Awakened Anesthetist

Your Complete Guide to Understanding Certified Anesthesiologist Assistants Pt. 3 Where Can CAAs Work?

• Season 4 • Episode 66

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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. 

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Speaker 1:

Welcome to the Awakened Anesthetist podcast, the first podcast to highlight the CAA experience.

Speaker 1:

I'm your host, mary Jean, and I've been a certified anesthesiologist assistant for close to two decades. Throughout my journey and struggles, I've searched for guidance that includes my unique perspective as a CAA, at one of my lowest one. I encourage you to stick around and experience the power of being in a community filled with voices who sound like yours, sharing experiences you never believed possible. I know you will find yourself here at the Awakend Anesthetist podcast. Welcome in, welcome back Awakend Anesthetist community. This is your host, mary jean, and welcome back to this mini series in season four that I'm calling your complete guide to understanding certified anesthesiologist assistants. You have tuned in to part three, which is answering the question where can caas work? And I just want to note that each of these episodes in this mini-series do build on one another, so if you're really not familiar with certified anesthesiologist assistants at all, hearing this episode as a standalone is going to be a little bit confusing. So I really recommend going back and listening to part one, which is defining what a CAA is, and then part two, which is me giving you some behind the scenes of why you should not and why you also should become a CAA. And just the lingo, the verbiage, the acronyms, the sort of medical ease speak that I will use in this episode isn't going to make a lot of sense unless you've listened to those episodes or you have some baseline familiarity with being a CAA, whether that means you're a current AA student or a practicing CAA or a prospective AA student. These episodes are really meant to make more clear what a CAA is and where we are in the medical hierarchy and what we do, and just really be a conversation between a big sister or best friend to you all, the listener. That really is going to keep it real and cut it to you straight on what a CAA is.

Speaker 1:

So again, in this episode we're going to be answering the question where can CAAs work? And as a longtime practicing CAA, I found a lot of answers to questions that I've had since I started or since before I started being a CAA. So really this episode is going to be interesting to everyone listening, even if you're practicing CAA and you feel pretty familiar with the basics. I learned a lot and so I really encourage you to stay tuned and, you know, just be a more informed CAA so that you can advocate for our profession more gracefully, so that you have some more places and resources to turn to If you have a question you are not knowing the answer to. I'm going to put a bunch of resources in the show notes, so check that out. And yeah, this might be a little bit of a longer episode. We're going to see how long it takes me to feel like I explain everything well enough, but I'm really hoping that it's helpful and that it's a resource you can keep going back to over and over again. So let me lay out the framework for how I'm going to tackle this really important question where can CAAs work? I'm going to start on the most macro level and then move, you know, step by step down into a micro level and we're going to get to really specific conversation on where in a hospital a CAA could work, where in an anesthetizing location do CAAs work, and what types of anesthetizing locations, and so we're going to be talking about this question in several different levels. So let's start with the biggest, most sort of duh macro level on where CAAs can work. Let's talk a little bit about where in the world we can work.

Speaker 1:

So CAAs were first established within the United States of America in about the 1960s. So this profession originated in the United States and I thought that was the only place a CAA has ever or could have ever worked. But recently in season three of this podcast, which is episode 46, it's called Transatlantic Tales of a CAA I interviewed a CAA who is currently working in the state of Florida in the United States. His name is Mark Leonard, but he actually began his anesthesia career in the United Kingdom, specifically in England, and he details the association between United States CAA and the United Kingdom equivalent, which is called an anesthesia associate. And he has been both, and so I just wanted to reference that episode because I really in that episode learned a lot myself on how a CAA could work outside of the United States.

Speaker 1:

And the overall theme to how a CAA gets to use their license outside of the United States is that they have to find an equivalent leveled anesthesia provider in the country that they're in. So as far as I know, this has only happened in the United Kingdom, specifically England, and in Canada. So you find our equivalent in that country and then you petition their agency, their medical board, their health services association, whatever regulates their equivalent anesthesia provider. You basically petition them and ask them to convert your license your United States CAA license into their equivalent, and how you would go about that is something that they would determine, and so then you have the option of jumping through their hoops in order to give anesthesia in their country. Jumping through their hoops in order to give anesthesia in their country. So that's the most macro level. Dropping down one level closer.

Speaker 1:

Let's focus on the United States and let's focus on the how and the why behind CAAs being able to work in certain states but not in others. And I was able to find a little bit of specific legislative lingo about where a CAA can work on the Quad A website, so I'm just going to read that really quickly, because it brings up two important points that I'm going to talk about further. So, from the Quad A quote, the legal ability for CAA practice is created by legislation that is enacted and codified into state law or through regulation that is adopted by the Board of Medicine in each state. Caas can practice within the anesthesia care team under two models licensure authority or delegatory authority. Both state licensure and state delegatory authority require oversight by a state medical board, and both delegatory authority and licensure can vary by state, depending upon how the statute, rule or legislation reads, end quote.

Speaker 1:

Okay, that was kind of dense and I want to come back to the difference between licensure authority and delegatory authority. But first I want to tell you what actual states and territories CAAs can work in as of the recording of this podcast episode, which is November of 2024. And I am going to tell you the year that the legislation was passed and whether it was a licensure 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 were created, educated and licensed was in 1971. That was licensure authority, quickly followed by the state of Ohio. In 1973, we were licensed through delegatory authority and then in 2000, the legislation was changed to licensure authority. Michigan in 1978 has delegatory authority. Wisconsin in 1980 had delegatory authority and then in 2012, it was changed to licensure. Alabama in 1998 has licensure authority. Texas in 1999 has delegatory authority. New Mexico in 2001 had licensure authority that was limited to specific counties and then in 2023, there is still licensure authority but CAAs can work in more counties, or at least it's guaranteed for longer that CAAs can work in more counties.

Speaker 1:

There's an episode on this. I will put it in the show notes so 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 licensure that's where I work. Vermont in 2003 with licensure. The District of Columbia in 2004 with licensure. Florida, 2004 licensure. North Carolina, 2007 licensure. Oklahoma, 2008 licensure. Colorado, 2012 licensure. Guam, 2015 delegatory authority. Indiana, 2015 licensure. Kansas in 2021 with delegatory authority. Utah in 2022, we have licensure authority. Pennsylvania in 2022, we have delegatory authority. Nevada in 2023, we have licensure. There's an episode I'll link with the Nevada state president and that is going to explain a lot more of that. And, of course, washington in 2024, we have licensure authority and I interviewed Sarah Brown in the season opening for season four that I will link in the show notes for you to learn more about Washington's process. Okay, so those are all the places that CAAs can currently work within the United States, and then, of course, in Guam.

Speaker 1:

Okay, this is Mary Jean from the Future in the Edits and I did not mention that CAAs are also licensed to work in any VA hospital. So even a VA hospital in a state where CAAs are not statewide legislatively allowed to work. We can work within a VA hospital. It has to do with billing and you know the governance of a VA hospital versus the other hospitals in that state. I did not fully research this. I do not fully understand this. I actually am currently searching for a CAA who is working within the VA system who is willing to come on the podcast and share their journey. So if you are a CAA or know someone who is a CAA working in the VA hospital, email me at awakenesthetist at gmailcom, dm me on Instagram you can find me at awakenesthetist or just chat me in the show notes. I would love to tell your story so we can all learn from you.

Speaker 1:

Okay, let's get back to the original episode. So let's break down exactly what licensure authority means versus delegatory authority, because now you know the states and how their legislation is written, but I did not really understand the difference between those two types of legislation until like last week when I was doing all the research for this. Okay, so let me give a little bit more of a statement that I found on the ASA so the American Society of Anesthesiologists those are the physicians about CAAs and where we can practice, because they had some specific language around delegatory authority. Let me read that and then I'll give you my own understanding and interpretation. So this is a little bit of an explanation of what delegatory authority is. From the ASA's website, quote certain common law principles inherent to a physician's authority and licensure may be delegated to an unlicensed person if there is a statutory grant of authority to delegate medical acts to unlicensed persons and there is not a statement in the Medical Practice Acts which precludes unlicensed persons from performing any medical act. A prohibition on unlicensed persons performing an injection or a prohibition on unlicensed persons administering anesthesia end quote persons administering anesthesia end quote. Okay, so here is my big sister interpretation of all of that specific language. So CAAs still have to have legislation passed in the state or district saying that we can work, but that legislation can either be through an actual license so being a licensed profession in the state or through delegatory authority.

Speaker 1:

Delegatory authority is the more confusing one. So let me start there. Basically, within the state legislation for each state, there is language talking about who can deliver medical care and again, this is my very basic understanding, said in very basic words that we can all have a grasp on this and there will be more detailed notes in the show notes. But if in the state legislation there is some language that a physician can delegate their responsibilities to a professional that they deem qualified, that language can then be sort of pulled from the state legislation and applied to our situation where a physician anesthesiologist delegates the authority for a CAA to deliver anesthesia. So it is a sort of blanket statement that can be found in state legislation. It's not in every state's legislation, so you have to go state by state and read the legislation to see how that state says a physician can deliver care. And if there is sort of this general blanket statement that a licensed and qualified physician can delegate their own authority to deliver medical care to another professional that is deemed qualified, if that language is there in a way that doesn't prohibit a CAA from working, we can take that language out of the legislation, like you know, make an example of it and say here in your state legislation there is language that says physician anesthesiologists can do this for a CAA here. See how your language can be applied to our specific situation and we can be granted delegatory authority to work in that specific state. If the regulating authorities, which usually are the medical boards, like the people who are licensing the physicians, if they accept that as what the state legislation says, an appropriate interpretation of it, and that executing it from a physician anesthesiologist delegating to a CAA is a proper execution of that state legislation.

Speaker 1:

So in some states this legislation 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 state legislation, the statement of this that was kind of pulled out and then applied to physician anesthesiologists delegating authority to CAAs.

Speaker 1:

So let's read just a little bit of that statute. It's from the Public Health Code, it is Act 368 of 1978, and it is titled Delegation of Acts, tasks or Functions to Licensed or Unlicensed Individual Supervision Rules, immunity, third-party Reimbursement or Workers' Compensation Benefits. So within this act there's a lot of things addressed and the delegatory authority is just one of those things addressed. So basically putting it all together, this act is saying that an MD or a DO can quote delegate to a licensed or unlicensed individual who is otherwise qualified by education, training or experience, the performance of selected tasks, training or experience, the performance of selected tasks, acts or functions where the acts, tasks or functions fall within the scope of practice of the licensees the doctor's profession and will be performed under the licensees' supervision, end quote. And then it goes on to just give a lot more specifics and it even calls out some of the professions that this pertains to.

Speaker 1:

I didn't specifically see CAAs noted in this section. I'm not sure if this was created before or after CAAs were licensed through delegatory authority in the state of Michigan, but you can see how that sort of general statement can then be pulled out by our professional body and say hey look, you say that this is OK in your state legislation if a physician does this. And hey look, an anesthesiologist is a physician who could delegate this to a CAA. So that is an example of the language that can be utilized for delegatory authority. And you might be asking why in the world would we want to do this? Like, why would there be language that an unlicensed person could deliver any sort of medical care? And I guess on one end it can sound a little bit, I don't know, maybe like avant-garde or careless, like, oh, anyone can do this, but it's just a way to ensure that health care can be delivered in this country, because there are not enough physician providers to give direct care to every person who needs health care, and so there has to be ways to extend physician care. And because there are so many types of physicians and so many type of physician extenders or mid-level providers In health care, there's some generalized language that says how a physician can delegate their responsibilities, their licensed act to give health care to another provider that is a non-physician.

Speaker 1:

And remember also I want to say that you can't just delegate it to some person off the street. You have to delegate the authority to deliver health care and, in our specific case, to deliver anesthesia, to a professional who has met standards that have been set by our governing body as well as, oftentimes, hospitals' governing bodies. You know we have to meet certain qualifications and so it's not just like, oh well, a physician can do this for anyone. It's very specific. Now, delegatory authority is not even possible in every state, and as I'm sort of trying to explain it, you can see how it is a bit cumbersome Licensure authority.

Speaker 1:

So passing an actual specific licensure for CAAs within a state is harder to do. It takes more money, it can take more time. It oftentimes because we are introducing completely new legislation. It allows for the people who don't want us to be working in states to sort of like stand up and speak out and say no and hear all the reasons why CAA shouldn't come to this state, so it kind of makes a bigger fuss about it. Then delegatory can sometimes be more of like a slide under the radar because the authority for physicians to delegate their medical care to qualified professionals already exists in the legislation, and so that's why some states would choose to try to pass delegatory authority instead of licensure. But truly we as a profession would benefit more from having licensure authority in all 50 states, because it's just more sort of ironclad than this delegatory authority. But a state like Texas has been having delegatory authority since 1999, and there's a lot of CAAs who are happily working in Texas under delegatory authority, and you know who's to say if that will one day be tried to move into licensure authority.

Speaker 1:

Okay, hopefully that is clear. Please use the chat tool, the text message tool in the show notes, or DM me at my Instagram at awakenedanesthetist, if you have more specific questions or you feel like I misspoke or, you know, said something that needs clarification, because this is tricky, which is why a lot of CAAs don't really understand this and why I had to work so hard for myself to even find people who could educate me. Okay, let's keep moving down levels here to get smaller and smaller, and let's talk not on the state level now, but let's talk about working and giving anesthesia as part of, like, an anesthesia community. So, in the culture of medicine, how is anesthesia delivered and, specifically, how can CAAs deliver anesthesia Like? What could be said is that a CAA can work wherever legislation has been passed that allows CAAs to work in state or district and, number two, that within those states and districts, caas can work wherever anesthesia care is delivered via the anesthesia care team model. But the anesthesia care team model can have several different methods of function. One is medical direction and one of the others is called medical supervision. So within the anesthesia care team model, caas can, again, only work when medical direction is being used, nothing else. So that begs the question what's medical direction and how is it different from the other ways the anesthesia care team model can be presented?

Speaker 1:

Okay, so here's a statement on the anesthesia care team by the ASA. This was again updated in 2023. It says, quote in the anesthesia care team, the physician anesthesiologist involvement in the care varies when the physician anesthesiologist directs versus supervises care. Again, we can only work in medical direction when the anesthesiologist is directing the care. When he or she directs care, the physician anesthesiologist has substantially more direct involvement with the care than when he or she is supervising. At a minimum, to meet the ASA guidelines for the ethical practice of anesthesiology, in both situations a physician anesthesiologist must perform the following the pre-anesthesia evaluation, medical determination for patient to proceed with procedure, prescribing of anesthetic plan for periprocedural care and manage post-anesthesia care. End quote.

Speaker 1:

Okay, so that's sort of describing what a physician anesthesiologist or how they define an anesthesia care team and they're highlighting the difference between directing care within the anesthesia care team versus supervising care. And directing care, again through their own statement, has substantially more direct involvement. Okay, what does that mean? So here's my like big sister speak coming in. So in medical direction, the states have said how many mid-level providers so non-physician anesthesia providers the physician anesthesiologist can supervise at any one time. And in states where CAAs can work, we can work no more than a four to one ratio, meaning four CAAs are directed by one anesthesiologist, so they are more able to be involved with the care because they're not directing care of seven CAAs with only one anesthesiologist. So seven CAAs working in seven different rooms. It's four, and so when you call them and say hey, I need some help, they can be there quicker or with more immediacy than if they were, you know, fielding calls from seven CAAs. So that's a little bit more of the specifics there.

Speaker 1:

Let me see what else I want to tell you. You can see how that every definition sort of brings up more questions. I just sort of danced around the terminology of a physician anesthesiologist being immediately available, but under medical direction. So medical direction is a way that a physician anesthesiologist works within the anesthesia care team model. The main point is that the anesthesiologist must be immediately available. And then there's a definition of what immediately available means and the main point is that they can not be outside of the hospital. They cannot be personally performing another anesthetic by themselves, so they can't be billing for the care I'm doing and then also billing for the care they're doing like a completely other anesthetic, other anesthetic, and they can be putting in an epidural, they can be giving a quick break to another fellow provider in a different room and they can be immediately available by phone and then if they can't come, they can have someone else come. So basically, their immediate availability means that an anesthesiologist has to be able to come when I call for one. Basically, it doesn't have to be Susan. If you know, dr Susan is the one that I have supervising me directly. Hey, you know, I need John to come help you because I'm stuck in the middle of doing what else that would still be considered immediately available in terms of the definition of what immediately available means by the ASA.

Speaker 1:

Okay, are we all confused? Yet how are we doing? Because this is why a lot of CAAs don't understand all of this, because it's confusing. You have to understand the entire big picture on a macro and micro level in order to make sense of it. And so we're getting smaller and smaller now and we're going closer and closer to like, an individual CAA sitting in an anesthetizing location. So let's take it down a notch and talk about hospitals, like what types of hospitals a CAA can work in. Again, we could use that framework of CAAs can work in any hospital that is located in a state where CAAs have legal authority to work and we are performing anesthesia within the anesthesia care team model, within the anesthesia care team model, and the hospital bylaws have been changed to allow CAAs to be one of the approved providers within their walls and we've been hired by that hospital to work, or their anesthesia group that is maybe contracted with the hospital to work there.

Speaker 1:

So again, if all the other above things are true, caas can work in non-operating room anesthetizing locations. So that means in interventional radiology, in the cath lab, in satellite operating rooms. We can work in procedure rooms that don't have anesthesia machines, so, for example, gi procedure rooms, gastrointestinal procedure rooms. We can work in pain clinics. We can work in injection clinics, surgery centers, specialty surgery centers, like ones that only do bariatrics or ones that only do pediatrics or plastics 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 do any of that. We can deliver anesthesia in any place, anytime, anywhere.

Speaker 1:

But all the other things have to be true. So again, let's start from the bottom and go up so we can work in any of those places I just listed, so long as we're working in an anesthesia care team model under medical direction, so that sort of talks to how many anesthesiologists are there per CAA, then we have to be working in a hospital, in the institution, so under the roof and the four walls. That institution has to have had CAAs placed into their bylaws, which is generally some sort of procedural thing that has to be approved and written in. So that has to have happened. Then, on the state level, we have to have some sort of legislative authority to practice whether it's delegatory or licensure. And then at the state level, the CAA.

Speaker 1:

You can't just graduate from a CAA school and be like OK, I'm a CAA. You have to meet the state's requirements for what a CAA is. And these are things. Like you know, a CAA has to have graduated from an accredited AA school. We have to have passed our national board exam. We have to meet a continuing education credit hour per year or every two years. There has to be like ongoing continuing education. We have to be certified in certain specific types of CPR, like BLS, acls and PALS CPR. Like BLS, acls and PALS. We have to not have any sort of holds on our licensure, meaning that we've been arrested or other things that would preclude us from having a license in good standing. I can't think of anything else right now, but I'm sure there's other things. So all of those things have to be true in order for us to work in the types of settings where we can work, we can deliver anesthesia. That's not the problem. It's sort of all the other things that have to be put into place that would allow a CAA to work.

Speaker 1:

I think that sort of wraps up the highlights and the lowlights and the intense lights of what I wanted to tell you. I'm going to listen back to this and just make sure it's clear-ish, and I suspect there's going to be some follow-up questions. I suspect if you're not super comfortable with what a CAA is, you might feel a little confused or lost Again. Go back and listen to part one and part two in this complete guide to understanding certified anesthesiologist assistance. My goal here is really to be clear and sort of plain language, pull in some facts and some truths so that you can start understanding the framework of what it means to be a CAA, so that you can make the most informed decision if you're trying to enter into this profession or if you're already a CAA, so that you can be the most informed advocate for our profession, because we need people who have a deep and clear knowledge of what their profession is, where they can work, what we can do, what we're licensed to do and all of the other things. So, again, I hope this takes us all one step closer to understanding where CAAs can work.

Speaker 1:

I will be back with part four in this mini series, which is going to be a good fun one. It's going to be how much do CAAs make? I know this is a hot topic. I know a lot of people are sort of drawn in by the money and unfortunately and fortunately it is true we do make a good salary and there's a lot of stipulations around how that money is made, where you can make it and what it looks like and what you have to do for it. You can't just get it because you're a CAA. You have to do some really hard work to get it, and so I'm just going to take the conversation in a little bit of a new direction, give some more behind the scenes. I hope it's a really good one after listening to this and yeah, I'm recording this a week before Thanksgiving.

Speaker 1:

This episode comes out the day after Thanksgiving 2024. I hope everyone had at least a little bit of time off, maybe a good meal. They got to see their family or talk to their family. I know that if you're in the hospital right now on call, it's a really hard weekend. It's a hard holiday Any holidays are hard when you're at the hospital and not with people you love. So we're thinking of you and we appreciate you working today so that the rest of us could be home and your patients truly appreciate you as well when they're in the hospital on Thanksgiving. So let me know what questions you have, let's talk soon, y'all. Amelia, you want to say Happy Thanksgiving into the mic? Happy Thanksgiving.

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Mary Jeanne Roberts, CAA

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