WEBVTT 00:13.160 --> 00:14.963 [SPEAKER_01]: Hello and welcome back to ACRAC. 00:15.203 --> 00:18.328 [SPEAKER_01]: I'm Jed Wolffaugh and we are back with another keyword episode. 00:18.448 --> 00:29.184 [SPEAKER_01]: I'm thrilled to have with me as always Dr. Tim Kaistura who is going to take us through actually the kind of miscellaneous section of the outline. 00:29.224 --> 00:38.538 [SPEAKER_01]: He's going to tell us what that means and about that, but we're going to take you through this stuff that actually appears on the exam's quite a lot, but doesn't fall under anyone giving category and so let's get to it. 00:38.838 --> 00:40.180 [SPEAKER_01]: Tim, welcome back to the show. 00:40.413 --> 00:40.994 [SPEAKER_02]: Thank you. 00:41.154 --> 00:42.476 [SPEAKER_02]: Again, it's always for having me. 00:43.198 --> 00:43.899 [SPEAKER_02]: You're totally right. 00:43.959 --> 00:47.464 [SPEAKER_02]: So we're doing special problems or issues in anesthesia today. 00:47.685 --> 00:52.152 [SPEAKER_02]: And today is interesting because we're covering all of part D of a basic topic's outline. 00:52.172 --> 00:53.194 [SPEAKER_02]: So part A is huge. 00:53.234 --> 00:54.336 [SPEAKER_02]: It's all of basic science. 00:54.496 --> 00:55.437 [SPEAKER_02]: B is huge. 00:55.498 --> 01:02.609 [SPEAKER_02]: It's all of clinical science, which is procedures and methods and techniques and C is all of organ-based basic and clinical sciences. 01:02.749 --> 01:06.235 [SPEAKER_02]: And then there's this D of miscellaneous stuff like you said. 01:06.215 --> 01:09.238 [SPEAKER_02]: It covers one physician impairment or disability. 01:09.279 --> 01:14.865 [SPEAKER_02]: It covers two physics, practice, management, and medical legal issues. 01:15.486 --> 01:16.947 [SPEAKER_02]: And there's a whole subset in there. 01:17.768 --> 01:18.609 [SPEAKER_02]: I'll cover all of that. 01:19.410 --> 01:20.211 [SPEAKER_02]: And I was looking at it. 01:20.251 --> 01:28.260 [SPEAKER_02]: And actually, there's also a corresponding session in advanced topics as well, called Part E. It's special problems or issues in an sociology, same name. 01:28.541 --> 01:29.742 [SPEAKER_02]: It looks pretty similar. 01:29.722 --> 01:44.322 [SPEAKER_02]: It has electrical controls of therapy in it, organ donation, radiologic procedures and anesthesia locations outside of our operating rooms, and then the big ethics, practice, management, and medical legal issues that the basic does. 01:44.403 --> 01:46.445 [SPEAKER_02]: and also patient safety and quality improvement. 01:46.846 --> 01:48.147 [SPEAKER_02]: And that's a lot to cover. 01:48.727 --> 01:51.070 [SPEAKER_02]: ECT, we've already covered in a different keyword episode. 01:51.130 --> 01:53.392 [SPEAKER_02]: There are two accurate episodes on the organization. 01:53.412 --> 01:55.975 [SPEAKER_02]: There's an episode on non-operative human anesthesia. 01:55.995 --> 01:58.698 [SPEAKER_02]: So I don't think we need to rehash all of that stuff. 01:58.858 --> 02:06.926 [SPEAKER_02]: We'll cover all of the basic outland party and add in the corresponding topics in advance to sort of round out that stuff so we don't have to come back to it. 02:07.206 --> 02:12.672 [SPEAKER_02]: And all we'll have left that will tack in at some future point is quality improvement from Part E. 02:12.972 --> 02:14.615 [SPEAKER_02]: And again, you sort of alluded to this. 02:14.675 --> 02:15.717 [SPEAKER_02]: This is often the case here. 02:15.797 --> 02:17.720 [SPEAKER_02]: We can't cover everything in these topics. 02:18.080 --> 02:19.162 [SPEAKER_02]: And it's actually a hard topic. 02:19.182 --> 02:20.224 [SPEAKER_02]: I looked at the textbooks. 02:20.324 --> 02:27.596 [SPEAKER_02]: And there aren't chapters sort of devoted in Miller, or in Morgan McKell that cover this and say, this is what you need to know. 02:28.177 --> 02:30.641 [SPEAKER_02]: It really is a little bit of a grab bag area. 02:30.681 --> 02:36.651 [SPEAKER_02]: So my goal is to make sure we have all a good grasp of the foundational basics and highlight the things that seem to get tested the most. 02:37.002 --> 02:39.348 [SPEAKER_02]: And I'm going to throw in one other quick plug here. 02:39.388 --> 02:48.410 [SPEAKER_02]: If people listening to this have requests, have ideas of what we should cover on the keyword episodes, feel like we've missed something, send us an email. 02:48.811 --> 02:53.863 [SPEAKER_02]: I am happy to key up whatever people want to listen to next. 02:54.012 --> 02:57.660 [SPEAKER_02]: I think you want to add to that before we sort of dive into our initial concepts. 02:58.001 --> 02:58.903 [SPEAKER_01]: No, I think that's great. 02:59.023 --> 03:00.747 [SPEAKER_01]: And I love the reach out. 03:00.767 --> 03:11.532 [SPEAKER_01]: People can use the acrack podcast at gmail.com or also acrackadacrack.com to send any emails if there's a keyword topic that you want to see covered. 03:12.305 --> 03:15.748 [SPEAKER_02]: OK, so we'll split today broadly into four topics. 03:15.808 --> 03:19.532 [SPEAKER_02]: We'll talk about licensure credentialing certification to the vet stuff. 03:20.632 --> 03:22.995 [SPEAKER_02]: Second, we'll talk about physician impairment and malpractice. 03:23.355 --> 03:24.596 [SPEAKER_02]: I'll tell you why I lump those together. 03:24.656 --> 03:27.299 [SPEAKER_02]: And then three ethics and four patient safety. 03:27.339 --> 03:30.341 [SPEAKER_02]: So first up is licensure credentialing certification. 03:30.401 --> 03:42.312 [SPEAKER_02]: And what the ABA wants to make sure you understand here is how you get certified, how you maintain that certification, and it differences between all of those term certification, licensure, and credentials. 03:42.292 --> 03:49.061 [SPEAKER_02]: That is the recognition that you've met the baseline requirements necessary to practice a profession in our case medicine. 03:49.782 --> 04:01.837 [SPEAKER_02]: In the U.S. and I realize there are some international listeners here and I apologize that a lot of this stuff is U.S. specific, which will typically require having graduated from the medical school and completing the U.S. semile step exams and is a state-specific process. 04:01.857 --> 04:04.080 [SPEAKER_02]: So you get licensed in different states. 04:04.060 --> 04:14.833 [SPEAKER_02]: key concept to certification in this context and in medicine is meeting a national board requirement for some level beyond that basic license or practice medicine. 04:15.314 --> 04:26.507 [SPEAKER_02]: And incredibly applicable example is how few skewered episodes are aimed at helping us pass the required written examinations and certification as an anesthesiologist by the American Board of anesthesiologists. 04:26.487 --> 04:32.439 [SPEAKER_02]: The American Board of NCCL just also has some special T certifications that you can go for as well. 04:32.560 --> 04:35.886 [SPEAKER_02]: All of those are above just your license. 04:35.907 --> 04:42.420 [SPEAKER_02]: Key concept 3, credentialing and privileging are hospital and employer-driven process process. 04:42.721 --> 05:02.007 [SPEAKER_02]: Credentially usually happens when you initiate employment in the process by wishing employer confirms that you have the correct license, credentialing, if there is any experience they require above that, and then privileging is related, but more specifically, it relates to an employee begin permission to perform certain clinical activities at their place of employment. 05:02.027 --> 05:08.796 [SPEAKER_02]: So you could theoretically be certified to do some cases that your hospital hasn't given you privileges to do. 05:09.181 --> 05:09.922 [SPEAKER_02]: Yeah. 05:09.942 --> 05:10.923 [SPEAKER_02]: And you want to add about that. 05:11.003 --> 05:11.644 [SPEAKER_02]: Yeah, go ahead. 05:11.664 --> 05:18.431 [SPEAKER_01]: No, I mean, I think this stuff is it certainly may come up on exams, but also it's just good to know for in general. 05:18.491 --> 05:20.833 [SPEAKER_01]: And I'm always amazed that people don't necessarily know this stuff. 05:20.853 --> 05:24.637 [SPEAKER_01]: For example, you do not have to complete a residency to get licensed. 05:24.897 --> 05:27.860 [SPEAKER_01]: You can complete, I think most states do require one year. 05:27.900 --> 05:32.846 [SPEAKER_01]: So you can do it for example, an intern year and then get a license and practice medicine. 05:33.286 --> 05:35.188 [SPEAKER_01]: In theory, you could open up. 05:35.168 --> 05:38.853 [SPEAKER_01]: You can hang a shingle in your front door and say, I do neurosurgery here. 05:39.474 --> 05:51.030 [SPEAKER_01]: And if someone wanted to come to you to receive neurosurgery, you could do it in theory, so you're not applying for credentialing or privileges, since you have your own house and you're running a clinic. 05:51.050 --> 05:54.114 [SPEAKER_01]: I don't know about getting the machines and things that would be needed. 05:54.494 --> 05:58.560 [SPEAKER_01]: But the point is that you can get a license to practice medicine without completing a residency. 05:58.540 --> 06:12.786 [SPEAKER_01]: That is different than getting board certified as Tim said and getting privileges and credentialing and most hospitals in order to credential you and give you privileges will require that you be board certified not just licensed, but again, that's up to the hospital. 06:13.424 --> 06:20.998 [SPEAKER_02]: And just because I think this will come up at some point, I'll mention that actually, not just board certification, but at least be boarded eligible. 06:21.279 --> 06:31.077 [SPEAKER_02]: So if you were early out of residency and are still in the process that you may end up certified and just having completed those exams yet, that's often enough, as long as you haven't lost your eligibility for some reason. 06:31.357 --> 06:36.647 [SPEAKER_01]: Yep, you're totally right, sorry, I misspoke and you are corrected should be board eligible or board certified, exactly. 06:37.117 --> 06:38.520 [SPEAKER_02]: All right, let's do some questions. 06:38.961 --> 06:46.035 [SPEAKER_02]: Number one, medical doctor successfully graduates from an accredited anesthesiology residency and applies for a new job at a community hospital. 06:46.415 --> 06:49.882 [SPEAKER_02]: Whichever following can wait until after they start working clinically. 06:50.263 --> 06:57.758 [SPEAKER_02]: A, gaining certification in anesthesiology, be being credentialed by their employer or see obtaining a state medical license. 06:57.890 --> 06:58.130 [SPEAKER_01]: Great. 06:58.190 --> 07:07.465 [SPEAKER_01]: And so hopefully what we just went over helps answer this, but you probably will not be board certified in anesthesiology when you first get a job. 07:07.946 --> 07:13.495 [SPEAKER_01]: You will be board eligible, meaning you are in the process of trying to get it, but you don't have to have it yet. 07:13.535 --> 07:15.218 [SPEAKER_01]: And so that would make aid a correct answer. 07:15.518 --> 07:25.534 [SPEAKER_01]: But you do, of course, in order to start working clinically, need to be credentialed at your hospital and you will probably not be able to get credentialed or be allowed to practice in a state without a state license. 07:26.273 --> 07:26.634 [SPEAKER_02]: Perfect. 07:26.974 --> 07:27.656 [SPEAKER_02]: Question 2. 07:28.157 --> 07:35.792 [SPEAKER_02]: An anesthesiologist who has been practicing in their current setting learns a new procedure at an anesthesiology conference and incorporates it into their practice. 07:36.454 --> 07:41.023 [SPEAKER_02]: After having an initially fact by the building department, they are told they are not allowed to perform this procedure. 07:41.444 --> 07:46.915 [SPEAKER_02]: This is most likely related to their A, licensure, B, profession or C privileges. 07:47.097 --> 08:14.893 [SPEAKER_01]: right so this gets down to what you are saying to him that the specific procedures you are allowed to do at a hospital are your privileges and so you can't just decide to do a new procedure you have to be privileged to do it and so privileges is the correct answer here and your licensure does not dictate you can do this you can't do that right 08:14.873 --> 08:19.602 [SPEAKER_01]: The hospital you work at has to decide which things you are allowed to practice at that hospital. 08:20.560 --> 08:32.771 [SPEAKER_02]: Yeah, and that last sense of profession, I don't know exactly what they're getting at, but if it's, you know, you're practicing anesthesia, but it's something that anesthesia conferences, it's probably not that you're trying to suddenly do some kind of neural surgery, so it's probably not related to your profession. 08:33.132 --> 08:44.442 [SPEAKER_01]: Right, although I will say that's a little tricky because you might think, oh yeah, you know, like I can't come and bring something back that isn't in my specialty, but actually you could get privilege to do something that isn't traditionally done by your specialty. 08:44.462 --> 08:49.707 [SPEAKER_01]: So if you are an anesthesiologist and you go and you learn how to do, 08:49.957 --> 09:05.805 [SPEAKER_01]: uh... you know percutaneous tracheostomies which is more typical for someone with critical care training but not so much for just people who just do anesthesia but you could apply for privileges and if your hospital was willing to privilege you to do that you could do it absolutely 09:06.038 --> 09:12.565 [SPEAKER_02]: Right, another set of questions on certification that are common on the ABA Samus deal with maintenance of certification. 09:12.965 --> 09:17.230 [SPEAKER_02]: And unfortunately, these questions tend to test knowledge that simply just must be memorized. 09:17.310 --> 09:20.253 [SPEAKER_02]: It's just the rules of maintenance of certification that the ABA has. 09:20.654 --> 09:28.982 [SPEAKER_02]: And you don't really come across this until you actually start working on maintaining your certification, which by definition is after you've taken all of these exams and passed them. 09:29.443 --> 09:35.269 [SPEAKER_02]: So they just sort of force you to learn and stuff a little bit early. 09:35.249 --> 09:38.693 [SPEAKER_02]: give you the numbers and what you need to know and what I've seen to show up on exams. 09:38.773 --> 09:45.400 [SPEAKER_02]: And the current maintenance of certification program from the ABA is the Mocha 2.0 program. 09:46.382 --> 09:49.625 [SPEAKER_02]: I think this applies to everyone in 2016 or after somewhere around there. 09:50.006 --> 09:51.748 [SPEAKER_02]: In this cycle is a 10-year cycle. 09:52.508 --> 09:56.493 [SPEAKER_02]: Those summary requirements need to be done at more specific time frames than there are four parts. 09:56.913 --> 10:00.177 [SPEAKER_02]: One, you must hold an active unrestricted medical license. 10:00.157 --> 10:06.266 [SPEAKER_02]: Two, you must earn 250 category one CME credits, 20 of which must be related to patient safety. 10:06.947 --> 10:13.536 [SPEAKER_02]: Three, you must participate in most minute, answering 120 questions a year, and at least 30 questions per quarter. 10:13.896 --> 10:23.009 [SPEAKER_02]: In four, you must earn 50 quality improvement points, 25 in the first five years, and 25 in the second five years, thank you for pleading to add a session towards the end of that 10 years. 10:23.450 --> 10:29.218 [SPEAKER_02]: And I apologize, those are just numbers you're gonna have to learn, and they do come up pretty regularly on examinations. 10:29.198 --> 10:44.252 [SPEAKER_01]: And I'll just make one small thing, which is that it changed actually recently, so that it's now a five year, not a 10 year cycle in anesthesiology, and I think that was mandated by across all boards and all specialties, but for sure it's true in anesthesi. 10:44.292 --> 10:59.205 [SPEAKER_01]: So now it doesn't really matter all it means is that instead of five in the first five years, I've been 25 in the first five years, 25 in the second five years, it's just 25 in five years, and then it resets, which essentially makes it the exact same thing, but 10:59.185 --> 11:01.248 [SPEAKER_02]: Perfect. 11:01.548 --> 11:06.694 [SPEAKER_02]: It shows you even I who am starting my maintenance right now, it's not quite clear on the numbers. 11:07.596 --> 11:07.956 [SPEAKER_02]: Exactly. 11:07.976 --> 11:08.617 [SPEAKER_02]: All right. 11:08.777 --> 11:09.418 [SPEAKER_02]: Question three. 11:09.578 --> 11:15.646 [SPEAKER_02]: Which of the following qualifies toward the quality improvement portion of the current ABA maintenance of certification guidelines? 11:16.407 --> 11:18.930 [SPEAKER_02]: A attending immortality and morbidity conference? 11:19.491 --> 11:26.239 [SPEAKER_02]: B presenting at a more tallity morbidity conference, or C completing 30 locomotive questions at quarter. 11:26.557 --> 11:39.395 [SPEAKER_01]: Yeah, and so what you'll see when you do get board certified is that there are a list of things that count toward the quality improvement portion and attending an M&M conference is not but presenting does count for part of it and so that's the answer here. 11:39.435 --> 11:48.227 [SPEAKER_01]: And while you do need to do 30 locomotive and questions per quarter in order to maintain your board certification that does not count toward the quality improvement part other things that count are. 11:48.207 --> 11:58.977 [SPEAKER_01]: attending simulations around that have to do with quality improvement, writing up cases leading a quality improvement project at your institution and things like that. 12:00.323 --> 12:07.756 [SPEAKER_02]: And for which of a following is required to be compliant with the ABA's maintenance of certification to point on program? 12:08.217 --> 12:18.636 [SPEAKER_02]: A, completing 120 mocha minute questions per quarter, B, having an active driver's license at the time of resortification, and C, paying an annual mocha program fee. 12:18.785 --> 12:19.046 [SPEAKER_01]: right. 12:19.066 --> 12:24.279 [SPEAKER_01]: So it was a tricky maybe because you think a but it's 30 a quarter, not 120 per quarter. 12:24.299 --> 12:25.282 [SPEAKER_01]: So a is incorrect. 12:26.084 --> 12:27.508 [SPEAKER_01]: Uh, having an active driver's license. 12:27.628 --> 12:35.308 [SPEAKER_01]: Everyone in New York just panic, but no, you do not need a driver's license to do any of this, but you do need to pay an annual Mocha program fee. 12:36.115 --> 12:44.545 [SPEAKER_02]: Yeah, and you do need an active medical license, but the driver's license, but in the next session, I want to talk about physician impairment and malpractice. 12:44.565 --> 12:55.718 [SPEAKER_02]: And the reason this kind of follows naturally is that the questions that they ask often relate to what needs to be reported regarding malpractice and impairment and how that impacts licensure and re-certification. 12:55.738 --> 12:59.342 [SPEAKER_02]: So we just talked about all the rules for how to get certified and maintain that. 13:00.123 --> 13:04.468 [SPEAKER_02]: And then these are some things that could potentially cause a challenge in those. 13:04.448 --> 13:11.005 [SPEAKER_02]: Key concept 5 to establish a medical malpractice lawsuit, a plaintiff must prove four elements. 13:11.025 --> 13:12.188 [SPEAKER_02]: And I think these are worth knowing. 13:12.629 --> 13:18.043 [SPEAKER_02]: One is causation, did an act or no mission cause the poor outcome to do due to the patient. 13:18.143 --> 13:19.707 [SPEAKER_02]: Was that defendants? 13:19.687 --> 13:22.334 [SPEAKER_02]: In our case, we would probably be a state anesthesiologist. 13:22.394 --> 13:24.279 [SPEAKER_02]: Are we responsible for the patient's care? 13:24.319 --> 13:29.432 [SPEAKER_02]: Three negligence or breach of duty was the standard of care not met. 13:30.053 --> 13:31.758 [SPEAKER_02]: And four are their damages. 13:31.818 --> 13:35.788 [SPEAKER_02]: Does a male practice rise to the level that money should be given to the plaintiff? 13:36.477 --> 13:42.892 [SPEAKER_02]: So whenever I ask about malpractice, they talk about, you know, if this is malpractice or not, think about whether those things are true. 13:43.594 --> 13:52.275 [SPEAKER_02]: And then key concepts, and email practice payment must be reported to the national practitioner data bank, even in the case of settled out of court. 13:52.255 --> 14:11.563 [SPEAKER_02]: Additionally, for following our also reportable events, adverse clinical privilege actions, professional society actions, exclusions from federal or state health care programs, licensure and certification actions, health care related criminal or civil convictions, regiments, and negative actions from peer review or private accreditation organizations. 14:11.543 --> 14:13.167 [SPEAKER_02]: And I don't want you to memorize all that. 14:13.207 --> 14:14.430 [SPEAKER_02]: I'm glad you just heard it. 14:14.490 --> 14:15.132 [SPEAKER_02]: Thank you for that. 14:15.573 --> 14:28.303 [SPEAKER_02]: But for test taking purposes, just assume that if some entity within the licensing certification or credentialing pipeline or a court took action against you or an anesthesiologist in some way, it's reportable. 14:28.283 --> 14:35.236 [SPEAKER_02]: Also note that you have 60 days to notify the AAPABA, if a restriction has been placed on your license. 14:35.277 --> 14:39.104 [SPEAKER_02]: And that's something that generally a very portable event will be reported by someone else. 14:39.284 --> 14:43.272 [SPEAKER_02]: You're required to tell the ABA if someone has restricted your license. 14:43.825 --> 14:45.427 [SPEAKER_02]: Okay, G comes up seven. 14:45.887 --> 14:57.680 [SPEAKER_02]: Physician impairment in anesthesiologists can occur secondary to substance use disorder, commonly tested, or a plethora of other issues, including depression, financial strain, medical disorders, personal relationships, et cetera. 14:58.682 --> 15:04.688 [SPEAKER_02]: Substance use, including alcohol and anesthesiologists that present the same rate as a general public about 10 to 20%. 15:04.969 --> 15:12.617 [SPEAKER_02]: And it's about one to two percent for drugs other than alcohol and anesthesiologists, which opioids are the most commonly misused. 15:12.597 --> 15:26.698 [SPEAKER_02]: The death rate for anesthesiologists who have a substance use disorder is about 10 to 15 percent, and it's notable that the risk of death for anesthesiologists who had a substance use disorder during training, it's much higher than those who did not later on in their careers. 15:27.279 --> 15:36.633 [SPEAKER_02]: Those are all numbers of things that I've seen tested before, and that's why I've given some of those numbers to those facts. 15:37.194 --> 15:37.554 [SPEAKER_02]: Great. 15:37.574 --> 15:38.436 [SPEAKER_01]: Yeah, I agree. 15:38.656 --> 15:42.081 [SPEAKER_01]: This stuff, especially the substance impairment stuff, comes up a lot on test. 15:42.905 --> 15:45.968 [SPEAKER_02]: Okay, so let's do a few practice questions. 15:46.629 --> 15:54.156 [SPEAKER_02]: Number five, an anesthesiologist in an academic practice is concerned their colleagues' performances and parents secondary to a substance use disorder. 15:54.517 --> 15:55.418 [SPEAKER_02]: What is the best approach? 15:56.459 --> 15:59.001 [SPEAKER_02]: A, privately asked them if they are abusing opioids. 15:59.702 --> 16:02.705 [SPEAKER_02]: B, tell a department leader what their concerns are. 16:03.306 --> 16:07.630 [SPEAKER_02]: Or see ignore this as impairment and can occur due to non-substance use issues. 16:07.812 --> 16:12.440 [SPEAKER_01]: Yeah, so I mean, hopefully C is something you can cross out and then you're trying to tie between A and B. 16:12.480 --> 16:16.708 [SPEAKER_01]: And while you might be tempted to think like, look, I don't want to get them in trouble. 16:16.748 --> 16:18.370 [SPEAKER_01]: Maybe I should talk to them individually. 16:18.411 --> 16:21.416 [SPEAKER_01]: The right answer here is to tell a departmental leader about your concerns. 16:22.578 --> 16:26.224 [SPEAKER_01]: And that is going to be the answer on these types of questions. 16:27.186 --> 16:28.067 [SPEAKER_02]: Yeah, and I'm curious. 16:28.108 --> 16:30.231 [SPEAKER_02]: I think there's a few reasons why that's the best sense. 16:30.251 --> 16:32.976 [SPEAKER_02]: So why do you think that's the best sense through Jen? 16:33.158 --> 16:34.440 [SPEAKER_01]: So I think there's a few reasons. 16:34.600 --> 16:44.275 [SPEAKER_01]: One is that you want this handled in a professional way by people who are expert and trained in handling this, so that the person doesn't feel threatened. 16:44.315 --> 16:52.167 [SPEAKER_01]: They feel supported, and that they can be, if it is, in fact, a justified concern and they are appearing to be imperative work. 16:52.207 --> 16:55.993 [SPEAKER_01]: They can be tested, appropriately, and get the support they need. 16:56.433 --> 17:01.461 [SPEAKER_01]: If you go tell them, first of all, the chances are they're going to say no, even if they are. 17:01.441 --> 17:20.007 [SPEAKER_01]: It may spook them, it may make them feel panic, it may make them do something rash, it may make them feel like they need to, you know, take, go hide all of the things that they have been doing in a way that would make it a lot harder to find out that they're doing it and then get them to help they need. 17:20.780 --> 17:23.103 [SPEAKER_02]: Yeah, and I think I think I'm right there with you. 17:23.123 --> 17:43.288 [SPEAKER_02]: I'm not sure that in any of the research I did for this, I sort of found that slam dunk answer of why that's the best course of action, but I think leaving it in the hands of people that have the most experience in doing this, have the knowledge and how to approach these things is going to lead to the best outcome for anyone if they are in any kind of danger, or you need any kind of support. 17:43.609 --> 17:44.610 [SPEAKER_01]: For sure. 17:44.590 --> 17:53.584 [SPEAKER_02]: Question 6, you are named in a malpractice lawsuit after a patient experience and extended hospitalization, secondary to a complication from a radio or terial line. 17:54.044 --> 17:56.508 [SPEAKER_02]: You and your hospital system decide to settle out of court. 17:56.869 --> 17:58.070 [SPEAKER_02]: The following is now required. 17:58.711 --> 18:02.537 [SPEAKER_02]: A, this must be reported to the National Practitioner Data Bank. 18:02.938 --> 18:10.429 [SPEAKER_02]: B, you must inform the American Board of NSC'sology within 60 days, or C, you must reapply for our terial line placement privileges. 18:10.966 --> 18:20.778 [SPEAKER_01]: Yeah, so the answer here's a, as you said in your overview, if you have a finding against you or you settle a lawsuit against you, you have to report that to the National Practitioner Data Bank. 18:21.919 --> 18:36.197 [SPEAKER_01]: Unless an action was a restriction of place on your license, you do not have to report it at all to the board and unless your hospital decided to rescind your privileges for our territorial line placement, then you would not have to reapply for privileges. 18:36.886 --> 18:37.286 [SPEAKER_02]: Perfect. 18:37.927 --> 18:38.167 [SPEAKER_02]: 7. 18:38.508 --> 18:40.970 [SPEAKER_02]: You are a resident in an anesthesiology program. 18:41.250 --> 18:47.877 [SPEAKER_02]: You are surprised when one of your colleagues announces that they are taking leave of absence to obtain treatment for substance use disorder. 18:47.897 --> 18:50.960 [SPEAKER_02]: You look up this to 6 and 5-met compared to the general population. 18:51.120 --> 18:53.483 [SPEAKER_02]: Substance use in anesthesiology is 8. 18:54.404 --> 19:02.792 [SPEAKER_02]: Much less common than the general population, be much more common than the general population or see above as common as in the general population. 19:02.772 --> 19:09.908 [SPEAKER_01]: Yeah, and I think maybe somewhat surprisingly for people, the answer as you went over earlier is about as common as in the general population. 19:10.048 --> 19:21.574 [SPEAKER_01]: So it's a big problem because one is too many, but also remember the general population includes a huge number of people, they're going to be lots of people with. 19:21.554 --> 19:34.693 [SPEAKER_01]: something's used disorder, et cetera, where as we're taking a people who are very successful professionally and then saying that actually the same, the rate is about the same, which means quite, quite disturbingly, a large number. 19:35.855 --> 19:41.042 [SPEAKER_01]: So we want to be really aware of this, but the number is about as common, the percent is about as common. 19:41.563 --> 19:43.025 [SPEAKER_00]: Stay with us, we'll be right back. 19:45.950 --> 19:46.971 [SPEAKER_00]: All right, and we're back. 19:47.643 --> 19:55.576 [SPEAKER_02]: And just worth hammering that point home, which is why that question is here again, that you would think that secondary to all of the things we hear about. 19:55.656 --> 20:07.035 [SPEAKER_02]: The ease of access to medications I can be abused, the stress of being in anesthesiologists that you think that the rate is higher, it is not at least than the general population. 20:07.724 --> 20:14.302 [SPEAKER_02]: Next up, Ethics, and I know I'm being repetitive here, but again, we won't incompossibly cover all of medical ethics here. 20:14.823 --> 20:22.965 [SPEAKER_02]: I just want to refresh some of the foundational definitions and give a few examples of how these show up on the anesthesiology boards. 20:22.945 --> 20:48.970 [SPEAKER_02]: Um, he concept eight, um, the four main principles of ethics as a reminder, there is one autonomy, respect of an individual is right to make it on decisions, uh, beneficence, the obligation to act in a way that promotes good outcomes, three non-malficence, the obligation to avoid causing harm to do no harm principle, and for justice ensuring fairness and a distribution of resources and the treatment of individuals. 20:50.215 --> 21:06.206 [SPEAKER_02]: And key concept 9, one of the ethical principles I get tested a lot is consent and what is informed of consent, so I'll remind you that capacity is the ability to understand information and use it to make a decision and communicate that decision with others. 21:06.687 --> 21:11.076 [SPEAKER_02]: And capacity can be specific to individual decisions. 21:11.056 --> 21:22.695 [SPEAKER_02]: Consent is the voluntary agreement itself to a decision, such as to undergo a certain treatment or surgery, and consent is not permanent, and it can be revoked at any time. 21:22.775 --> 21:27.523 [SPEAKER_02]: So just because someone did consent does not mean that they continue to consent to something. 21:29.366 --> 21:30.548 [SPEAKER_02]: You want to dive right into questions? 21:30.848 --> 21:31.309 [SPEAKER_02]: Let's do it. 21:32.065 --> 21:32.325 [SPEAKER_02]: 8. 21:33.026 --> 21:36.450 [SPEAKER_02]: A 14-year-old child presents for an elective outpatient procedure. 21:36.751 --> 21:42.858 [SPEAKER_02]: You arrive to the pre-operative holding area and discuss the risk and benefits of anesthesia with the patient and their mother. 21:43.399 --> 21:55.474 [SPEAKER_02]: Before proceeding with the case, you should get a, consent from the mother and consent from the child, be consent from the mother and a sent from the child, or see a sent from the mother and consent from the child. 21:55.572 --> 22:01.101 [SPEAKER_01]: Yeah, so I think this is so interesting because this concept of a scent was not taught. 22:01.863 --> 22:04.387 [SPEAKER_01]: I don't it may have existed, but it wasn't taught when I was in medical school. 22:04.828 --> 22:09.936 [SPEAKER_01]: And yet it is being now and I know this because I'm an oral board examiner and I've had people use this term. 22:09.956 --> 22:14.003 [SPEAKER_01]: You know, the examiners and I had to look it up because I had not heard it before. 22:13.983 --> 22:16.588 [SPEAKER_01]: So it turns out that this is a thing. 22:16.648 --> 22:21.417 [SPEAKER_01]: So you have to get consent, which is the legal requirement from an adult. 22:21.497 --> 22:26.407 [SPEAKER_01]: So it's either the patient who's an adult or in this setting because the patient is under 18. 22:26.787 --> 22:30.555 [SPEAKER_01]: You need to get the mother or father or guardians consent, in this case it's the mother. 22:30.995 --> 22:32.518 [SPEAKER_01]: So you need consent from the mother. 22:32.939 --> 22:33.460 [SPEAKER_01]: But 22:33.440 --> 22:39.773 [SPEAKER_01]: The ethical thing to do with a child who's old enough to give us sent is to get us sent. 22:39.813 --> 22:48.310 [SPEAKER_01]: In other words, you want the child to agree that they want to have this procedure too, even though the legal consent comes from the Guardian. 22:49.201 --> 22:52.604 [SPEAKER_02]: Yeah, and so in this question, it's pretty straightforward. 22:52.644 --> 22:53.125 [SPEAKER_02]: Yeah, be. 22:53.185 --> 22:55.567 [SPEAKER_02]: Get consent from the mother and get a sent from the child. 22:55.768 --> 23:07.019 [SPEAKER_02]: I would be surprised if you start seeing the ethical gray areas of illegal guardian giving consent and you not having a sent from the minor and then asking you what you should do. 23:08.040 --> 23:16.288 [SPEAKER_02]: You know, there's few answers that are correct when they just say colon ethics consult, but that would probably be one of them depending on the urgency of the procedure. 23:16.268 --> 23:19.074 [SPEAKER_01]: Yeah, there's no way that would come up on written boards. 23:19.134 --> 23:20.217 [SPEAKER_01]: I just cannot imagine. 23:20.337 --> 23:27.513 [SPEAKER_01]: I think in theory it could come up in oral boards, but that would be something you would have to kind of think your way through. 23:27.674 --> 23:29.718 [SPEAKER_01]: I don't think, I mean, there are some wrong answers right. 23:29.738 --> 23:32.103 [SPEAKER_01]: I think the wrong answer would be to say we don't care what the kid thinks. 23:32.925 --> 23:35.070 [SPEAKER_01]: But, you know, again, talking it over. 23:35.050 --> 23:48.617 [SPEAKER_01]: trying to get some understanding of what's going on, maybe bringing in the FX team, deciding whether it's an emergent or urgent procedure or not, so lots of things that could play a role in your discussion if it was or a board's, but not going to happen. 23:48.677 --> 23:51.102 [SPEAKER_01]: Two complex for our written board question. 23:51.706 --> 23:52.287 [SPEAKER_02]: Absolutely. 23:53.127 --> 24:00.494 [SPEAKER_02]: Question nine, a patient is admitted to the intensive care unit from the floor after emergent intubation for acute hypercarbic respiratory failure. 24:00.994 --> 24:21.713 [SPEAKER_02]: After reviewing the medical record, the intensive notes that the patient received multiple intravenous policies of opioids prior to respiratory failure from the first call provider due to reported 10 out of 10 pain, which ethical principle to the first call provider most likely follow in ordering these medications. 24:21.693 --> 24:25.477 [SPEAKER_01]: Yeah, so these, like this comes up all the time, right? 24:25.497 --> 24:27.219 [SPEAKER_01]: They want you to know these terms and what they mean. 24:27.679 --> 24:35.788 [SPEAKER_01]: So this doctor was trying to do what he or she thought was going to help the patient the most to do good for the patient. 24:36.228 --> 24:37.189 [SPEAKER_01]: And that's beneficence. 24:37.229 --> 24:38.491 [SPEAKER_01]: So that's a, that's the answer. 24:38.851 --> 24:41.774 [SPEAKER_01]: Non-malficence would have been do no harm, which would have actually been the opposite, right? 24:41.794 --> 24:45.658 [SPEAKER_01]: Which would be to say, well, I'm not going to give it because I'm afraid of the harm it might do. 24:45.638 --> 24:49.017 [SPEAKER_01]: And autonomy would be to maybe give the patient a PCA, right? 24:49.037 --> 24:52.898 [SPEAKER_01]: It'll give them some control over the dose of the medicine that they're getting. 24:53.941 --> 24:54.321 [SPEAKER_01]: Perfect. 24:55.002 --> 24:55.683 [SPEAKER_02]: Question 10. 24:55.843 --> 25:01.127 [SPEAKER_02]: You are asked by a colleague to consent an inpatient for general anesthesia for a procedure scheduled the next day. 25:01.648 --> 25:06.012 [SPEAKER_02]: The patient does not know why they are in the hospital or what procedure they are going to have. 25:06.592 --> 25:14.459 [SPEAKER_02]: They happen to be retired anesthesiologists can recite back the risks and benefits of a general anesthetic you described and agree to general anesthesia for the procedure. 25:14.920 --> 25:23.948 [SPEAKER_02]: You should have them sign an anesthesia consent form, be tell the primary team the patient 25:23.928 --> 25:26.393 [SPEAKER_01]: Yeah, actually, this one is a little tricky. 25:27.074 --> 25:35.551 [SPEAKER_01]: So what they're describing is a patient who clearly knows what anesthesia is, what the risk and benefits are, and can recite that back to you and discuss it. 25:35.852 --> 25:41.363 [SPEAKER_01]: So they understand the risk and benefits of anesthesia, and they are willing to consent for anesthesia. 25:41.343 --> 25:46.011 [SPEAKER_01]: They clearly cannot, at this moment, consent for surgery because they don't even know what surgery they are going to have. 25:46.512 --> 25:55.146 [SPEAKER_01]: But I think what they're getting at here is that you can consent them for general anesthesia because they understand there are some benefits of general anesthesia, and that does not mean they're consenting for surgery. 25:55.627 --> 25:57.430 [SPEAKER_01]: And so you can do that. 25:57.510 --> 25:58.672 [SPEAKER_01]: You can have them sign the consent form. 25:58.952 --> 26:01.917 [SPEAKER_01]: The primary team, it's not that the patient lacks capacity, is that they just don't know. 26:01.957 --> 26:04.802 [SPEAKER_01]: So the primary team would have to, of course, have a discussion with them. 26:04.968 --> 26:21.762 [SPEAKER_01]: under explained the risk and benefits of the surgery they're having and make sure they can understand the surgery they're having and all that in order to consent for surgery and you don't need an ethics console here unless it were to happen maybe that you felt a patient did not have capacity to consent and the surgical team was insisting on consenting them then you might need an ethics console. 26:23.328 --> 26:28.915 [SPEAKER_02]: Yeah, and I think this is sort of splitting here as but importantly to make sure that you understand it. 26:28.935 --> 26:36.384 [SPEAKER_02]: It's uneasy as it is to have someone sign an anesthesia consent form and say they know how to consent for anesthesia and can't consent for anesthesia. 26:36.424 --> 26:39.587 [SPEAKER_02]: When they don't even, you know, they may not know why they're in the hospital. 26:40.288 --> 26:44.413 [SPEAKER_02]: Um, capacity is a decision specific date. 26:44.773 --> 26:51.141 [SPEAKER_02]: You can have capacity to consent for anesthesia, even if you don't have capacity to consent for something else like surgery. 26:52.741 --> 26:57.546 [SPEAKER_02]: OK, and lastly, we'll cover some of the most commonly tested patient safety topics. 26:57.566 --> 27:00.509 [SPEAKER_02]: So this is the fourth of our four topics today. 27:01.450 --> 27:13.043 [SPEAKER_02]: Key concept 10, while supportive non-judgmental voluntary patients need to reporting programs on tourism and systems hospitals, the reporting of Sentinel events to the joint commission is mandatory. 27:13.563 --> 27:22.613 [SPEAKER_02]: Sentinel events include those that result in death, permanent harm, severe temporary harm, and intervention required to sustain life. 27:23.167 --> 27:29.137 [SPEAKER_02]: key concept 11, medication errors are a common source of adverse patient safety and anesthesia. 27:29.558 --> 27:40.536 [SPEAKER_02]: Errors can include omission, given the wrong medication, given the medication to the wrong route, given the wrong dose of a correct medication, misdocumentation or an inadvertent bolus. 27:40.777 --> 27:48.550 [SPEAKER_02]: I think by this sort of the most common example is if you have a phasopressor, 27:48.530 --> 28:11.449 [SPEAKER_02]: infusion going and you give a medication you meant to give but your flush and extra vasopressor that's an inventant bolus and the risk of medication error can be reduced through the use of pre-filled syringes, color coding of drug types, avoiding look-alike names or vials, barcode labeling, sparn infusion pumps, including cold decision supports software. 28:11.429 --> 28:21.123 [SPEAKER_02]: A lot of the questions in patient safety, I think, especially in anesthesiology, rightfully so focus on medication errors, as they are some of the most common errors in our field. 28:22.545 --> 28:25.409 [SPEAKER_02]: And then key concepts, 12, and our last key concepts for the day. 28:25.929 --> 28:33.560 [SPEAKER_02]: When medication errors or other unintestated outcomes occur, these should be disclosed to the patient and family in a timely manner. 28:34.121 --> 28:40.069 [SPEAKER_02]: Beyond the ethical requirement, to do so, studies have found that the disclosure of errors reduces the risk of litigation. 28:41.399 --> 28:43.382 [SPEAKER_02]: anything to add in terms of patient safety. 28:43.402 --> 28:45.665 [SPEAKER_02]: Anything you see often that I haven't mentioned. 28:46.406 --> 28:47.287 [SPEAKER_01]: No, I think these are key. 28:47.367 --> 28:50.651 [SPEAKER_01]: I guess I would say that a part about disclosure is really important. 28:50.812 --> 28:52.434 [SPEAKER_01]: It's the first time you do this. 28:52.634 --> 28:53.816 [SPEAKER_01]: It's really scary. 28:53.876 --> 28:56.079 [SPEAKER_01]: You're going to be tempted not to do it. 28:56.740 --> 29:00.585 [SPEAKER_01]: And as a trainee, I mean, you should obviously be doing this with an attending who can help you through it. 29:00.605 --> 29:02.547 [SPEAKER_01]: But it is really important. 29:02.648 --> 29:03.989 [SPEAKER_01]: And it does engender trust. 29:04.070 --> 29:05.912 [SPEAKER_01]: If you go and you say, look, this is what happened. 29:05.952 --> 29:08.636 [SPEAKER_01]: This was a word, we're terribly sorry that this happened. 29:08.876 --> 29:11.119 [SPEAKER_01]: And by the way, there are laws in most states 29:11.099 --> 29:17.591 [SPEAKER_01]: protect you, you cannot be sued and to be said you admitted to fall because you use the word I'm sorry. 29:17.651 --> 29:22.921 [SPEAKER_01]: So it is okay to say I'm really sorry that this happened, you know, this is what happened, this is what we're doing about it. 29:23.362 --> 29:33.040 [SPEAKER_01]: So as you said, doing that actually will reduce the risk of litigation and we want to disclose and we want to be very clear about what we're doing to try to correct the problem. 29:34.673 --> 29:35.474 [SPEAKER_02]: Yeah, thanks for that. 29:36.356 --> 29:39.380 [SPEAKER_02]: All right, a couple of last questions, and we'll wrap up for the day. 29:40.262 --> 29:43.928 [SPEAKER_02]: Question 11, an immersion abdominal case is starting in an operating room. 29:44.408 --> 29:48.655 [SPEAKER_02]: During time out, it is stated that the patient received measure night as all in the emergency department. 29:49.296 --> 29:53.543 [SPEAKER_02]: The anesthesiologist in the room and ministers' sephasology before incision. 29:53.523 --> 30:02.254 [SPEAKER_02]: The patient later develops a post-operative infection, which requires emergent re-operation, and it is discovered the likely cause was that the mentioned eye to solve was never administered. 30:02.775 --> 30:05.258 [SPEAKER_02]: Whichever following is true regarding this medication error. 30:05.918 --> 30:09.663 [SPEAKER_02]: A, it could have potentially been avoided with clinical decision support software. 30:10.224 --> 30:17.573 [SPEAKER_02]: B, it does not need to be disclosed as where unmedication was not given, and C, it does not need to be reported to the joint commission. 30:18.059 --> 30:23.854 [SPEAKER_01]: So this is an error that led to significant patient harm, so it does need to be reported to the joint commission. 30:23.914 --> 30:33.199 [SPEAKER_01]: It should be disclosed because again, it was an error and we should be open about that with the patient and family. 30:33.179 --> 30:42.456 [SPEAKER_01]: And so the answer is going to be a could have potentially been avoided with clinical decisions for software and like many medical errors, the system could be better that might have prevented it. 30:42.496 --> 30:46.543 [SPEAKER_01]: So we don't want to be necessarily saying, oh, this individual provider really screwed up. 30:47.084 --> 30:49.669 [SPEAKER_01]: Any of us could have made this mistake. 30:49.649 --> 31:06.606 [SPEAKER_01]: If there had been a system which was able to make it clear, if the medicine had or hadn't been given, if there was a requirement, for example, that the nurse scanned the medication as it was being given, that wouldn't have happened, and then a alert would have popped up on the anesthesia provider screen saying, you know, a flagell never given, then that might have prevented this. 31:06.666 --> 31:08.029 [SPEAKER_01]: So, while 31:08.009 --> 31:16.567 [SPEAKER_01]: You know, we do want to disclose this, and we do need to report it to the Joint Commission that doesn't mean the provider who had this error is somehow a bad provider. 31:16.888 --> 31:24.685 [SPEAKER_01]: It means that the system should be improved so that this doesn't happen again. 31:26.099 --> 31:50.014 [SPEAKER_02]: briefly mentioned it or sort of assume that it's understood in like he concept 10 that that these the voluntary reporting systems should be supportive and non-judgmental and in doing that they should look at the systems issues that led to these errors being happening rather than sort of figuring out who is to blame for them. 31:50.450 --> 32:00.950 [SPEAKER_02]: And I guess one other thing we can add here is the idea of a root cause analysis, which is a investigation into a reported event. 32:01.511 --> 32:10.368 [SPEAKER_02]: Always looks to figure out what could be what was the ultimate cause of something, not to give blame, but so that can be fixed. 32:10.608 --> 32:12.492 [SPEAKER_02]: If you see those steps of questions come up. 32:13.467 --> 32:22.156 [SPEAKER_02]: And then number 12, an anesthesiology resident is finishing an outpatient surgical procedure and proceeds to administer what they think is on dance of trun. 32:22.716 --> 32:29.303 [SPEAKER_02]: Shortly thereafter, the patient's heart rate increases and the resident notices the viral they thought was on dance of trun was in fact extra peed. 32:29.323 --> 32:33.387 [SPEAKER_02]: The resident did not spot this mistake earlier because the two drug bios appear similar. 32:33.908 --> 32:38.833 [SPEAKER_02]: Which of a following would be a cost effective and appropriate method to help prevent this error in the future? 32:38.813 --> 32:48.351 [SPEAKER_02]: A, the use of tall men lettering B, the use of an electronic barcode laborer, or C, the use of a second person to check medications prior to administration. 32:48.820 --> 33:09.922 [SPEAKER_01]: Yeah, so first of all, I love this question because if anyone was at ASA, I did a live podcast episode there where we talk specifically about how the human brain can actually tell you that the vile you're looking at that says after pain, your brain may actually make it seem to your eyes like it says on the answer to it, right? 33:10.342 --> 33:13.005 [SPEAKER_01]: So it actually isn't sufficient. 33:12.985 --> 33:16.009 [SPEAKER_01]: to just say, oh, Tim, you made this mistake. 33:16.029 --> 33:17.570 [SPEAKER_01]: You need to look more closely. 33:17.731 --> 33:18.752 [SPEAKER_01]: Read closely, Tim. 33:18.792 --> 33:20.334 [SPEAKER_01]: Just read closely, and it won't happen. 33:20.354 --> 33:29.945 [SPEAKER_01]: That actually is not a good solution because you may have actually picked up that file and looked at it, but because the situation and the color of the file and everything was telling your brain, this is on Dancetron. 33:29.965 --> 33:34.470 [SPEAKER_01]: You may actually have seen on Dancetron written there, which is crazy, but that's actually how the human brain works. 33:34.450 --> 33:36.753 [SPEAKER_01]: So, it isn't, I mean, it's a good idea. 33:36.793 --> 33:42.520 [SPEAKER_01]: We should always read the labels, but we can't just say, if you make an medication, or it's because you didn't read the label, okay? 33:42.900 --> 33:47.586 [SPEAKER_01]: And so changing the size of the lettering is not going to necessarily help in that situation. 33:48.127 --> 33:49.989 [SPEAKER_01]: But the use of an electronic barcode label, right? 33:50.049 --> 33:54.214 [SPEAKER_01]: Where you scan the barcode, and that pops up, right? 33:54.254 --> 33:57.538 [SPEAKER_01]: So that you would see a presumably, 33:57.518 --> 34:12.609 [SPEAKER_01]: I mean, we don't actually have this, so I don't know how this would work, but presumably this is going to cause a pop-up that's going to say atrapeen on your screen or something so that you would know exactly what you were giving and maybe even an alert that would say, are you sure you want to give atrapeen to this patient whose heart rate is 80, right? 34:13.210 --> 34:16.557 [SPEAKER_01]: And so that is a systems change, which could make a big difference. 34:16.537 --> 34:20.104 [SPEAKER_01]: And the use of a second person to check medications, I mean, sure that probably would help. 34:20.385 --> 34:30.906 [SPEAKER_01]: But again, that's not cost effective because now you're trying to have to pay another person to be there to do this or take a nurse away from what they're doing and delay things in the OR. 34:30.926 --> 34:36.958 [SPEAKER_01]: So while that is possible and it would probably help, it's going to not be as cost effective as having an automatic way to do this. 34:37.968 --> 34:38.509 [SPEAKER_02]: Absolutely. 34:38.929 --> 34:42.913 [SPEAKER_02]: And the common lettering is absolutely cost effective and appropriate. 34:43.113 --> 34:46.917 [SPEAKER_02]: It's just for sound alike medications, which is isn't right. 34:46.937 --> 34:49.300 [SPEAKER_02]: This is a look alike issue, not a sound alike issue. 34:49.660 --> 34:54.285 [SPEAKER_02]: The common lettering is great for difference between Ephedian and Epidephrine and things like that. 34:57.108 --> 34:57.368 [SPEAKER_02]: Great. 34:57.668 --> 35:00.751 [SPEAKER_02]: All the key concepts I have today, those are all the questions I have for today. 35:00.771 --> 35:02.473 [SPEAKER_02]: Anything else we should talk about? 35:02.521 --> 35:04.283 [SPEAKER_01]: Faddle is now this is really high yield stuff. 35:04.323 --> 35:05.004 [SPEAKER_01]: Thank you Tim. 35:05.024 --> 35:07.786 [SPEAKER_01]: Let's turn to the portion of our show where we make random recommendations. 35:07.887 --> 35:10.149 [SPEAKER_01]: Do you have something you'd recommend the audience check out for fun? 35:11.090 --> 35:11.410 [SPEAKER_02]: I do. 35:11.691 --> 35:23.523 [SPEAKER_02]: I thought of this recommendation soon after we recorded our last podcast and realized that I think many people myself included just recommended the like last thing that was sort of like cool that that came into their life. 35:24.063 --> 35:28.528 [SPEAKER_02]: And I realized there's something that I use every single day that I absolutely love. 35:28.508 --> 35:48.492 [SPEAKER_02]: helps me stay organized, and it's called Workflowy, it's a note-taking application, it's a website, it has mobile app as well, and it is flexible, it's minimalist, it has a really simple design, and I use it to keep track of all of my projects, all of my daily to do this. 35:49.073 --> 35:54.820 [SPEAKER_02]: I don't think I haven't looked at this multiple times a day for probably a decade or more. 35:54.800 --> 36:00.900 [SPEAKER_02]: So strong strong recommendation for workflow if you're looking for any way to get and stay organized. 36:01.461 --> 36:01.783 [SPEAKER_01]: Awesome. 36:01.843 --> 36:02.886 [SPEAKER_01]: Is it how do you spell it? 36:03.406 --> 36:31.168 [SPEAKER_01]: uh... works like work in an s l o w y like work flow by workflow with a while in the end all right awesome fabulous i'm gonna recommend uh... a tv show Wednesday uh... is a great tv show on Netflix uh... that's like the modern take on the adam family at the adam family uh... but the second season just uh... we just finished and so we enjoy the first season and the second season also was really entertaining it's interesting it's really well done it's kind of a mix of 36:31.148 --> 36:37.234 [SPEAKER_01]: a little humor, definitely mystery, murder mystery, it's incredibly well acted and it's fun to watch. 36:37.474 --> 36:39.997 [SPEAKER_01]: So I recommend you check out season two of Wednesday. 36:40.737 --> 36:41.718 [SPEAKER_01]: All right, Tim. 36:41.738 --> 36:43.220 [SPEAKER_01]: Thanks so much for coming back on the show. 36:44.021 --> 36:44.301 [SPEAKER_02]: Thank you. 36:44.441 --> 36:45.382 [SPEAKER_02]: I'll see you for the next one. 36:45.562 --> 36:58.675 [SPEAKER_02]: And again, if anyone has any requests on what to cover on the next keywords podcast, you know, aircraft at 36:59.077 --> 37:01.499 [SPEAKER_01]: All right, hopefully you got as much out of that as I did. 37:01.940 --> 37:03.041 [SPEAKER_01]: That was really fantastic. 37:03.321 --> 37:04.382 [SPEAKER_01]: Let us know what you thought. 37:04.663 --> 37:08.146 [SPEAKER_01]: Go to the website,acrack.com where you can leave a comment. 37:08.546 --> 37:10.428 [SPEAKER_01]: Others can learn from what you have to say. 37:11.289 --> 37:14.292 [SPEAKER_01]: If you are a fan of the show, you can follow us. 37:14.592 --> 37:15.393 [SPEAKER_01]: We're on Twitter. 37:15.854 --> 37:17.095 [SPEAKER_01]: We are on Facebook. 37:17.575 --> 37:19.017 [SPEAKER_01]: We are on Reddit. 37:19.417 --> 37:20.478 [SPEAKER_01]: And we are an Instagram. 37:21.159 --> 37:22.720 [SPEAKER_01]: I'm at Jay Wolpa on Twitter. 37:22.780 --> 37:24.242 [SPEAKER_01]: And we're at Acrack Podcast. 37:24.522 --> 37:27.345 [SPEAKER_01]: And you can find us on all those other platforms as well. 37:27.325 --> 37:35.816 [SPEAKER_01]: If you are a fan of the show, please consider going to Apple Podcasts or wherever you get your podcasts and leaving a comment and a rating, it really helps others find the show. 37:36.297 --> 37:46.650 [SPEAKER_01]: If you'd like to support the making of the show, please consider going to patreon.com slash accurate, that's p-a-t-r-e-o-n-dot-com slash ac-c-r-ac where you can become a patron of the show. 37:46.630 --> 37:50.255 [SPEAKER_01]: Even if it's just a dollar or two that you pledge, it makes a big difference and we really appreciate it. 37:50.655 --> 37:58.505 [SPEAKER_01]: You can also make donations anytime by going to PayPal.me-slash-acrack, or looking up J Wallpaw on Venmo. 37:58.806 --> 38:03.472 [SPEAKER_01]: Thank you so much to those who have already made donations and become patrons, we really appreciate it. 38:03.912 --> 38:06.836 [SPEAKER_01]: Thanks as always to our fantastic acrack crew. 38:07.537 --> 38:15.507 [SPEAKER_01]: Sonia Aminat is our tech lead, Taylor Duggen, William Mao, and Rachel Furman are our production assistance and social media managers. 38:15.487 --> 38:16.969 [SPEAKER_01]: Thanks so much for all you do. 38:17.009 --> 38:20.473 [SPEAKER_01]: Our original ACRAG Music is by Dr. Dennis Quow. 38:20.833 --> 38:23.857 [SPEAKER_01]: You can check out his website at studybusicproject.com. 38:24.738 --> 38:27.101 [SPEAKER_01]: All right, that is it for today. 38:27.141 --> 38:28.883 [SPEAKER_01]: For the ACRAG Podcast. 38:29.304 --> 38:30.205 [SPEAKER_01]: I'm Jed Wolpa. 38:30.705 --> 38:31.466 [SPEAKER_01]: Thanks for listening. 38:32.007 --> 38:34.350 [SPEAKER_01]: Remember what you're doing out there every day. 38:34.410 --> 38:43.941 [SPEAKER_00]: He's really important and valued.