LINDA:  In the early '80s, I -- I sort of upset the apple cart and went and said to the program, we need to go from 70 to 80 percent became the standard. 

At the time, the preceptorships that I mentioned earlier was one faculty and six students coming in and getting their skills list signed off.  And I said, no, that's not a preceptorship, that's just basically following a gaggle of geese sort of thing.
 
And I said, what we need is something that really tells us that they have the clinical skills that we feel that their basic training is completed. 
And so we created, in 1983, the one-to-one model for preceptorship.  And that was the significant sort of change in how we looked at the -- the whole process of pulling it together. 

And then in 1984, '85, we created the pre-session because of the lag time from employment.  And again, health aides are employed, there are 178 villages throughout the state and there is no sort of entry date of employment and termination. 

So every single day if you -- in any corporation, there's folks coming and going from -- from them.  And so it could be that people have to wait months before they can get a slot in one of the basic training sessions. 
And so in order to sort of give them something to start with, we created a Pre-Session 1 that could be delivered by the corporation, in just giving them some sort of basic tools in starting patient care. 

So that was in '85.  And one of my earliest experiences with the program, I mentioned before about the field folks, but one of the roles in early training, and they sort of returned to it now, is where the training instructors go out to the villages.  Most training instructors are center based, but a key element is when those individuals get to go to the village themselves. 

And so in 198 -- spring of '81, I went out to Atmauthluak, and there was a health aide who was -- had finished Session 1, quote, unquote, finished.  This is before we had some of these changes.  And she wasn't getting it.  People were concerned.
 
And I went to work with her and I knew I had my list of things that I was going to be required to see how she was doing.  And she was a very nice young woman, but lost.  And she said, I don't know where to begin.  If somebody's old or if they are young or if they are man or a woman, if they are a baby, I don't know where I begin the visit. 

When she shared that, and that took probably a half a day to get to that question, because we can have our own agenda, but if we don't listen to what the person's problem is -- and once I realized she's -- that was her key thing, she didn't know how to begin, and I just said, well, you just need one question.  What brought you to clinic today?
 
And as soon as she could see that everything started from the same place, she could organize her thoughts and get some clarity to it.  But she really thought that she needed a separate script for each of these individuals. 
And that was the beginning of my education to see that we really hadn't provided the tools that individuals needed to do their job. 

They had, at this time in the program, the old Indian Health Service had what they call progress note paper that I used in patient charts that were blank, sort of like the paper you're using right there, a tablet.  And health aides were to do their care and to write up the patient visit.  Well, there was no -- there's nothing on the paper. 

So if you're someone who doesn't even know what your first question should be, at this -- my training, for those who know the program, this is prior to the 1987 CHAM, which was a focused history and exam.
 
The earlier book, and the history of the program is really mirrored by the tools and the materials that we have for the program.  They didn't have a scripted visit.  So she really needed help in how to sort out her work. 

And so in 1985, I wrote the first Patient Encounter Form, which gave them a piece of paper, and it was made into triplicate, that allowed them to write up their patient visit. 

And it starts with chief complaint, then goes through history of present illness, down through past medical history, allergies, medications, habits, and then into the physical exam.  Vital signs. 

Each of the body parts or systems are identified with blank lines for space down to the assessment, which is another way of saying sort of the medical diagnosis, assessment they come to conclusion by history and exam, and then a section for the plan, which is then patient education, medicine, treatment, return to clinic. 

The form has been revised a few times to add a few things, but it's sort of fun to watch it now 20 years later to be so similar to what the original one. 

And I think of all of the things that I've been a part of, that one piece of paper has impacted the care only in that it would allow people to have an organized way to record it, and then an organized way to report it to the physicians. 

But again, the health aide role is the connector.  They are the connector between the physician in Bethel and their village community member in Anvik, Aniak, St. Mary's, Eek.  And they are -- it's about communication. 
And you need, then, clear ways to communicate information.  That also, then, allowed for a copy to go into patient records, and also to the supervisor instructors who could then review them for -- also, then, the information and know, well, it looks like the health aide needs help in this arena and they could go out and focus a visit.  That was 1985.