Dr. Karen O'Neill was interviewed on September 14, 2005 by Karen Brewster at the Norton Sound Health Corporation Health Aide Training Center in Nome, Alaska. In this interview, Karen talks about the early days of medical care in the region when there was not reliable communication systems or advanced equipment or facilities, the development of telemedicine, and what it was like traveling to the villages. She is a big supporter of health aides and the Community Health Aide Program, so she talks about the establishment of the Nome health aide training center, the training provided to health aides, what talented people they are, and changes in the quality of medical services in the region. She also discusses her work at the center, as well as her role in the development of statewide health aide curriculum.
Digital Asset Information
Project: Community Health Aide Program Project Jukebox
Date of Interview: Sep 14, 2005
Narrator(s): Dr. Karen O'Neill
Interviewer(s): Karen Brewster
Transcriber: Carol McCue
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Her early career and how she became interested in the career path she chose.
The evolution of the community health aide program, especially in terms of communications technology and how that has affected the quality of care provided in villages.
More on communications, and the role of health aides in diagnosing patients.
Her impressions about the administration of medical programs in rural Alaska, and how it felt to arrive straight from Washington D.C.
Stories of emergencies in villages and how health aides manage them.
How the Community Health Aide Manual (CHAM) is developed, who is involved, and the input health aides have contributed.
The extent of a health aide's ability to diagnose patients, the importance of a dental health aide program, and the role of the medical director at the training center.
The qualities that make a good health aide.
The difficulties health aides face in their work and social lives, and how the model of the community health aide program is inspiring other similar programs.
Changes in the working conditions of health aides over the years and the support system in place to help them through the stresses of training and work.
Her assessment of the health aide program through time.
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After clicking play, click a section of the transcript to navigate the audio or video clip.
KAREN: Okay. Today is September 14th, 2005, and this is Karen Brewster. I'm here in Nome with Karen -- Dr. Karen O'Neill at the Community Health Aide Training Center here in Nome. And this is for the Community Health Aide Project Jukebox. Thank you for finding some time in your busy day to talk to me. DR. O'NEILL: I'm happy to talk about the Health Aide Program. KAREN: Great. So why don't you tell me a little bit about what your current role is with the Health Aide Program. I think it's probably changed through the years. DR. O'NEILL: I came here in 1975 through the National Health Service Corps. The Health Aide Program was pretty young at that time, as was I. And I came -- went away for a while and then came back a little more than 10 years ago as the Director of Community Health Services. And one of my jobs at that point was to oversee the Health Aide Training Center here in Nome, which is one of the four health aide training centers in the state. So I've been the medical director for the Health Aide Training Center here since 1995. Prior to that, my experience was as a doctor working with the health aides and doing occasional training with health aides and traveling to the villages. KAREN: So you were a doctor here at the Nome hospital? DR. O'NEILL: Uh-hum. KAREN: And then so how did you end up coming to Alaska? When and where were you born? DR. O'NEILL: Well, I was raised on the East Coast, and I did my residency training in Washington D.C. And back in 1975, when we were finishing our training, everybody was either joining an HMO, which was a brand new concept back then, or going into a private practice, neither of which I wanted to do. And I was reading one of the throw-away resident journals one day and I saw this ad that said see Alaska or something like that, and it was the National Health Service Corps ad. Back then the National Health Service Corps was an alternate pathway for Vietnam because Vietnam was still going on then, and it allowed doctors, instead of going to Vietnam, to do an alternate service by being -- going to under-served area. And so I didn't have to go to Vietnam, but I was interested in going to an under-served area because I sort of always had a public health interest rather than private practice interest. So I applied and I was one of the few people at that time who was already through my residency who was applying. So they let me pick where I wanted to go, and I came up and looked at Anchorage and Nome, and Nome looked more of a challenge, so I came to Nome and pretty much have been here. I'm a poster girl for National Health Service Corps. Been here pretty much since then. KAREN: Is the Health Service Corps, is that the Public Health Service -- DR. O'NEILL: No. KAREN: Native Health Service? It's different? DR. O'NEILL: It's different. It's still in existence today. And people who are doing their training and need scholarship assistance for the most part can become scholars with the National Health Service Corps, and then they do pay back after their training is finished for the amount of money that was lent to them. KAREN: Well, I guess I always thought that was Public Health Service. DR. O'NEILL: Public Health Service is more like one of the uniform services. So you wear a uniform if you're part of the Public Health Service. KAREN: Right. DR. O'NEILL: It's a different system. KAREN: In the National Health Service Corps you didn't have to wear a uniform? DR. O'NEILL: If you chose to, you could become part of the Public Health Service or you could be a civil servant, or you had a couple different choices back then. Now it's -- it's not associated with the Public Health Service so it's different. If you want to be part of the Public Health Service, it is a uniform service and you join it and you're treated pretty much like another military branch. You can be called up and assigned to another place, like sent to New Orleans or something like that. Called up to Public Health Service. Quite a few people who work here, you'll see them wear uniforms and they are part of the Public Health Service, but different than the National Health Service Corps. Which is sort of like the Peace Corps in the United States when it started. President Kennedy started it. KAREN: Yeah. I've never heard of it. It's interesting. I've heard of Vista and the Peace Corps, but I've never heard of -- DR. O'NEILL: And this is the medical branch of it. Mainly for physicians, PAs, nurse practitioners. KAREN: What got you interested in going into medicine? DR. O'NEILL: I -- do you know about Nancy Drew books? There were also Cherry Ames books and they were about a nurse. And when I was young and there wasn't all this stuff on TV that there is now, I used to read a lot. I read Cherry Ames books and I thought, jeez, it would be really cool to be a nurse and Florence Nightingale and things like that. And my mother, when I was about 8 years old when I told her I thought I wanted to be a nurse, she said, you shouldn't be a nurse because you never like anybody to tell you what to do, you should be a doctor. And so I said, oh, that sounds like a good idea. And it was just always -- after that, I was always going to be a doctor. I never had any other thought of what I would be, I was just sure when I was 8 years old that that was what I was going to be. KAREN: And was the family history of anybody else doing it? DR. O'NEILL: Huh-uh. No. No. I was the first one that went to college. KAREN: Okay. DR. O'NEILL: See what books can do for you.
KAREN: So you got up here in 1975, and what kind of work did you do? DR. O'NEILL: So I was a doctor here with the hospital. And it wasn't Norton Sound back then. The Native corporations took over health care in 1970 through Public Law 638, and so Norton Sound was just coming into existence. The hospital was still was run by a Methodist Missionary organization that was called Maynard McDougall Memorial Hospital. That facility is sort of incorporated into the hospital that's here now, which was built after Norton Sound took over in 1975. So I was just coming on when Norton Sound was taking over the hospital. So I was one of the physicians that was here. There were only three of us at that time. And we saw patients in the hospital and in the outpatient clinic, and we went to the villages and provided care, and we worked with the health aides. And the system was very different back then. Some of the health aides that you talked to yesterday were practicing then. There's still one or two health aides around who grew up with me, basically, we grew up together. Their training wasn't nearly as rigid or outlined or focused. They were using a different manual and the training was more regionalized than it is now. When I first came, there was electricity in the villages, but there was no phones. We -- there was one phone in the village but it wasn't in the clinic. We communicated with the villages by radio, shortwave radio. And it was very challenging sometimes. Certain parts of the times of the year, like October and April, the reception isn't very good and you'd have to maybe relay between one village that could hear you to a village that didn't hear you. So talking back and forth was a great challenge back then. KAREN: Why October and April? DR. O'NEILL: Sunspots or something. Sunspots. I don't know. Anyway. So it was very challenging. Just communication was a major challenge back then. And the health aides' training wasn't as good as it is now. They weren't paid back then, so there were unpaid volunteers back then. KAREN: When did they start getting paid, do you know? DR. O'NEILL: I would think in the '80s. So a health aide could probably tell you better. KAREN: Yeah. DR. O'NEILL: So some of them got a small stipend but they didn't have any regular salaries. The early ones were doing it because they were healers or because they had some other avocation to be health aides to help other people in their community. I think you do know already about the early origins of the program, but I think the ladies who did it in the beginning were quite astounding. And often it was only one or two people in the village, so they would be on call for weeks or months at a time without a break. So we would talk to them every day on the radio just the way we do now except with the phone, so that's been a major change. And we would go make twice-a-year visits to each of the villages to see the patients that the health aides had questions about or needed things that the health aides weren't able to do because their scope of practice is more limited. And we would do some training when we were out there. But they were part of our team and we got to know them very well. And know their strengths and weaknesses. And then in the '80s they got telephones, which was a big boon because we didn't have to rely on the radio, which was very challenging. So radios -- telephones made a difference. And the fax machine made a big difference, and we probably didn't get fax machines until the mid '90s, out in the villages. And so until we got fax machines, everything was just oral. So if they had a patient to report, we had to just have them read what they wrote down or just speak to us. Once we got the fax machine, they could at least write something on a piece of paper so that guaranteed that we could hear every word and know better what they are saying. So that made a difference to our ability to be able to provide good health care through the health aide. And then in the late '90s, we got telemedicine which, again, was a gigantic, gigantic improvement because then they could take a picture. So we could actually see what they were seeing, which was often different than the way they described it. Because for one thing, health aides only have 15 weeks of training, and their vocabulary may be on a much different level than ours. A lot of them have English as a second language, and medical keys is language even today that a lot of lay people don't understand very well. So having a health aide try to describe a rash or something that they see is often difficult in the best of times, even with good training. And the telemedicine picture has made a gigantic improvement in our ability to do medicine across the miles.
KAREN: So how does telemedicine work? It's a picture, it's not video? DR. O'NEILL: We only have still shooting forward those pictures right now. Some of the regions like Kotzebue already has video teleconferencing. We are still hoping to hear that we've gotten a USDA grant so that we, too, can have video teleconferencing, which will be another giant step forward for us. But we haven't gotten the funding yet. We're waiting to hear. But even a picture, I don't know if you've seen a picture. KAREN: I haven't seen it. DR. O'NEILL: Makes a tremendous impression. KAREN: I can imagine it would be a big difference, especially like you say, going from the radio. DR. O'NEILL: Yeah. KAREN: I can't imagine how as a physician, you having something described to you over the radio you can make a diagnosis. DR. O'NEILL: I think it's the hardest part of our job. And when we have people come pass through here either in their training or as a locum tenens or something like that, it really is the hardest part of the job. It takes a long time to know each individual health aide, what their strong points and weaknesses are, how reliable they are when they report information to you. Some of them will exaggerate or misrepresent what they are seeing for whatever reason. Use the wrong word sometimes. So it's -- it is a great challenge to do that without seeing the patients, or oftentimes being able to talk to them. But it's an art. KAREN: It's an art. Yeah. I'm wondering also from the Western trained professional medicine side, if there's ever been problems with, you know, doctors coming in and not accepting what the health aide said, if there's a problem with the different levels of knowledge. DR. O'NEILL: I think it's more they are not understanding the scope of what a health aide can do, not understanding the scant amount of training that they've had. And their training is more based on collecting information for us. They do have some limited diagnosis choices in the CHAM, but the CHAM doesn't nearly provide for every diagnosis that's possible for a patient. It can't. And it never will. So the most important thing that a health aide does is collect the information that we need, to be a detective and try to figure out. So they can only work within the limitations of the health aide manual. So yes, it's a challenge. So people get frustrated because they think they are dealing with a little doctor or a mid-level or a nurse or something and they are not any of those things since no other state has a similar program. So they will get annoyed the health aide doesn't -- hasn't -- they will get annoyed if the health aide doesn't ask a question that's not in the CHAM that somebody who knows more about a disease process or something would have seen as the obvious thing to ask, and the health aides won't necessarily ask that because they don't have the breadth of information about diseases to know to ask that. KAREN: Have there been times when the doctor doesn't believe or accept what the health aide has told them and then what do you do? DR. O'NEILL: I'm sure. Well, in our corporation, if there's a question between a provider and a health aide, they have a -- a way to deal with it. So they either call myself or Dr. Head who is the medical director, depending on who's around, to say they feel like the person who is taking their call isn't understanding what they have to say. So we have a way for them to get a second opinion if they need it. And it happens occasionally. KAREN: Sort of a grievance process. DR. O'NEILL: Uh-hum. KAREN: That's good. DR. O'NEILL: Or we may know something about the situation or the politics or there's politics, too, of a particular situation. And so we try to err on the side of people coming into town if there's any question about whether they need a service. KAREN: And the health corporation pays for travel? DR. O'NEILL: This health corporation pays for travel if the person doesn't have another resource like Medicaid to pay for them. Some other regions make choices to use their money in other ways. So it depends upon the corporation.
KAREN: And how do you feel that the corporation works, the concept of the corporation works as a mechanism for rural health delivery? Because you know, it used to be Public Health Service, and you have experience with how they did it versus how the regional corporations are handling it. DR. O'NEILL: I never really -- I'm not sure that I have the answer to that question. Maybe a patient might know better, someone who used the old service and the new service. Public Health Service, at least in this region, you know, because it was a Methodist Missionary hospital rather than a Public Health Service hospital, hasn't been here in a really long time. So I don't know the answer to that. KAREN: I wonder why it wasn't a Public Health Service hospital? DR. O'NEILL: Because it was a Methodist Missionary hospital. The Methodists got here first. KAREN: Yeah. DR. O'NEILL: I don't know. Kotzebue was a Public Health Service hospital, so I can't say how that worked, but I know there were always Methodist doctors here and Public Health nurses who provided care for a long time out in the Bush. And did lots of things. But I don't know how to compare it to. I think there's many more services available and people, their expectation is much higher than it used to be about what they want. They are much more savvy recipients of service, and so, you know, they -- they want to go to Anchorage and get their Cat scan or this that or the other thing, they watch TV, they know about all the things that are available. So their expectations are higher. KAREN: And when you first got here, going out to the village and doing visits, what was that like? DR. O'NEILL: It was like going to the moon. Because I came from Washington D.C. and the East Coast, so I came to a place where there wasn't -- even today some of our villages don't have sewer and water, so people don't realize that there are places that still have honey buckets and we have to go to the washateria to take a shower. So just the -- the way life is in the village is very different than even what's in Nome, but you -- coming from a hospital, George Washington, which had everything, it was in the forefront of medicine and coming to Nome, which didn't even have some of the basic things, where they were still developing X-rays by hand instead of with a machine, it was quite a culture shock and a change to do those things and not have things easily available to you. TV used to come on movie reels from Washington, and it was about two weeks late. So if you were hearing the news or something on TV, it was all things because it was a movie reel that was being played somewhere in town, it was two weeks old news that you would be hearing. And in the store, I mean, things weren't nice and fresh the way they are today, so we got used to eating yellow broccoli if you were going to eat anything like that. So and even going to the villages was more remote than that. They didn't have TV. They only had the radio station here from Nome. The things in the store were even less fresh and less choices than in Nome. The village clinic, the health aides didn't have as much technology as they do today. Today a health aide can do an EKG, a heart test, they can take the pictures, they have labs that they can do, there are only one or two labs that the health aides could do back in the '70s. So it's come a long way, the whole program. I mean, they are much better trained than they were 30 years ago. Not -- but their heart was in it just as much 30 years ago, the people that did it, as today. So I don't think the program was less or the people that were doing it was less, they just had less to work with.
KAREN: Do you have any memories of particular success story cases that you were involved with that were critical and it all worked out for the best in interacting with health aides? DR. O'NEILL: I think health aides did and continue to do amazing things. They deliver breach babies, they take care of gunshot wounds. Even last year on Christmas Eve a person shot themselves with a rifle, or shotgun, out on St. Lawrence Island and the weather was really bad. And she had a hole in her back that you probably could have put two footballs in. But we couldn't go out to get her and the health aides were able to sustain her by packing towels into the wounds and by starting IVs on her and resuscitating her for about 6 hours until we were able to get out to get her. And she survived okay. They do things like that on a regular basis. I remember myself being down in Unalakleet back in about 1976, I was with my six month -- six week old baby, and somebody shot themselves and it was very cold and we didn't have the medevac service that we have now. And this man was dying and I needed to get him out of there and into Nome, so I just gave my baby to somebody I hardly knew. And the plane was cold, it wasn't heated, and so I had to pass IV tubing through my clothes to keep it warm on its way into the patient while we brought him into town, and tried to worry about my baby on the side, not even sure who I gave him to, and try to get this man into town. So we did things like that. I was here actually in 1975 when the Wien plane crashed out in Gambell. KAREN: I don't know about that. DR. O'NEILL: I don't know if you ever heard about that. It was an F-27, I think. And it crashed at Gambell and there were 24 survivors. And again, communications wasn't nearly as well back then. So we knew that the plane had crashed and we knew that there were some survivors, but that was about all that we knew. And so I took one of the PAs and I took all IV fluids and all the Demerol and morphine that we had in the hospital and jumped in the little plane and we went out there not having a clue what we were going to get into. And the community, in the meantime, had -- the plane crashed on a mountain so they had to bring the people off the mountain into the village. So the health aides and some people in the town organized that to bring the patients down into -- I think we were in the school, we were in some big building. But there were 24 people that survived the accident. KAREN: Wow. DR. O'NEILL: And myself, this other person and the health aides just sort of triaged and prioritized people and splinted people with magazines and, you know, pieces of board that we found around the town. And let Anchorage know because they were our referral center what was going on. And they found a C-130 plane that just happened to be up in Port Clarence which they sent out to the island. And we were able to put all the patients in one plane and get them down to Anchorage. And everybody who survived the plane crash actually survived the resuscitation and the trip to Anchorage. And that was a pretty major experience for health aides to be able to do that. But they take care of major trauma all the time. And it's people that they know, their family, their friends. So we have tons of stories like that. KAREN: I know.
DR. O'NEILL: And sometimes our health aides, I have to say, may not know a diagnosis, so they can't tell you a specific thing that's the matter with the patient, but they know that the patient is sick or not. And so we've learned to know who to trust, and if they say this person is sick, you need to get them out of here, that's enough for us to go out and get somebody. But they can diagnose botulism with the doctor, and like a doctor in the Lower 48 probably wouldn't even think about because they don't see it down there. KAREN: Right. DR. O'NEILL: And things like that. And they suture and they splint and they deliver babies and they stabilize patients. They, you know, put their lives at risk to go -- they don't just see patients in the clinic, so they will respond to out of the clinic to accidents out of town, as well. KAREN: So what got you doing sort of this health aide part instead of just staying and being a doctor in the hospital? DR. O'NEILL: The -- there's four health aide training centers in the state, and one of the requirements to have a training center is to have a medical director overseeing it. And I had gone back to Maine for a couple years because my mother was sick. And the person who had been doing the medical oversight was leaving, so they knew how passionate I was about the Health Aide Program, they called me to see if I wanted to come back and be involved again, which I did because I was really missing Alaska. So I came back and I've been involved in it ever since then. I'm a pretty strong advocate of health aides and the Health Aide Program. And I've been involved in the last two health aide manuals, '98 one and the one that's going to come out this year, to try and make them be user friendly for the health aides instead of -- they are the people that need to use it, so I'm a strong advocate for the book, too. KAREN: So what has been your role in the current CHAM? DR. O'NEILL: I'm the medical advisor so I read every chapter. It means I read every chapter over and over again and make comments about -- one, about the content, about -- and two, since I've been familiar with the Health Aide Program for so long, that it's set so that a health aide can use it. Because health aides don't write the book, other people write the book, and they don't necessarily have a vision of how a patient's going to present to the clinic, what they are going to say to the health aide and what the health aide is going to see. And that's how the book has to work. So I'm -- you know, I feel I'm one of the people who has enough vision and have been around long enough to know how it's going to look to the health aide and how the health aide can process the patient to get to the other end, to get to the answer that we need them to get to. KAREN: And you also, you review in terms of the -- you know, what questions to ask and the diagnosis and the medications and all that part of it? DR. O'NEILL: Uh-hum. KAREN: All those little diagrams? DR. O'NEILL: Uh-hum. Yes. So, no, it's a big process, a lot of people involved in writing it. And in the last one, too. KAREN: Yeah. DR. O'NEILL: So we're into our fourth manual, I think. So actually, the green one was one that was written by somebody in this region. KAREN: Oh, okay. I haven't seen that. DR. O'NEILL: Even before. So then the yellow one is the first official one in '76. The white one, blue one and -- KAREN: I've seen the yellow one, the '76 one, then Burgess' '88 one. DR. O'NEILL: '88. And then the '98. KAREN: I haven't see the '98 one. DR. O'NEILL: That blue one? KAREN: Yeah. DR. O'NEILL: Is the '98 one, yeah. Two volumes, 11 pounds. KAREN: And now it's like three or four volumes? DR. O'NEILL: This one that's going to come out at the end of this year will be four volumes. And what we've done since this is so heavy and right now a health aide, if they have to respond to an emergency, they have to lug this whole thing with them, which truly weighs 11 pounds. They have a separate emergency volume which is going to be much smaller and compact, which they will take with them when they go out of the clinic. They don't have to bring this whole big book with them. KAREN: So you've -- have you received feedback through the years from the health aides -- DR. O'NEILL: Oh, yes. KAREN: -- about what they like and don't like? DR. O'NEILL: It's a very -- yes. KAREN: Such as? DR. O'NEILL: There is a group part of CHAP directors, there's a group that collects information on it. So each time, even with the '98 book, too, a lot of information was collected from the health aides about what works and what doesn't work and what they need, how it needs to be set up for them. And you know, there are people on the committee, health aides, that read the chapters before it goes to press, which will be any day now. KAREN: Do you have examples? Can you think of something that somebody said about the last one that you've made a change on? DR. O'NEILL: We've made a lot of changes to make it easier for the health aides. The last one was built more on a time schedule, so it wasn't as -- each chapter wasn't as scrutinized and done and redone and redone. I think the focus was a little different, we just wanted to get it done. There was a need to get it done and there was a time line and we followed the time line. And so the people that wrote it weren't necessarily health aides or thinking with the health aide mind. And so it turned out to be a little bit hard in some areas for the health aide to use. So this one has taken longer to redo, but every chapter has been scrutinized over and over again and taken to different -- we've taken some of the chapters and used them with the health aides to make sure they work better. But medicine changes all the time, so by the time it's out, we will probably need to have changes in it again. So. KAREN: Like computer technology. DR. O'NEILL: Yes. KAREN: Continually changing.
KAREN: One of the things I'm wondering, too, about, in the earlier days of the program was the communication between the doctors and the health aides, and how that worked or didn't work. You know, in terms of, you know, you've already talked about the radio and it's hard, but just, you know, sort of a different language. Not the English, Iñupiat, but just the different language of medicine versus not. I don't know. I don't know how that all worked. DR. O'NEILL: Well, the yellow CHAM wasn't -- well, the white CHAM was sort of set up the same way these are. And so in the '70s, the health aides would just collect information and give it to us, and we would try to figure out what was going on. And they didn't have assessments and plans the way the book is set up now, so that was a little different, but the main challenge was just to be able to hear the person and to get through to them. And it definitely was not private. Anybody who had shortwave radio could hear us. So we weren't supposed to say names over the radio. So sometimes there were surprises. It's easier to know who you're -- because we know the patients fairly well, we have a fairly close population, so they could never tell us the name of the person. Now with the phone we can find out who the person is, pull their chart, look at their chart and things like that. But back then we couldn't do that. And just being able to hear them with static, with not being as well trained. It was a big challenge. KAREN: And it's amazing. DR. O'NEILL: Not having pictures, not having EKGs. KAREN: It's amazing that this system worked as well as it seems to have in the old days when there wasn't all this training and all the good communication. DR. O'NEILL: Uh-hum. But it was the only thing that was there. And it certainly has grown and sophisticated. But just like the dental at that time Health Aide Program, which I'm passionate about, if you don't have another choice, you work with the choice you have. So. KAREN: Yeah, I know that the Dental Health Aide Program that they are trying to get started there's been some opposition to. I don't know about what the Community Health Aide Program, has there been -- how many years have there been opposition or hardships and things you have to fight for? DR. O'NEILL: I don't think there's ever been anybody else who wanted to go out and work in the village. The health aide has not been a threat to the medical community or to the nursing community or to any other group who thought that they might be losing money. And I think the big motivator of the American Dental Association is they are fearful that if this works well, that those dental health aides might move into their community some day and take work away from them. They certainly don't come up here and see patients. KAREN: Yeah. DR. O'NEILL: And so -- KAREN: There isn't a dentist here in Nome? DR. O'NEILL: There are. There's a couple dentists in Nome, but we have 10,000 people and 26,000 teeth, or however many, and they can only get to go to a village once or twice a year for two or three weeks, and all the rest of the time we don't pay for dental travel. And we don't have many people -- we don't have dental health aides in the village, so they don't have a choice, they either lose their teeth and have pain for months or find some way to go to Nome and see the dentist, and it's not very easy. KAREN: Right. DR. O'NEILL: On the first day of each month you call for an appointment, and usually by 10:00 a.m. all the appointments are filled. So the easiest way to get one is to go to the dental clinic because the phone's always busy. And if you live in a village -- KAREN: You can't do that. DR. O'NEILL: -- you can't even get an appointment. So it's really hard. So I feel passionate that we need dental health aides. KAREN: Yeah. Were doctors selected to work with the health aides or is it everybody did it? As a doctor in the hospital. DR. O'NEILL: Well, we each had villages and then you're on call. So who was ever on call that day is the one who talks to a health aide about a patient. Even today that's still the same. KAREN: So it's right out -- DR. O'NEILL: So we have more doctors, we have seven doctors now instead of three, but the docs each have their own villages that they go to. But then when you're on call, the health aide talks to the person on call if they are having a problem. KAREN: So is there still a regular radio call kind of deal? DR. O'NEILL: Uh-hum. Yes, we do it every day. 365 days a year. And the health aides see patients, either that need to be talked to about right away, so we take their calls any time, 24 hours a day if the patient can't wait. And if it's a routine thing that it can wait until radio call, which is in the afternoon, then the patient sees -- the health aide sees the patient like in the morning and then calls us in the afternoon and has the patient come back to get what they need. There are things called medical standing orders. I don't know if anybody talked to you about those. KAREN: I've heard of it but I'm not -- DR. O'NEILL: So there are a few things in the CHAM where if a health aide has been through a process and the process includes being evaluated by a health aide trainer, taking a written test, and being signed off by a doc, they are given a medical standing order for some certain simple things that we feel that they can diagnose and treat without a call. So some health aides, and not all of them, have orders that they can treat a sore throat or a earache or a cold or something like that without calling the doc. But most of the things they have to call about. Anything that's not really straightforward and everyday. KAREN: Because of the liability issues involved? DR. O'NEILL: Because they are not doctors. And because we need to know that they are able to diagnose something. You know, if you can't make the right diagnosis, then you can't provide the right treatment. And even nurses aren't supposed to diagnose, even paramedics aren't supposed to diagnose. They can make assessments or, you know, collect information, and again, health aides collect the information for the most part, and we come up with the diagnosis of what's going on. KAREN: How does it work with the medication? Because they have medicine out or some medicines out in the villages. DR. O'NEILL: And unless they have a standing order, they are not allowed to dispense it without an order from a physician. So that's the only time. Even a Tylenol or aspirin, they are not allowed to dispense any of those things unless they have a standing order or a verbal order from a doctor. KAREN: So if they call in and they give the information, the doctor says, okay, you can prescribe this medication and then they give it out. DR. O'NEILL: Uh-hum. And so people have to come back for a second trip to the clinic to get their medication after that. KAREN: And they receive training or -- on the medication? DR. O'NEILL: As far as how to dispense it, how it mix it up, how to count it out. KAREN: So they are a pharmacist, as well? DR. O'NEILL: They are everything. They are the secretary, the billing clerk, the pharmacist, the lab tech because they draw the blood, they do the whole thing. They are the nurse, they are the doctor, they are the -- KAREN: Now, you still see patients in the clinic here and at the hospital -- DR. O'NEILL: Uh-hum. KAREN: -- as well? DR. O'NEILL: Uh-hum. Yeah. That's my part-time job. KAREN: And so as medical director overseeing this training center, what kind of things do you do? DR. O'NEILL: I'm a referee. So if there's either trainer problems or questions about a student, I'll sort of oversee those things. Do policies and procedures. But I teach health aides and I go to clinic with health aides. KAREN: You do trainings? DR. O'NEILL: Uh-hum. So I give lectures and I take them to outpatient clinic and work with them myself. Half their training is in the classroom, and then the other half is either learning skills or going to see patients. And so it's usually one-on-one with a trainer and I'm just a trainer at that point. So. So I used to teach, like, health. I like teaching them.
KAREN: In all your years of interacting with people and health aides, what have you noticed sort of the qualities that have made the best health aides and the most successful ones? DR. O'NEILL: You have to be smart. And you have to be dedicated. It's really hard because it's not an 8-hour-a-day job, it's a 24-hour-a-day job. And they have to absorb an incredible amount of knowledge in 15 weeks. The vocabulary itself, the words that they need to learn and the rudimentary anatomy and physiology that they need to learn is enormous, is mind boggling. And they have to leave their families and their children and come to town to do this for four weeks at a time. And then they have to go back home and do the work and take the wrath of the community because, you know, if they don't do something right, then they sustain the unhappiness of the community. It's just a really major job. KAREN: How do you ever get anybody to do the job? DR. O'NEILL: I don't know. And it's -- it's sort of hard to put your finger on it because we can oftentimes tell early on when somebody first starts coming to a training center whether they are going to do well or not. We can pick out the ones in there. There's something, a light or brightness about them or a little quicker or more passionate about it. You have to have a passion for it I think to be able to keep on doing it. If you just have it because it's a job, you're not going to be able to sustain it because it's too hard. Its an incredibly stressful, burdensome job. KAREN: It seems like both health aides and doctors and administrators I've met through this project all have an incredible passion and devotion and commitment. And I don't know that -- DR. O'NEILL: Not here for the money. KAREN: And I don't know -- DR. O'NEILL: Or the honor and the glory. KAREN: -- if that's unique to the Health Aide Program, or is it the medical profession in general, Public Health side of things, I don't know. DR. O'NEILL: Well, I don't think any of the docs are here for the money or the glory or the big cars or anything like that. I think you have to -- I think working here makes you feel like you're doing something important, that you're -- you're needed. So there's lots of rewards for working here, the patients appreciate it. And you can see when you're making a difference. But I guess it depends on what you're looking for in life. Why you're here. We are having a hard time recruiting doctors lately. But the ones that are here have been here a long time. KAREN: And so why have you stayed with it and you stayed up here? DR. O'NEILL: I just -- Nome is my home and I feel like I'm doing important stuff here. I'm not done yet. I can't imagine doing it any other place. KAREN: What has your interactions with health aides kind of meant to you personally? DR. O'NEILL: I love them. They are wonderful. We -- I think we built great affection for them, in great appreciation for them. KAREN: You've been up here doing this for a long time. DR. O'NEILL: I could never do their job. I -- I just think it's amazing that they can -- it's so scary to be out there to know you're it until -- it takes us at least two hours to get there. If they have a major problem, they have to support a patient and be it for at least two hours or longer, depending on the weather. KAREN: Yeah. DR. O'NEILL: So they really are our gatekeepers, our front line. They are amazing. KAREN: Yeah.
KAREN: You just sort of touched on it a little bit about in some communities maybe the relationship between health aide and the village is not always the best or always easy. What do you do about that? DR. O'NEILL: If we have major issues, we try to go to the community and talk to folks and give the health aides a lot of support. KAREN: Can you -- do you have any examples that you can talk about, about what conflicts have come up? DR. O'NEILL: We have had health aides commit suicide -- KAREN: Wow. DR. O'NEILL: -- over pressure from communities. And it's usually over a bad outcome. And it's almost always something that the health aide doesn't have control over. Most people have a hard time grasping the fact that people are going to die sometimes no matter what you do. And that there's some things that you can't fix. And most of the time when we've been major things, it's been with children who have died. That seems to be a bigger trigger for communities to be mad at the health aides. But they only -- and I think at that point the health aides -- the community has a bigger expectation about what the health aides can do than what they can really do. And we really, we have had two health aides commit suicide over things from villages. And two years ago, we had a child who the village took out its wrath on the health aide and the PA who happened to be there. But they gave a child, like I think the baby was maybe 6 months old, an immunization, and about 8 hours later the baby died. And so they blamed it on the immunization, although that was never proven. And the community never talked about the fact that the baby actually died while being packed on the mom's back on a snow machine. So it's quite possible that the baby suffocated or had some other event. But everybody didn't want to blame the mom, they wanted to blame the health aide and the PA that were there. And it was really difficult for six or eight months. I mean, they were just all over health aide. And the PA was uncomfortable going back there because people were being so rude to her and stuff. So it's always easier to blame somebody else. So those things happen. And people aren't always considerate of health aides. We have signs everywhere about what we consider is an emergency and what a health aide is supposed to respond to at night, but people still, if they don't have their Tylenol at 3:00 in the morning, they want to wake up the health aide to get some Tylenol because they have a headache, which we don't think is appropriate. So people grumble and health aides aren't willing to be up 24 hours a day to answer their non-emergencies. And health aides live in aquariums, and so when they are not on call, if they are doing something the community may think is inappropriate, like playing poker, you know, we hear about it, so they make judgments on health aides even. KAREN: So there's a lot of pressures on the health aide. DR. O'NEILL: Lots of pressures. It's like being a celebrity in the village, I guess. KAREN: How do they handle that? DR. O'NEILL: Sometimes they quit. And burn out. We try -- if there's a crisis in a village, we have a CISD team that goes out there and tries to diffuse some of the things and tries to take some of the -- KAREN: What's CISD? DR. O'NEILL: Critical Incidence Stress Debriefings. So. And usually we try to have somebody from either the Village Health Services or somebody go along with behavior health people to go out there and talk to people and try to diffuse situations. KAREN: That's a lot -- health aides have a lot to -- DR. O'NEILL: Something bad to. And I mean, we had the whalers that drowned out in Gambell last April, that was major. And those people were already dead, but that just brings the village to a standstill and to a crisis. KAREN: A major crisis mode. Someone was mentioning about the behavioral health aides now. DR. O'NEILL: Well, because the Health Aide Program has been quite successful in the Bush, the other areas that aren't being filled, the needs, dental and behavioral, they are looking to try and model programs similar to the Health Aide Program to try and meet the needs there because outside people aren't coming in to do that. We haven't been able to have a psychiatrist here in years. I mean, we just can't recruit these people. KAREN: Right. DR. O'NEILL: They don't come. And we have a few dentists but not enough. And so we actually already have a behavioral Health Aide Program here, which is our own, but the state is trying to do them, they don't bill for these services, the ones that we have right now. It's just sort of an internal program. But the state is working on it -- not the state, the ANTHC. KAREN: Alaska Native Tribal Health Consortium? DR. O'NEILL: Yeah. I mean under that they are working on trying to build the Behavior Health Aide Program just like the Dental Health Aide Program. It's not quite as advanced yet, and it won't have -- the dental health aide therapist is a mid-level therapist that goes to New Zealand for training for two years. And although they are not licensed as the TV ads from the ADA mention, they are certified. So they do have a credential and they do have to pass a rigorous amount of training before they actually get to touch a patient. And they come back after they do their two years in New Zealand and then work six months here with a dentist before they even go anywhere. So the ads that you see on TV aren't -- KAREN: Well, but that's even more commitment to training than the four weeks in Nome. DR. O'NEILL: It's major. It's like mid-levels. KAREN: Two years in New Zealand, wow. DR. O'NEILL: So they are like mid-levels. So the ads that the ADA have on TV are so bogus. It makes me crazy.
KAREN: So do you have behavioral health aides in each village now? DR. O'NEILL: Uh-hum. KAREN: And how are they trained? DR. O'NEILL: They are just trained here. So they are just a local program. And if the state ever actually has -- and I say the state, not meaning the state, but if there is a regular program -- KAREN: Right. DR. O'NEILL: -- they will go to that. They will be trained there. So right now they are just Norton Sound based. People that -- they are trained to do counseling and to identify people who are maybe suicidal or maybe need interventions from a clinician. So. And just to be community support. And we've had that program for at least six or seven years. KAREN: Oh, great. Has it been effective? DR. O'NEILL: Hard to measure that. I don't know the answer that I can really decide, but at first people were kind of, I think, uncomfortable going to somebody in their community to spill out their guts, but in most communities the BC is busy, so people are going to them and talking to them and using them. They are not therapists so they can't provide care at the same level, but least there's an ear for people to have in the village. KAREN: That sounds promising. DR. O'NEILL: To try and identify some at-risk folks that need help. KAREN: What kind of changes have you seen along the way in terms of medical care in rural Alaska and in the Health Aide Program? DR. O'NEILL: Well, in Nome, we have -- you know, we do baby steps compared to Anchorage, so we don't have a Cat scan or an MRI, but we do some procedures that you don't have to go to Anchorage for. So you can get a colonoscopy here or EGD or culdoscopy, or some things like that. A mammogram. But you have to wait for them usually. So if you expect to have things done the same day or the next day, they don't happen here like they would in Anchorage. But we've improved our village service, and not to say that the Health Aide Program is bad, but their scope is limited, and we now have mid-levels in seven of our bigger villages because they can provide at home a higher level of care. They can only practice within what's in the clinic, so people still have to come to Nome if they need an ultrasound or some -- an X-ray or things like that done. So things that people take for granted and just have to go around the corner to get in the Lower 48, you still have to take a plane ride to Nome or to Anchorage to get. So it's still very much harder to access services. KAREN: If you could change anything about the Health Aide Program, what would it be? DR. O'NEILL: I'd pay them more. I'd have more of them so that they weren't to stressed about call. I'd have video teleconferencing so that we could see the patients and make it easier for them, too, I think. Everything that we can do to give them more assistive technology, I think, helps them out and de-stresses them. KAREN: Have you noticed any changes along the way that have had a negative effect? DR. O'NEILL: On the health aides? KAREN: Uh-huh. DR. O'NEILL: Oh, I think some of them don't like the paperwork and the politics, but no. No, I think the ones that have been around a while appreciate the improvements. KAREN: I've heard a lot about problems with the turnover and attrition. DR. O'NEILL: We have about a 20 percent turnover a year. And there's many factors, I think, that factor into that. One of them is burnout. But that's only one of them. There's a lot of call. There's a lot of family stresses. Oftentimes the partner doesn't work and baby-sitting can become a issue because a lot of the health aides are young. So even having them come in for training is an issue. So it's not just one thing. Some of them move around to another region. So. And sometimes they will come back again. So you know, we have a 20 percent attrition rate, but you know, maybe at least 5 percent of them will be back again or 10 percent will be back again working after whatever their issue was goes away. KAREN: So as the trainers and support system for the health aides, how do you handle that? How do you deal with the thing that may or may not be there or how you get them to stay? DR. O'NEILL: Well, the training center doesn't deal with that. I mean, we try to support the students while they are here. We try to make this not be a high stress, each of them has their own counselor, and if there's issues, we try to identify them early and give them extra help. As far as the things that go on in the village, you know, there's a different system in place once they are in practice. So Karen Fagenstrom could probably talk to you about that better. We encourage people to take a leave of absence rather than quitting. You know, if they have something big going on that they can't deal with going to work, we offer them time off to try and go deal with their problems instead of quitting. And they do have some resources. They can talk to counselors. There's a phone number that they can call to talk about problems and things like that. If they don't want it to be within the corporation, the corporation has an agreement with some -- it used to be called EAR, I don't even remember what it is now, but you can call a counselor and talk to a counselor outside the corporation and get some guidance and stuff like that -- KAREN: All right. How -- DR. O'NEILL: -- with their issues.
KAREN: How it feels as a trainer, you put time and effort into somebody, and if they don't stick with it, then what? DR. O'NEILL: Well, we try to see if we can help them make a different decision. And some of them we think are so fabulous that we try to convince them to go on into nursing, PA position, other -- you know, if it looks like they could -- if they would be interested in moving out of the village and doing something more. Or we try to find ways for them to stay in training. But we always have something new. In the last session, somebody's baby got chicken pox while we were there so we had to send her home because they couldn't have the chicken pox in the building where she was staying because the state building with the pregnant ladies that were waiting to deliver. So we get a new problem every time. KAREN: Yeah. So when they come into town, where do the students stay? DR. O'NEILL: We have housing specific for them. It's over closer to the hospital. KAREN: Okay. DR. O'NEILL: It's a requirement of the training center that we provide housing. KAREN: So what would you say is your assessment of the Health Aide Program in terms of its strengths and weaknesses and through time? DR. O'NEILL: I think it's come a long way, and I think it will continue to be a necessary part of life in village Alaska because I don't see that every village is going to have a mid-level. Some of our villages are pretty small. And even if there is a mid-level in a village, they are not there all the time, if they want to go on vacation and CME and have their weekends off and things like that. So we are always, as long as there's Bush villages, going to need health aides. And they need to be well trained and well supported. And handle all the equipment, they need to do their job, and their certification requires ongoing education, even though when they are finished with the training. So we need to support them every way we can. KAREN: Are there things that you would have done differently along the way? Now that you look back on it? DR. O'NEILL: With the health aides? KAREN: Yeah, or with your work. DR. O'NEILL: Probably try to get more money to pay for stuff. Write more grants. No. I think we've done well. I'm glad they stuck the Dental Health Aide Program onto the Health Aide Program. I think it made it easier for it to become successful. KAREN: Well, that's about it for -- DR. O'NEILL: Okay. KAREN: -- my questions, unless you have anything else that you want to talk about, like being here since 1975? DR. O'NEILL: Things cost more.