, like the people who arelicensing the physicians, if
they accept that as what thestate legislation says, an
appropriate interpretation of it, and that executing it from a
physician anesthesiologistdelegating to a CAA is a proper
(15:49):
execution of that statelegislation.
So in some states thislegislation has been used.
So they've looked through.
Let's take an example Texas.
No, no, let's take Michigan,because I actually have
Michigan's actual statelegislation, the statement of
this that was kind of pulled outand then applied to physician
(16:12):
anesthesiologists delegatingauthority to CAAs.
So let's read just a little bitof that statute.
It's from the Public HealthCode, it is Act 368 of 1978, and
it is titled Delegation of Acts, tasks or Functions to Licensed
(16:33):
or Unlicensed IndividualSupervision Rules, immunity,
third-party Reimbursement orWorkers' Compensation Benefits.
So within this act there's alot of things addressed and the
delegatory authority is just oneof those things addressed.
So basically putting it alltogether, this act is saying
(16:54):
that an MD or a DO can quotedelegate to a licensed or
unlicensed individual who isotherwise qualified by education
, training or experience, theperformance of selected tasks,
training or experience, theperformance of selected tasks,
acts or functions where the acts, tasks or functions fall within
(17:16):
the scope of practice of thelicensees the doctor's
profession and will be performedunder the licensees'
supervision, end quote.
And then it goes on to justgive a lot more specifics and it
even calls out some of theprofessions that this pertains
to.
I didn't specifically see CAAsnoted in this section.
(17:38):
I'm not sure if this wascreated before or after CAAs
were licensed through delegatoryauthority in the state of
Michigan, but you can see howthat sort of general statement
can then be pulled out by ourprofessional body and say hey
look, you say that this is OK inyour state legislation if a
(17:58):
physician does this.
And hey look, ananesthesiologist is a physician
who could delegate this to a CAA.
So that is an example of thelanguage that can be utilized
for delegatory authority.
And you might be asking why inthe world would we want to do
this?
Like, why would there belanguage that an unlicensed
person could deliver any sort ofmedical care?
(18:18):
And I guess on one end it cansound a little bit, I don't know
, maybe like avant-garde orcareless, like, oh, anyone can
do this, but it's just a way toensure that health care can be
delivered in this country,because there are not enough
physician providers to givedirect care to every person who
(18:40):
needs health care, and so therehas to be ways to extend
physician care.
And because there are so manytypes of physicians and so many
type of physician extenders ormid-level providers In health
care, there's some generalizedlanguage that says how a
physician can delegate theirresponsibilities, their licensed
(19:02):
act to give health care toanother provider that is a
non-physician.
And remember also I want to saythat you can't just delegate it
to some person off the street.
You have to delegate theauthority to deliver health care
and, in our specific case, todeliver anesthesia, to a
professional who has metstandards that have been set by
(19:23):
our governing body as well as,oftentimes, hospitals' governing
bodies.
You know we have to meetcertain qualifications and so
it's not just like, oh well, aphysician can do this for anyone
.
It's very specific.
Now, delegatory authority isnot even possible in every state
, and as I'm sort of trying toexplain it, you can see how it
(19:45):
is a bit cumbersome Licensureauthority.
So passing an actual specificlicensure for CAAs within a
state is harder to do.
It takes more money, it cantake more time.
It oftentimes because we areintroducing completely new
legislation.
It allows for the people whodon't want us to be working in
(20:10):
states to sort of like stand upand speak out and say no and
hear all the reasons why CAAshouldn't come to this state, so
it kind of makes a bigger fussabout it.
Then delegatory can sometimesbe more of like a slide under
the radar because the authorityfor physicians to delegate their
medical care to qualifiedprofessionals already exists in
(20:31):
the legislation, and so that'swhy some states would choose to
try to pass delegatory authorityinstead of licensure.
But truly we as a professionwould benefit more from having
licensure authority in all 50states, because it's just more
sort of ironclad than thisdelegatory authority.
(20:53):
But a state like Texas has beenhaving delegatory authority
since 1999, and there's a lot ofCAAs who are happily working in
Texas under delegatoryauthority, and you know who's to
say if that will one day betried to move into licensure
authority.
Okay, hopefully that is clear.
Please use the chat tool, thetext message tool in the show
(21:17):
notes, or DM me at my Instagramat awakenedanesthetist, if you
have more specific questions oryou feel like I misspoke or, you
know, said something that needsclarification, because this is
tricky, which is why a lot ofCAAs don't really understand
this and why I had to work sohard for myself to even find
people who could educate me.
Okay, let's keep moving downlevels here to get smaller and
(21:42):
smaller, and let's talk not onthe state level now, but let's
talk about working and givinganesthesia as part of, like, an
anesthesia community.
So, in the culture of medicine,how is anesthesia delivered and
, specifically, how can CAAsdeliver anesthesia Like?
(22:03):
What could be said is that aCAA can work wherever
legislation has been passed thatallows CAAs to work in state or
district and, number two, thatwithin those states and
districts, caas can workwherever anesthesia care is
delivered via the anesthesiacare team model.
(22:23):
But the anesthesia care teammodel can have several different
methods of function.
One is medical direction andone of the others is called
medical supervision.
So within the anesthesia careteam model, caas can, again,
only work when medical directionis being used, nothing else.
(22:45):
So that begs the questionwhat's medical direction and how
is it different from the otherways the anesthesia care team
model can be presented?
Okay, so here's a statement onthe anesthesia care team by the
ASA.
This was again updated in 2023.
It says, quote in theanesthesia care team, the
physician anesthesiologistinvolvement in the care varies
(23:09):
when the physiciananesthesiologist directs versus
supervises care.
Again, we can only work inmedical direction when the
anesthesiologist is directingthe care.
When he or she directs care,the physician anesthesiologist
has substantially more directinvolvement with the care than
(23:29):
when he or she is supervising.
At a minimum, to meet the ASAguidelines for the ethical
practice of anesthesiology, inboth situations a physician
anesthesiologist must performthe following the pre-anesthesia
evaluation, medicaldetermination for patient to
proceed with procedure,prescribing of anesthetic plan
(23:52):
for periprocedural care andmanage post-anesthesia care.
End quote.
Okay, so that's sort ofdescribing what a physician
anesthesiologist or how theydefine an anesthesia care team
and they're highlighting thedifference between directing
care within the anesthesia careteam versus supervising care.
(24:14):
And directing care, againthrough their own statement, has
substantially more directinvolvement.
Okay, what does that mean?
So here's my like big sisterspeak coming in.
So in medical direction, thestates have said how many
mid-level providers sonon-physician anesthesia
(24:34):
providers the physiciananesthesiologist can supervise
at any one time.
And in states where CAAs canwork, we can work no more than a
four to one ratio, meaning fourCAAs are directed by one
anesthesiologist, so they aremore able to be involved with
(24:55):
the care because they're notdirecting care of seven CAAs
with only one anesthesiologist.
So seven CAAs working in sevendifferent rooms.
It's four, and so when you callthem and say hey, I need some
help, they can be there quickeror with more immediacy than if
they were, you know, fieldingcalls from seven CAAs.
(25:17):
So that's a little bit more ofthe specifics there.
Let me see what else I want totell you.
You can see how that everydefinition sort of brings up
more questions.
I just sort of danced aroundthe terminology of a physician
anesthesiologist beingimmediately available, but under
(25:41):
medical direction.
So medical direction is a waythat a physician
anesthesiologist works withinthe anesthesia care team model.
The main point is that theanesthesiologist must be
immediately available.
And then there's a definitionof what immediately available
means and the main point is thatthey can not be outside of the
(26:06):
hospital.
They cannot be personallyperforming another anesthetic by
themselves, so they can't bebilling for the care I'm doing
and then also billing for thecare they're doing like a
completely other anesthetic,other anesthetic, and they can
(26:28):
be putting in an epidural, theycan be giving a quick break to
another fellow provider in adifferent room and they can be
immediately available by phoneand then if they can't come,
they can have someone else come.
So basically, their immediateavailability means that an
anesthesiologist has to be ableto come when I call for one.
Basically, it doesn't have tobe Susan.
(26:50):
If you know, dr Susan is theone that I have supervising me
directly.
Hey, you know, I need John tocome help you because I'm stuck
in the middle of doing what elsethat would still be considered
(27:11):
immediately available in termsof the definition of what
immediately available means bythe ASA.
Okay, are we all confused?
Yet how are we doing?
Because this is why a lot ofCAAs don't understand all of
this, because it's confusing.
You have to understand theentire big picture on a macro
and micro level in order to makesense of it.
And so we're getting smallerand smaller now and we're going
(27:32):
closer and closer to like, anindividual CAA sitting in an
anesthetizing location.
So let's take it down a notchand talk about hospitals, like
what types of hospitals a CAAcan work in.
Again, we could use thatframework of CAAs can work in
any hospital that is located ina state where CAAs have legal
(27:54):
authority to work and we areperforming anesthesia within the
anesthesia care team model,within the anesthesia care team
model, and the hospital bylawshave been changed to allow CAAs
to be one of the approvedproviders within their walls and
we've been hired by thathospital to work, or their
(28:15):
anesthesia group that is maybecontracted with the hospital to
work there.
So again, if all the other abovethings are true, caas can work
in non-operating roomanesthetizing locations.
So that means in interventionalradiology, in the cath lab, in
(28:35):
satellite operating rooms.
We can work in procedure roomsthat don't have anesthesia
machines, so, for example, giprocedure rooms,
gastrointestinal procedure rooms.
We can work in pain clinics.
We can work in injectionclinics, surgery centers,
specialty surgery centers, likeones that only do bariatrics or
(28:56):
ones that only do pediatrics orplastics or ENT.
We can work in level one, big,huge city hospitals.
We can work in teeny, tiny,small regional hospitals.
We can work in any specialty,any specialty location cardiac
peds, neuro, ob, gi we can doany of that.
We can deliver anesthesia inany place, anytime, anywhere.
(29:19):
But all the other things have tobe true.
So again, let's start from thebottom and go up so we can work
in any of those places I justlisted, so long as we're working
in an anesthesia care teammodel under medical direction,
so that sort of talks to howmany anesthesiologists are there
per CAA, then we have to beworking in a hospital, in the
(29:42):
institution, so under the roofand the four walls.
That institution has to havehad CAAs placed into their
bylaws, which is generally somesort of procedural thing that
has to be approved and writtenin.
So that has to have happened.
Then, on the state level, wehave to have some sort of
legislative authority topractice whether it's delegatory
(30:04):
or licensure.
And then at the state level,the CAA.
You can't just graduate from aCAA school and be like OK, I'm a
CAA.
You have to meet the state'srequirements for what a CAA is.
And these are things.
Like you know, a CAA has tohave graduated from an
accredited AA school.
We have to have passed ournational board exam.
We have to meet a continuingeducation credit hour per year
(30:29):
or every two years.
There has to be like ongoingcontinuing education.
We have to be certified incertain specific types of CPR,
like BLS, acls and PALS CPR.
Like BLS, acls and PALS.
We have to not have any sort ofholds on our licensure, meaning
(30:49):
that we've been arrested orother things that would preclude
us from having a license ingood standing.
I can't think of anything elseright now, but I'm sure there's
other things.
So all of those things have tobe true in order for us to work
in the types of settings wherewe can work, we can deliver
anesthesia.
That's not the problem.
It's sort of all the otherthings that have to be put into
place that would allow a CAA towork.
(31:13):
I think that sort of wraps upthe highlights and the lowlights
and the intense lights of whatI wanted to tell you.
I'm going to listen back tothis and just make sure it's
clear-ish, and I suspect there'sgoing to be some follow-up
questions.
I suspect if you're not supercomfortable with what a CAA is,
you might feel a little confusedor lost Again.
Go back and listen to part oneand part two in this complete
(31:36):
guide to understanding certifiedanesthesiologist assistance.
My goal here is really to beclear and sort of plain language
, pull in some facts and sometruths so that you can start
understanding the framework ofwhat it means to be a CAA, so
that you can make the mostinformed decision if you're
trying to enter into thisprofession or if you're already
(31:59):
a CAA, so that you can be themost informed advocate for our
profession, because we needpeople who have a deep and clear
knowledge of what theirprofession is, where they can
work, what we can do, what we'relicensed to do and all of the
other things.
So, again, I hope this takes usall one step closer to
understanding where CAAs canwork.
(32:21):
I will be back with part four inthis mini series, which is
going to be a good fun one.
It's going to be how much doCAAs make?
I know this is a hot topic.
I know a lot of people are sortof drawn in by the money and
unfortunately and fortunately itis true we do make a good
salary and there's a lot ofstipulations around how that
(32:42):
money is made, where you canmake it and what it looks like
and what you have to do for it.
You can't just get it becauseyou're a CAA.
You have to do some really hardwork to get it, and so I'm just
going to take the conversationin a little bit of a new
direction, give some more behindthe scenes.
I hope it's a really good oneafter listening to this and yeah
, I'm recording this a weekbefore Thanksgiving.
(33:03):
This episode comes out the dayafter Thanksgiving 2024.
I hope everyone had at least alittle bit of time off, maybe a
good meal.
They got to see their family ortalk to their family.
I know that if you're in thehospital right now on call, it's
a really hard weekend.
It's a hard holiday Anyholidays are hard when you're at
the hospital and not withpeople you love.
(33:24):
So we're thinking of you and weappreciate you working today so
that the rest of us could behome and your patients truly
appreciate you as well whenthey're in the hospital on
Thanksgiving.
So let me know what questionsyou have, let's talk soon, y'all
.
Amelia, you want to say HappyThanksgiving into the mic?
(33:44):
Happy Thanksgiving.
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