LINDA:  The -- the piece of the puzzle was not only looking at how to empower the students and the health aides themselves in their work, but one of my -- my goals was to look at how we can make better trainers and teachers within the program. 

And so the key is just to find individuals who themselves have the knowledge and skills to teach it, but also have what I call the subjective ability to -- to share and to believe that their role is to facilitate learning, not to teach at but to facilitate learning, and then to help them to get the skills to do the hands-on, not only the training and the patients for that, but the understanding that you're going to get out of the way.  That you're going to really provide the learning within an individual, and it's not about you, it's about them. 

And I've worked with a lot of trainers over the years, and there's really -- those individuals, it's another group of really amazing people who choose to be trainers and field supervisors because you are also trying to provide quality of care, and it is, again, through a trained individual, who you have to let go and sort of support in the village. 

But how do you give them that in terms of it's, again, about, to me, not only knowledge -- excuse me -- knowledge, but confidence, feeling capable that they can do that in an emergency situation, or in a difficult clinic visit, or a screaming baby, how you have that sort of support, and that they feel that. 

So that the trainers themselves, back in 1984, there are really no other folks doing quite -- as you know, the Health Aide Program is unique to Alaska.  There's no other program like it in the United States. 

And so folks, whether they are physicians working with health aides doing radio medical traffic or whether it's trainers in a training center working with health aides, there's nothing like it in the Lower 48.  So you don't come from that experience. 

So in the early '80s, I myself felt that as I was struggling with cutoff for grade level and how we could provide the materials for the students in a more supportive way, how we could look at consistency of faculty message, how could we do what I call objective testing versus subjective.  All of these things I was personally grappling with, and the other people dealing with these issues were the other faculty around the state.
 
So we started something called the Community Health Aide Forum, which has grown into the convocation now, which brought together the faculty around the state and field to look at elements of teaching. 

And through that, we found ourselves sharing, and how did we teach, how did we do things.  And with that, we started to really improve the program. 

And one of the areas that we worked on is we brought in a program -- I had been struggling with the whole arena of -- we do clinical testing.  Well, clinical testing can be very subjective, depending on the faculty member, the patient you have that the student is testing with, and how you look at whether students have proficiency in a clinical skill. 

And I believe it was Dartmouth, I'm trying to remember at this moment, but I started to look at where, I thought within the medical training somewhere in the country someone was looking at these same issues.  And so we brought out an individual from Dartmouth and we created what we call OSCEs, which are Objectives-Structured Clinical Exams.  O-S-C-E. 

And that training and that opportunity to look at how -- what -- what is the skill you want them to know, what are the components of it, to what level do you want them to be able to do that, and how can you measure it.  Just to help get the picture clearer. 

You can learn anything if it's step by step and you know the expectations.  There should be no surprises when you go to testing.  It should all be very clear as to expectations, and then test to what you've been taught.
 
So those -- those elements really began to standardize training, and then -- and we started doing OSCEs in the late '80s.