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Dan Thomas
Dan Thomas

Dan Thomas was interviewed on September 14, 2005 by Karen Brewster in his office at the Norton Sound Health Corporation Health Aide Training Center in Nome, Alaska. In this interview, Dan talks about the structure and content of the health aide training program, his job duties, retention and turnover of health aides, difficult aspects of health aide work, the use of mid-level providers, the use of telemedicine, and the history of the training center.

Digital Asset Information

Archive #: Oral History 2004-17-17

Project: Community Health Aide Program Project Jukebox
Date of Interview: Sep 14, 2005
Narrator(s): Dan Thomas
Interviewer(s): Karen Brewster
Transcriber: Carol McCue
Location of Interview:
Funding Partners:
U.S. Department of Health and Human Services, Health Resources and Services Administration, University of Alaska Health Programs
Alternate Transcripts
There is no alternate transcript for this interview.
Slideshow

After clicking play, click on a section to navigate the audio or video clip.

Sections

His personal history and how he became interested in and pursued a medical career.

His role as curriculum coordinator for statewide health aide training and some thoughts about the challenges health aides face during training and work.

A little bit about health aide training, and how the demographics of the health aides have changed over the years.

The presence of mid-level care providers in villages becoming more common and the benefits of this change.

Doctor - health aide relations and the importance of the Community Health Aide Manual (CHAM).

The importance of the Community Health Aide Manual and why some health aides do not use it in the way it is intended.

The new headquarters for the Nome training center, and how health aides are selected.

The administrative and technological evolution of the health aide program.

Using computer systems to do patient registration and billing, and how health care provided by health aides is funded.

Training health aides to work with doctors, and also how doctor learn to work with health aides.

The need for rules and regulations to guide health aides, the importance of the community health aide manual (CHAM), and some comments on the satisfaction he derives from his job.

How the scarcity of health aides affects the functioning of clinics and ways to cope with it, now and historically.


The system of certification and credentials for community health aides.

Possible reasons why not many health aides go on to become RNs, PAs, mid-level care providers or even doctors.

The traits of a good and successful community health aide.

Cross-cultural concerns like languages and traditional medicine and some final comments about the training program.

Click play, then use Sections or Transcript to navigate the interview.

After clicking play, click a section of the transcript to navigate the audio or video clip.

Transcript

KAREN:  This is Karen Brewster and today is September 14th, 2005, and I'm here with Dan Thomas at his office at the Community Health Aide Training Center in Nome.  And this is for the Community Health Aide Project Jukebox.  

Dan, thank you for taking some time to meet with me.
  
DAN:  My pleasure.  

KAREN:  Thank you.  And just to get us started, tell us a little bit about who you are and what you do.  

DAN:  Okay.  I'm a physician assistant is my training, and my current position, which I've held for many years, is the curriculum coordinator for the statewide training center situated here in Nome.  And what that means is I coordinate the training sessions that we do and attend the statewide Health Aide Program meetings that are concerned with training matters that affect health aides.  

KAREN:  Okay.  And how did you end up here in Nome?  Where did you come from?  

DAN:  My folks were teachers, and when I was in the ninth grade, we moved out to Shishmaref, which is our northernmost village in our region, and they taught there for a couple of years, so I was there for one of those years.
And then finished high school here in Nome a couple years later.  

KAREN:  So were you born -- born here in Nome? 

DAN:  No.  I was born in Northwest Washington, but I -- my folks, being teachers and fishermen, we moved around the state of Alaska most of my childhood.  And ended up those -- in Northwest Alaska.  

KAREN:  And may I ask when you were born?  

DAN:  1956.  

KAREN:  Okay.  Gives these people an idea of who you are.  

DAN:  Uh-hum.  

KAREN:  And so how did you end up becoming a PA?  

DAN:  Well, I wanted to be a -- someone in the health services, and originally had gone off to nursing school because I didn't have to leave the state of Alaska to do that.  

But after doing that for a few years, mostly here in Nome, I decided that I wanted something a little more intellectually challenging and went off to PA school in Seattle.  And graduated from there in '91 and came right back to Nome.  

KAREN:  So where did you go to nursing school? 

DAN:  Anchorage Community College.  

KAREN:  Okay.  And so then 1991 you're back here as a physician's assistant?  

DAN:  I guess it was actually in '93, I started in '91, and I was back here in '93.  And in '94 moved down to Unalakleet and worked as the mid-level provider in that clinic for three years.  And then returned to Nome to work as a health aide trainer and curriculum coordinator.

KAREN:  So in this role as curriculum coordinator, what's the interaction you have with the health aides?  How does that work?  

DAN:  I -- I interact with health aides a lot.  Not quite as much as the regular trainings because I have my administrative duties, but I -- every afternoon, basically, I'm training with either a small group of health aides or one-on-one with a health aide seeing patients.

 KAREN:  And so can you describe the training program that a new health aide has to go through.  

DAN:  Once they come to us, they have a couple of kind of introductory trainings that they have.  But once they come to us, they have four, what we call basic training sessions, which are -- most of them are four weeks long, so it ends up being about 15 weeks of training all together, spaced out over about a two-year period.  

And it's, you know, quite amazing what we expect them to learn in that short period of time.  They -- they have to learn about all of the body systems and all of the common and emergency problems that they might encounter, and how to treat those.  

And we have lots of hands-on training in skills, laboratory, and examination skills, and a lot of seeing patients in clinics here in the Nome hospital.  So they get some practice actually seeing patients before they have to go home and do it on their own.  

KAREN:  And is there a regular time when these sessions are offered, you know, like a regular academic year, you know it's fall semester, spring semester?  

DAN:  Uh-hum.   

KAREN:  How does that work?  

DAN:  Well, we -- 

KAREN:  Do you always have -- 

DAN:  We try to cater to the needs of our region.  So we offer usually two of each of the four sessions per year.  So about eight sessions, eight or nine sessions per year.  And the order of them changes, you know, frequently, depending on what the need is.  If there's a bunch of new health aides hired, then we will go back and teach the beginning session so that we can get those folks up and running.  

KAREN:  Okay.  So when a new health aide is hired, do they have to get the training before they start the job?  

DAN:  No.  They -- 

KAREN:  Or does it -- 

DAN:  They can't see patients until they've done, you know, the first session, but they are on the payroll as soon as they are hired and we try to get them into training as soon as possible.  But they are kind of a unique profession in that they are hired and earning their salary when they come to training.  

And the other unique aspect of that is that we have to work with what we've got.  We don't -- you know, they are not weeded out by their education before they take on their actual career.  So we get students that have a lot of academic challenges that they have to overcome.  And in other professions, they may have never made it to that point.  

And in a lot of ways, that makes sense because we're looking for characteristics -- characteristics other than just academic ability and, you know, we're looking at personalities that are, you know, caregiver-type people and that they have that kind of innate desire to serve the people of their village in that way.  

KAREN:  And are you finding enough people who fill that role?  

DAN:  That kind of depends on the village and it depends on -- it changes, you know, over time.  There will be periods when nobody will want to do it, and then they will find a whole bunch of people in a big clump.  So you never know.  

Some villages have a harder time than others in terms of turnover, so they are always looking for people, and then other villages are very stable and have the same health aides for decades.  

KAREN:  Do you have any thoughts on why those differences?  

DAN:  I think it's harder to be a health aide in some villages.  Some of the bigger, busier villages that have a larger amount of trauma tend to be a little harder on health aides.  

You know, they are -- they -- one of the harder part of their jobs is being on call and being woken up at all hours of the night and day and having to take care of family members and relatives and long-term friends that are having, you know, health emergencies can be very traumatic, and you know, deaths, and things like that.  

So I think that some villages are just tougher.  And then that causes the -- there to be shortage of health aides, and that's harder on the health aides that are left.  

So it's pretty well-known by those of us that are involved with health aides that some villages are just a much more challenging place to be, I think.
 
And other villages are quieter, smaller, the staffing is more stable, and you don't have to be on call as often or there's less things happening when you're on call, and they are not as stressful.

KAREN:  So in terms of as a training facility, what kinds of things have you guys tried to do to help keep the health aides in some of these difficult villages?  

DAN:  Well, our job is to try and prepare them so that they feel as much self-confidence and can do, you know, as well as they can in a situation.  
I'm sure that a part of what would burn out a health aide would be if they didn't feel that they were able to handle a situation properly or maybe feeling afterwards that they hadn't properly handled it the way they should have.  

And if we can, it's true with all health care providers, if we can feel that we have done what we were supposed to do, then we can feel a lot better regardless of the outcome for the patient.  

So that's the way I look at it is, you know, they are relying on us to prepare them for the challenges that they're going to face, and that's what we try to do.  

KAREN:  Do you get any feedback from the health aides who have gone through your program as to whether they feel like it's prepared them or do they want something different or more?
  
DAN:  I -- you know, we -- we don't have people complaining that we don't try to train them enough.  Usually the complaint is that we're trying to cram too much into their heads.  

So I've never had anybody complain that we didn't do our job by teaching them what they needed to know.  They are much more likely to complain that we are being a little too demanding when they are here.  Because we are very demanding.  

I mean, they -- they have classes for 8 hours a day, plus some evening classes, plus homework, got lots of homework every night, and they are -- they are pretty well mentally exhausted by the time they leave here after four weeks. 

KAREN:  Yeah.  I know it's a rigorous program, and for some people leaving home for four weeks with family left behind and all that, how do they handle that?  

DAN:  Well, when you hear what some of these people, the stress that they have in their personal lives in addition to what we put on them in terms of training, it's really quite amazing what they are able to handle.  And it is really tough on a lot of them.  

A lot of them get very homesick and may be having problems with their significant other, and you know, it's -- it's really tough.  And there's -- we support them as best we can, but they have to be able to continue to function for us or they have to leave the session.  

So there's only a certain amount of sympathy that we can have.  We can't really cut them much slack and still maintain our standards.  

KAREN:  Have you noticed a difference in all your years of when you were actually working in a village and then here, a change in the health aides in terms of staying with the job a long time?  

You know, you said some villages, they've had a steady supply of health aides, and other ones they have a lot of turnover.  But have you noticed a difference in -- through time?  

DAN:  You know, there were kind of a core group of the pioneer health aides that, you know, started way back in the '50s and '60s, and had long careers of 20 or 30 years.  And a lot of them have -- most of them have now retired.  So it's newer folks that have taken their place.  And sometimes they don't quite have the continuity that the pioneers from years past had.  

So I think we're seeing a lot of -- when I first started, it was this group of veteran health aides, primarily, and a few younger ones, but mostly a few veteran health aides, an now it's a lot of young people.  I mean, we have health aides that start as young as 18, and a lot of them are 20, 21.  So it's a different group of people.  

Another thing that we see is that we have a lot of very bright and academically strong students, more so than the earlier group, I think.  
Although we still have folks that are not academically strong and bring other, you know, characteristics to their job, and they do fine, too, as health aides.  But we do have a lot of very bright young people that is different than the old pioneer group that was there 20 years ago.

KAREN:  Can you talk a little bit about your work out in Unalakleet when you were out there and what that was like working out there.  

DAN:  Well, that's really been one of my favorite jobs that I've ever had.  Working with health aides for me is the big plus for my job.  That's why I do it.  If you've been a health aide for a while, you're going to be an extra special person.  There's not -- it's only the cream of the crop that will come into a job like that and stick with it.  

So they are wonderful people and just a joy to work with.  And that's been my experience wherever I've worked in a clinic.  I've been to numerous other clinics, you know, for a week at a time here and there, and it's always that way for me.  So it was a real pleasure to work with the health aides. 

And just for my own personal work, it was very rewarding because I was the primary provider to those people and had a lot of good continuity of care being a person's primary provider over a significant period of time.  

KAREN:  So how did that work with you as primary provider as physician's assistant, and health aide, how does that work structurally, I guess?  

DAN:  Well, we have like seven mid-level providers in our region now, which is a new thing, so that's -- that's a big change in our local Health Aide Program is we do have half of our villages or close to half have got a mid-level provider on site living there.  

And that does change the job of the health aide to a significant extent because they now have somebody right there that they can report their patients to instead of doing it over the telephone.  So that kind of changes the dynamics of being a health aide.  

And it makes it easier, to a large extent, to be a health aide in that when you're on call, you're not the only one.  You know, you -- the mid-level is always on second call, if they are in the village, they are on second call, they can help you out with the hairier emergencies.  So that takes a lot of the anxiety out of being on call for a health aide.  

KAREN:  So as the mid-level provider in Unalakleet, you would see patients, you would have clinic?  

DAN:  Uh-hum.  I'd see my own patients alongside the health aides that are seeing their own patients, and they would report those patients that they would report, they would report to me, rather than reporting to a doctor over the telephone. 

KAREN:  And then would you report to a doctor over the telephone?  

DAN:  I -- when I was down there, I had, you know, the doctors would call every day, and I would -- if I had somebody that I wanted to discuss with them, I would, and if I didn't, I would just take, you know, whatever messages they had to give me.  And it would be a short conversation.  

So our system is that the doctor will contact you once a day.  

I think now, I think that it's changed a little bit now that the health aides from some of the villages that don't have a mid-level will report to one of the mid-levels in a neighboring village.  I believe that's the way it's working now.  So that's a little bit different than before.  

KAREN:  Do you know why Norton Sound Health Corporation has chosen to go with this mid-level system?  Because I'm not sure that that exists anywhere else in the state. 

DAN:  Well, part of it is they've gotten funding to do it.  They've got a special grant that's paying for it.  

So it started off with the position in Unalakleet, which they had had whenever it could be filled for, I think, close to 20 years, although it was filled, you know, maybe half the time, just for lack of someone to work there.  And I think it was the success of that.  

You know, when I was working as -- down there and still just me as the sole mid-level village provider, but then towards the end of my three years there, they started to expand the concept and put Dave Davalos down in Stebbins and St. Michael shortly thereafter, and then just kind of grew from there.  

So I think it was just the satisfaction that the doctors and the health aides had, you know, with what was going on in Unalakleet was what paved the way for the other villages.  

It makes the job of the doctor a lot easier, too.  A doctor who is on call in Nome, if he's not having to take all of the calls from all of the health aides in the other villages, it makes their duties for that day much easier, as well.
  
So it's just -- and I believe from my own experience in Unalakleet that it provided better care for the village residents that they got in -- you know, they got the care that they needed sooner than maybe they would have if they had been going through a health aide to the doctor.  Just because they get a little bit more detailed evaluation on the spot.  And so I -- I was convinced that it was a good thing having a mid-level in the village.
  
KAREN:  What was the population of Unalakleet at that time?  

DAN:  It's somewhere around 800, I think.  

KAREN:  So it's one of the bigger villages in this region?  

DAN:  Uh-hum.  Uh-hum.  We have others that are of similar size, though.
 Gambell, Savoonga, Shishmaref, they are all pretty big, as well. 

KAREN:  Oh, I didn't realize that.

KAREN:  Another thing I'm wondering is the relationship between the doctors and the health aides and do the doctors accept what they are being told by the health aides?  

DAN:  Well, it's hard to make a generalization.

 KAREN:  Yeah.  

DAN:  You know, how well does the doctor know that particular health aide.
  
So we are fortunate in Nome here that we have a very stable medical staff, and the doctors are here for many years, usually, and they have a chance to really get to know the health aides because they rotate being on call, so they are talking to the same health aide, you know, several times a month. 

And they -- they get to know which health aides are reliable in their history and exam and get feelings regarding the patient, and which ones are not so reliable.  So I think it's purely a one on -- individual thing.  Can't make any generalizations about it. 

KAREN:  I was wondering, too, how that might have changed over time that when the Health Aide Program first started and the idea with doctors being professionally trained and them interacting with people who had, in some cases, no training, and how that all meshed together.  

DAN:  Well, what our -- I think one of the changes that has happened in training is it has become much more structured in the use of the health aide manual.  I don't know if you've talked with folks about that much, but that is really the -- the basis of how the health aide works up a patient.  

There's a -- for a particular chief complaint, like, say, a sore throat, there's a very structured list of questions that the health aide is supposed to ask, and a definite established exam of, you know, the different body parts that are supposed to go with that, and then that has become much more concrete, I think.  

I mean, that is certainly our goal as a training center is to get them to use their CHAM.  They use their CHAM when they are here because we don't give them a choice, but when they go home, do they continue to use their CHAM is the big challenge, and I think that that has definitely improved. 

One of the generalizations that you might make would be that the people that were trained 20 years ago got used -- you know, after you've been doing it for many years, you start to think that you don't need to use the book anymore.  And then your workup is going to be a lot less detailed and more likely to be incomplete and to end up with kind of a misleading report that you're giving to the doctor.

KAREN:  So have you been involved with this new revision to the CHAM that Linda Curda's been working on?  

DAN:  I have not done the amount of work that the core of authors has been doing.  I mainly have done kind of reviewing.  

I did a lot of commenting on what was wrong with the old one, or what I would like to see changed, and I've done some reviewing of the new one, and -- but I just have not had the time to -- I mean, I certainly wouldn't have done it during my work hours.  And so I have not done much work.  And I don't think that the other training center directors have, either.  We have a pretty busy town. 

KAREN:  Well, I was just wondering that you, as the trainers and working so closely with health aides and getting them to understand their jobs, would have experience with whether the CHAM works or doesn't work.  

DAN:  Uh-hum.  

KAREN:  And would be able to make suggestions.  

DAN:  Yes.  I mean, certainly I -- I have a good handle for what the problems are that health aides encounter with the CHAM. 

KAREN:  Can you give some examples?  

DAN:  Well, one of the problems with the current CHAM is that it's just a little too complex, a little too much bouncing back and forth between different sections within a chapter or between different chapters, and it just doesn't lend itself to being used the way it was intended.  

So hopefully, the new one is going to have ironed out a lot of that and made it just more user friendly. 

KAREN:  Is there anything else that you've noticed -- do the health aides comment on the manual, what they think about it?  

DAN:  You know, I think that any manual is going to have problems because the -- the big challenge with the CHAM is that it is -- you know when you're working up sore throat, there's a million things that can cause a sore throat.
 And the CHAM tries to cover them all.  The idea is that if the health aide asks all of these questions, she or he is not going to miss any of those diagnoses that you're hoping to, you know, not miss.  

So it ends up being this kind of a monstrous list of all these different questions, many of which are not really applicable to that particular patient because it's trying to cover everything.  

And the health aide, after a while, realizes that a lot of those are not applicable, and the temptation and what is often the case is that the health aide just stops to use the CHAM history and does it off the top of her head.
And may do an okay job of it, but not -- not as good as really we would like. 

When a health aide is using the -- not using the CHAM for the history, in particular, things get left out that wouldn't have been left out if they had used the CHAM.  

So that's the -- and there's lots of pressures on the health aide to not use the CHAM.  For instance, the patients sometimes wonder why are you using the CHAM.  You know, this other health aide who has been working here doesn't use the CHAM, so why are you having to use this book?  Are you -- are you just dumb or you're such a beginner that you could do it off the top of your head?  So that's one pressure.  

And the other pressure is that the -- the mentor of the health aide, you know, the senior health aide maybe isn't using the CHAM, and the other -- the new health aide sees that.  

KAREN:  I also think that for time, as well, if you have a patient and you have to go through this big, long history and step by step and go through a book, it takes a lot of -- it could take a lot of time, whereas you go, I know what it is and you just skip it all and just do it.  

DAN:  Right.  Yeah.  That's, you know, certainly one of the big things is that after you've done -- after you've worked up an earache 50 times, you know, you probably don't feel like you need to ask those questions in the book anymore, you can do them off the top of your head and do an adequate job.
  
And that's probably true with earache.  But if you're talking about headache, which has all these, you know, potentially serious causes that can relate to all different systems of the body, then you can't do it off the top of your head anymore if you're a health aide because you just don't have the knowledge base or the years of training that other health professions have.
And so you're going to not do a very good job trying to do it off the top of your head.  

But I think that health aides often will generalize, you know, I can do sore throat, I can do ear, I can probably do headache, too.  And that's where the problem arises.  

Plus there's the legal -- the legal requirement that a health aide use the book.  If they don't use the book, they are not following the standard of practice for the profession, and you know, if it ever -- if there's a bad outcome and there's a lawsuit, they will not look good in court.  

So that's -- that's a big part of our job here at the training center, in Nome in particular, because we do a lot of field-related training, as well.  And we are constantly kind of fighting that tendency to veer away from careful use of the CHAM.

KAREN:  When was this training center set up? 

DAN:  This building here?  

KAREN:  Well, the one -- one was when was the Nome training center established?  

DAN:  We were -- we were one of the first, back in the '70s, I believe, and -- but it's changed a lot.  

In about 1990, there was a lot of new money that came into the statewide program, allowing us to hire mid-level, increased number of mid-level trainers.  And at that point, we -- we got our own -- well, we rented a part of a building and had our own staff that was specific for training rather than also supervising health aides.  

So that was about 1990.  

KAREN:  Okay.  

DAN:  But we were doing it a lot longer before that.  I was working here in '86 as a health aide trainer and I actually did some health aide training even way back in 1977, when I was a counselor.  So I've seen it over several decades. 

KAREN:  And then when was this new building -- 

DAN:  I think it's been about three years now, or four years.  

KAREN:  It seems like a nice facility.  What all is in here?  

DAN:  Well, we're a -- we're kind of the prototype arctic construction clinic that our corporation has since put into several of our villages, identical buildings.  So this was kind of the one that they built first and used to kind of, you know, work out some of the problems with the design and stuff.
  
So it was after this was built, it was decided to put us in here, and that was about three or four years ago.  And we've been here ever since.  

So it's constructed like a clinic.  We have a trauma room, and exam rooms, and laboratory/medication room.  We took a couple of offices and made them into our classroom.  So it is a very nice building and allows us to kind of teach things a little bit more in the context of an actual village clinic.  

KAREN:  Well, that's good.  It seems from a lot of the interviews, a lot of the health aides seem to be women.  And I don't know that you as a man in this field, what that's been like?  

DAN:  I don't know that it makes a difference.  I mean, our -- our staff at the training center here have fluctuated from almost all women, I was the only guy for a while, and then it was all guys for a year, and now we're half and half.  So you know, we fluctuate depending on our own staffing changes.
  
I don't think that it makes a difference.  It's nice to have both.  But I think we did fine when we were all male, as well.  

KAREN:  It's interesting, though, that it seems like a lot of the health aides end up being women.  I don't know if that's true in this region.

 DAN:  It is.  But we -- 

KAREN:  And why?  

DAN:  We usually have -- our last several sessions that we've done have had at least one man and sometimes two.

 So why?  I'm not sure.  I think it's been more the -- the decision of the village males to not be a health aide.  I don't think that the corporation seeks out females to hire, it's just that the men often would prefer to be doing something else.  So -- but it -- and that hasn't -- there's always been exceptions to that.   And I would say if anything there's been more men in the last 10 years than we've ever seen before.  

We had one session that had three out of the six students were men.  So -- and I think that's probably going to continue, maybe one out of every six health aides, or one out of every eight, something like that, will be a man. 

KAREN:  And I know from talking to some of the long-time early health aides, you know, they were selected by their -- somebody from their council coming and asking them to be their community's health aide.  Is that still how health aides are selected or it's a job they apply for or how does that work?  

DAN:  The opinion of the IRA council is certainly a big part of it, but the application, the job is advertised, and whoever wants to apply for it, applies for it.  

And then our Village Health Services department, you know, looks at those applications to make sure that they meet certain requirements, such as their performance on reading and math tests.  And then the IRA has their input, I think, into who they would like or not like.  

But it's -- and there are still situations where the person who applies for the position has been approached by somebody in the community, whether it be the IRA or other health aides a have been, you know, could you -- could you please apply for this position, we think you would be a good health aide.  So I think that still happens.  

KAREN:  But the health aides, they are employed by Norton Sound Health Corporation?  

DAN:  Right. 

KAREN:  Not by their IRA council?  

DAN:  That's right.  Although the IRA council directly is the Norton Sound Health Corporation.  They are our board of directors.  So.
  
KAREN:  Oh, they are.  Oh.  

DAN:  Yeah.  

KAREN:  Okay.  And --

KAREN:  What happened around here before there was the Norton Sound Health Corporation, do you know how it all worked?
  
DAN:  Well -- 

KAREN:  Or didn't work.  

DAN:  Well, it would have been the Indian Health Service, and Norton Sound Health Corporation came into being, I think, with the land claims settlement.  I hope I'm not making a fool out of myself here, but I believe that's the way it worked.  

And then they purchased the hospital here in Nome, and they are -- and then the Health Aide Program, the clinics in the villages and the -- the hospital, you know, became one entity.  

I remember when I was in Shishmaref in '71, I believe it was, the health aide did not have a clinic, she worked in a little room in the school and talked on single sideband to the doctor.  So you know, there's been a lot of changes, what with, you know, actual village clinics being built since then.  

KAREN:  And what about telemedicine?  Is that being utilized up here?
  
DAN:  Yeah.  I think our region is one of the ones that uses it the most, the last I heard.  

And I -- it took awhile for it to -- for the doctors to buy into it and the health aides to buy into it, it really -- they, both parties needed to believe in it for it to happen, for people to take the time to learn how to do it and to make use of it.  

But now, I'm sure that every day there's several telemedicine cases that are sent in.  Primarily photographs. 

KAREN:  And what are the advantages or disadvantages of telemedicine?
  
DAN:  I don't know if there's any disadvantages.  The advantage is that, you know, it can be pretty challenging to try and describe something to somebody over the telephone, and even more challenging, perhaps, for a health aide that has a lesser grasp of the medical terminology that's used to do that.  

So having a picture, you know, a picture is worth a thousand words, as they say.  So.  And some regions even have live video, which we don't have yet, but we may get that at some point.  

KAREN:  So then what -- what is the telemedicine system?  It's not live video, what is it?  

DAN:  Photographs.  

KAREN:  Oh.  Okay.  

DAN:  And we've got an otoscope which can look in the ear and take pictures of, you know, like the inside of an ear, or you could take pictures of the inside of anywhere else, too, because it can poke in there and take a picture.  So it's mainly that.  And they use it for like trauma and rashes and eardrums and stuff like that.  

KAREN:  So how did you get -- do you know how you got everybody to start believing into -- in it and buying into it?  

DAN:  We had somebody hired with that specific responsibility here in Nome.  A lot of travel to villages and continual training.  And we continue under the auspices of our training center to put a couple hours of telemedicine training into every time we have a group of health aides in.  

So I think it's just continually promoting it.  And the -- you know, we've -- it kind of goes along with the use of computers, getting people used to doing stuff on computers was a big challenge, and it took years and years for that to really get into full swing.  

And there's still some of the dinosaurs out there who have not really made that leap and maybe never will, but you know, we've got lots of young, bright people who have grown up using computers in the schools and stuff and they are -- they are into it.  And I think that's part of it, it's just kind of the general culture of the use of computers.  And digital cameras and stuff like that.

 KAREN:  Right.

KAREN:  When was the whole computerization started around here with the clinics and health aides?  

DAN:  I think that was beginning when I was down in Unalakleet, which was around 1993 was when they really -- they started to try to do billing, you know, creating the -- oh, and the patient registration and patient billing, that kind of stuff.  

KAREN:  The patients are billed?
  
DAN:  Medicaid, yeah, that's one of the big things about -- big changes in the Health Aide Program is that the -- in the last few years, with the certification board, that's the federal certifying board, that provided enough legitimacy in the eyes of our government that they were able to bill Medicaid.  There was legislation passed for health aides in their latter stages of training to bill Medicaid.  

So -- and then I believe that third-party billing is -- other third-party billing like Blue Cross and Blue Shield is the latest thing.  So that's -- that's a big deal.  Especially as IHS monies kind of dwindle to, you know, to make the most benefit that you can of actually bringing money in.  So it's a new thing, but it's definitely important.  

KAREN:  Yeah, because I thought Native Alaskans, beneficiaries were provided free care under Indian Health Service or something like that.
  
DAN:  Right.  And that's still true.  But if you can bill, you should. 

KAREN:  Okay.  

DAN:  Because there's a limited pot of money to pay for that free treatment.
  
KAREN:  Oh, okay.  

DAN:  So if Norton Sound has X amount of money granted to them by IHS in the state to provide services for a year and it runs out in the 10th month of the year, then there's no money left to provide that free care.  So -- and we're talking like travel and stuff would be the first thing to be cut.  

KAREN:  Right.  

DAN:  Traveling from the village.  So that has happened.  Travel has been cut in the past.  And you know, you hate to see that happen.  

Plus the corporation, you know, has concerns about going bankrupt, so you have to maximize the amount of money that you have coming in.  But nobody's denied care because they don't have Medicaid or insurance, we just actively promote that they sign up for that.

KAREN:  One thing here we are talking about training of health aides, what about training of the doctors who come here?  Are they trained in any special way about how to work with the health aides and work in the villages?  

DAN:  You know, that's something that we've always felt was important, but it tends to be low on the priority list and doesn't occur as consistently as we would like, or not occur at all.  So they learn it pretty much from the other doctors in the context of, you know, doing their work.  

One of the main things that they need to learn is, you know, how to take medical traffic from the health aides over the telephone.
  
And I know that with the new CHAM there's going to be emphasis made on teaching the doctors how to use the new CHAM.  Because hopefully, the health aides are going to be reporting to them in the context of having used the CHAM.  

So, but experience, I think, has shown that for the most part, when doctors are taking call, they don't have the time to open up the CHAM and see what the health aide is doing.  

So there the responsibility falls back on us again to make sure the health aides are documenting their use of the CHAM properly, which is our other big challenge, and so that because the doctors really don't have time to teach the health aide how to use the book, or to report, really.  I mean, they are too busy going from one patient to the next with their other duties.  

KAREN:  Are they provide -- are the doctors provided any cross-cultural training?  

DAN:  We have cross-cultural training here at our corporation, yeah.  So as new employees, they would get that.  

KAREN:  You had mentioned earlier something about having been a counselor.  

DAN:  Uh-hum.  

KAREN:  Can you talk about that part of your career a little bit?  We skipped over that part. 

DAN:  Well, I've been involved with health aides in other contexts, as well.  I was a counselor for a year when I was fresh out of college back in '77, and we were doing counselor training at that time for health aides.  

And I was the -- the health aides were -- you know, we didn't have village-based counselors, which is another village position, except in a few villages.  So in a lot of villages, the health aides were it.  And so we were trying to give them training for that.  

That's -- that's one change that's happened is we now have village-based counselors which are similar to health aides except that they are purely for the mental health, substance abuse type problems.  And so that's taken some of the burden off the health aides, although they still, you know, do it all the time, I'm sure.  

Anyway, that was -- that was my job there was to do village travel, work with health aides about counseling skills, and seeing the patients that they were following there.  I did that for a year.  

KAREN:  So what's your college degree in?
  
DAN:  I had kind of just a general science pre-med type of a college degree.
  
KAREN:  From?  

DAN:  For that position. 

KAREN:  From where?
  
DAN:  Bellingham, Washington.  Yeah.  

KAREN:  Then you came here and did that, then you went to nursing school after that?  

DAN:  Right.  And when I got back from nursing school, after having been a nurse for a while, I became a -- a supervisor trainer for the health aides. 

And so I was involved in supervision, as well.  As well as being a trainer.  
Because we were -- we kind of did both jobs back then, the training center and the supervisors were the same people.  That was in the mid '80s.  

KAREN:  So you've spent a lot of time traveling to the villages, it sounds like. 

DAN:  I have, yeah.  Not so much lately because I -- I don't have time anymore, but I used to.  And really enjoyed it.  I haven't been to a village in nine months.  But I enjoyed the trip I made nine months ago.  

KAREN:  So when you went as a field trainer, you'd go out to a village and you'd do some sort of training for the health aide.  How did that work?  What kind of things did you do?  

DAN:  Well, it's kind of a follow-up on what they get in basic training.  So reviewing their emergency skills is a big one because that's something that if you don't do it very often, you lose it.  And they don't do it very often.  

So we would review emergency skills, like back-boarding and IVs and the suturing and stuff like that.  And then general charting things, also administrative things like how they are handling their medications and their supply ordering and stuff like that.  

So general, kind of just general administrative.  You know, health aides do everything in their clinics.  They do it all.  And now they have the help of a clinic travel clerk, but back then, they did everything.  And so there was lots for them to be supervised with.

KAREN:  What, was there a schedule that every village got visited once a year, or how did that work?  

DAN:  Well, that's kind of an ongoing issue throughout the state is how much direct supervision, you know, contact with supervisors or village trips do health aides need.  And ideally, I think people are in agreement that it should be every quarter.  It may end up being only twice a year, hopefully no less than that.  

Health aides, you know, they are on their own out there and they need support.  They need support to help them function.  And so that's a real important part of the program is the field support and supervision, which is kind of the other side of the coin.  You know, training center is half of it and the field supervisor trainers are the other half. 

KAREN:  Okay.  What about changes in the program and how that's worked?  Positive changes?  Negative changes? 

DAN:  There are those that feel that we have become too worried about rules and regulations.  I'm not one of those people.  I feel that our rules and regulations which, you know, I'm an active part of the committees that come up with those, and I think that they are a good thing.  Quality control, you know.  

The -- the thing that is going to happen with a health aide if they are out on their own without proper supervision and proper ongoing training is that they are going to develop bad habits and start taking shortcuts and stuff like that.  I mean, it's just human nature when you are out all by yourself 100 miles from your supervisor that that's going to happen.  So it's a rare health aide that does not need some rules and regulations and training and support to keep on track and doing the best job they can.  

So I think that improvements in those areas have been a good thing.  It's a fact that 10, 15 years ago, very few people were using the CHAM as it was intended to be used, and the CHAM has become a more complex thing.
And so I think the more effort that we can put into training with it and encouraging people to continue to use it, the better.  

KAREN:  Okay.  What about for you personally, what has it meant being in the health care field and working with health aides?  

DAN:  Well, I just derive great job satisfaction out of working with health aides.  I mean, I -- I think that indirectly I am helping with the care of their people in their villages who, you know, are out there without a doctor, and so I -- I just feel like I'm really making a difference.  

And then just knowing that I am helping the health aides to do their job well and to feel good about the job that they are doing.  That's how I get my satisfaction.  I guess it's like any teacher.

KAREN:  I know in some regions in the state now the health aide population is switching a little bit from long-term local residents to, you know, Non-Natives, maybe newer residents in the areas or whatever.  Is that happening up here or are health aides mostly still Native people from their villages?  

DAN:  I think that is happening more in other regions.  Our health aides are -- I can only think of one at this time in our region that is the spouse of a teacher.  

So the rest of them are local -- local residents.  And I don't see that changing.  I think what happens in some other regions is -- I mean, that would always be the preference would be a local person.  So I think in some regions they just can't find local people, for whatever reason that may be, and they hire who they can get.  

KAREN:  Now, what do you do if you have a village without a health aide?  Has that happened?  

DAN:  It hasn't happened up here.  I mean, I know in other regions, they will close the clinic down.  Now, we've never -- we're not in the habit of doing that around here, so if we were to somehow end up with no health aides, which has happened, where for a brief moment all of a sudden there is no health aide that's going to work at the clinic, then we will bring people in to cover the clinic on a temporary basis until we are able to scramble around and get some folks working again.  

But we have had villages that were down to like one health aide for a extended period of time, which is really tough on that person.  And other people from other villages volunteer for a course to go and help cover.  Plus we have our mid-levels now who can help cover in that kind of situation.
  
So -- but it hasn't been much of a problem here.  I mean, it's always a possibility.  

One thing that we have done differently in the last few years is to hire people -- relief health aides for -- even though there's not an open, full-time position, we've hired a couple of relief health aides, or tried to, for every village so that we always have some backup.  

Because things happen.  You know, people want to take a vacation, they have a family, medical emergency, or they are sick or they have to go off for training, and you can end up with nobody there.  Or the people can't take their vacation or can't leave for training because there's no coverage.  

So that's been a good thing is to get lots of new health aides hired and trained, even though there's not a full-time position for them.  

KAREN:  And that's something that seems very different from the early days when the health aide was the only person 24/7, they didn't have relief aides.
  
DAN:  I don't know how much that happened.  I know there was one village where one lady was a health aide for two years, but that's -- that eats you up.  

I don't know how many people can do that.  Because you can't really leave the town, you know, you can't go out and do the things you really want to do.  You have to stay in the village and be on call every night.  

So usually there was at least one other person.  So you might have villages with two health aides.  And back then, they did have a health aide, I think they were called alternate health aides that would work on the weekend who were actually hired by the city council.  They would work on the weekends, and the primary health aides would work during the week, hired by Norton Sound.  

KAREN:  And did those alternate health aides get paid?  

DAN:  Yeah.  I'm not sure how much.  

KAREN:  Right.  Well, it sounds like, yeah, a long time ago, lots of people did this kind of work without getting paid.  

DAN:  That was before my time.  

KAREN:  Yeah.  

DAN:  They still don't get paid very much for what they do. 

KAREN:  Really.

KAREN:  So what is your assessment of the health aide system and its effectiveness for providing health care in Rural Alaska?  

DAN:  I can't imagine.  You know, there's some doom sayers that say the Health Aide Program is -- you know, the funding will dry up and it won't exist anymore.  

I just don't see how that could happen.  I don't -- I mean, what would those people do then?  Would they have to fly in every time they needed to have a clinic appointment?  Every time they had any sort of an emergency, have to be flown into Nome to be seen?  I just don't see that happening.  

So I think that -- I mean, that would put us back in the Stone Ages where we were back in the 1950s.  I can't imagine that happening in the United States.  Unless we had, you know, complete economic collapse or something. 

KAREN:  So do you think it's a program that's done well for the villages?
  
DAN:  Yeah.  I think we -- I think it is a great program, and most -- as far as I know, anybody that comes and looks at our program from other parts of the country or the world that don't have it are very impressed.  The Alaska Health Aide Program is kind of a model for a lot of other parts of the world.
  
Our manual, I know, is very well regarded.  And the training.  

KAREN:  So the training, how does it work?  Do they become certified, do the health aides become certified somewhere along the way?  You know, like doctors -- 

DAN:  Uh-hum.  

KAREN:  -- like teachers get certificates?  

DAN:  There are two different systems and they are often confused, but certification now refers to what the federal certification board does, and it can be done at any level of their training.  

So if they are -- if they've completed Session 1, 2, 3 or 4, or have become a CHP, which is a Community Health Practitioner, they can be certified at any of those levels.  And that is what is being promoted is that they be certified at any of those levels.  And if they want to bill Medicaid, they have to be certified as a Level 3 or a Level 4 or a CHP.  

The other -- so that's a federal certification.  And then the other system is what the training centers do, which is credentialing we call it.  That is when they achieve their Community Health Practitioner credential.  Can't call it a certificate because then you get confused.  

KAREN:  Right.  

DAN:  And that's when they've completed all four sessions plus a, you know, a final preceptorship evaluation.  

And that has to be renewed every six years similar to what I do as a PA, and what doctors, like a family practice doctor does every six years, they have to be reevaluated.  They get -- they take the test again, they get a week of clinical preceptorship evaluation, seeing patients, and they have to have completed X amount of CME every two years, you know, their ongoing training. 

KAREN:  Continuing -- what is it?  

DAN:  Continuing medical education.  So they have to have a certain amount of ongoing training for which they receive credits through the certification board or hours.  And that's how the system works.  

KAREN:  So they start out -- the first level is -- becoming a Community Health Practitioner is getting a credential. 

DAN:  Uh-hum.  

KAREN:  And then above and beyond that, you can get certified?  

DAN:  Oh, no, they can get certified as a Session 1 health aide, Session 2 health aide, Session 3 health aide, Session 4 health aide, and a Community Health Practitioner.  

KAREN:  Oh, okay.  

DAN:  And that's -- you know, they are trying to promote that for all levels, but it costs $400 and bunches of paperwork and stuff.  And I think that I know in our region, we do it for 2, 3, 4 and CHP, and really there's a monetary incentive only for 3, 4, and CHP.  Because then you can bill.  

So that's being promoted, though, by the certification board.  They'd like to have all health aides get certified, and they have to get re-certified every two years, based on getting the education, you know, the ongoing education requirements and stuff.  So that's kind of the ideal, but it's not mandatory at this point.  Except for billing purposes. 

KAREN:  What's the rate of people going on to become physician's assistants or nurses or whatever beyond health aide?  

DAN:  In our region, it has not been very much.  We've had -- I mean, we have people that are bright enough and could do it, but it's just when you have grown up in a village and have your significant other and your children, it's very hard to leave for a couple years to go to PA school. 

The medics program in Seattle would take probably any health aide that -- you know, we could send them that could get -- well, they have to take a year of prerequisite college courses, which they can do by distance learning without leaving their village.  

So they probably could get in if they wanted to do it.  But there's just very few that are able to make that step.  There's a number that express interest and start taking the classes, but even taking a class when you're working full time with a family in a village --

 KAREN:  Right. 

DAN:  -- by distance is a challenge.  

KAREN:  Right.  

DAN:  So I think a lot of folks just never make it to that point.  They never get through the prerequisites.  

KAREN:  And a PA program is how many years?  

DAN:  The one in Seattle is unique in that it's two years, one year of prerequisite college stuff, and then in two years, and the second year, that's where I went, the second year I was here for the last half of the year.  I was back in Nome in a clinic here as a student.  

So you could be back in Alaska within a year and back in Nome within 18 months, which is what I did.  

But that's a long time to be in Seattle if you're from a village.  

KAREN:  Yeah.  

DAN:  So we promote it, but it hasn't happened for several years.
  
We did have a health aide that went off to nursing school and just graduated with her RN.  

KAREN:  Well, good.  And is she coming back here or -- 

DAN:  I'm not sure.  One of the problems is that, you know, if you're a mid-level or an RN, your job changes, you're not a health aide anymore.  

And I think that health aides may have to consider if you're an RN, you're not going to work in your village, you're going to be working in Nome will be as close as you want to get.  So is that what you want.  It's where do you want to work is a big part of career choices.  

And then for the mid-level, do you want to have the level of responsibility that a mid-level has or would you rather be a health aide working under a mid-level, and have the kind of the security of not being the top dog in your village.  

So that's what -- if you're a mid-level in the village, you're on call all the time. 
Second call.  But still, if there's anything bad happens, you're going to be there.  So you know, I think that it may be that people think twice about whether they want to do that.  

I personally think that we should not pressure health aides into feeling that they need to do something more, that being a health aide is not enough.  I think being an excellent health aide in your village is a wonderful career, and if you want to live in your village, you know, that -- that may be as far as you want to go.  And there's nothing wrong with that. 

Of course, I'm a mid-level, people are always saying to me, why didn't you go to medical school.  I don't want to be a doctor.  So that's my take on it.  I don't pressure people.

KAREN:  What you just said, it made me think of a question about what type of person do you think makes a good health aide?  

I mean, you've seen people who stayed with it for a long time and people who have come and gone and sort of what the personality traits or characteristics are that have made somebody successful versus somebody else who was not.  

DAN:  Maybe the first part of that question would be who -- who applies to be a health aide.  And I think that we probably should do this more often. 

We quizzed a class one time and half of them it was a job.  It was the job that was available.  

So they go into it not really feeling this, you know, this -- you know, a light didn't come out of the heavens and tell them you are to be a health aide, you know, that is your -- your mission in life.  It wasn't like that.  It was just a job opportunity.  

And some of those folks decide within a few months that, no, I don't want to do this.  And others grow and become motivated and it turns out that they are the right person for the job.  So you can grow into it.  Even if your motivation is, you know, a little shaky or that at the beginning.  

So I think to be a good health aide, you have to be someone who is a -- a care provider, you know, a nurturing type of person.  It's not like a surgeon where you put your patient unconscious and you go in there and do you some sort of technical skill.  

This is definitely face-to-face with people of all ages and you know you've got to enjoy working with children, you've got to enjoy working with pregnant women, you've got to enjoy working with elders.  So you have to have that sort of inclination.  

And then the other part of it is I think you have to be able to handle stress. 
So if you are a person who gets stressed out to the point where, you know, you are not able to handle the day-to-day pressures of being a health aide, and every health aide is going to have some, you know, real tragic circumstances that they are going to have to deal with at some point, and some more often than others, then you won't make it as a health aide either.
And we've had excellent health aides that just emotionally could not take it and went off into other professions.  

And to some extent, having the -- the intellectual ability to use the book, do the simple math that is required to, you know, give medications safely.  So that's -- that's part of it, too.  If it's too much of a struggle for you to read the health aide manual and to use it properly, then it's going to be just a daily struggle and they may decide that they don't want to do that.  

So those -- that would be the things that I could think of.  You know, being able to juggle the responsibilities of being -- well, like you say, most are women, so being a mother of small children, and a -- and a wife and maybe the primary housekeeper plus being a health aide, you know, certain people can do it and others can't.  

There's easier ways to earn a living, for sure, even in the village, you can -- you can find an easier job.  

KAREN:  You know, you're talking about some people who feel like it's a calling, sort of versus, well, this is a job.  

It sounds like for some of the early health aides, you know, they -- their -- somebody from their council came and said would you do this, so it wasn't necessarily a calling for them, it's not something they sought out, but they somehow were selected and it worked.  

DAN:  Well, early on they weren't getting paid. 

KAREN:  Right. 

DAN:  So there was certainly a -- a certain amount of, you know, volunteer, you know, wanting to do something for your community.  

KAREN:  That's true.

KAREN:  I think that's about it, unless there's other things that you can think of that I haven't talked about.  

Well, one thing I do -- I don't know if it applies up here is that cross-cultural and Native language versus the use of English, and I don't know how that's worked up here.  I know some regions, the Native language is stronger than in others.  

DAN:  It varies in our region.  Out on St. Lawrence Island Siberian Yup'ik is still to some extent the primary language.  And people are really -- most people are very bilingual.  With the exception of maybe some really old people that struggle with English.  

And here on the coast, it's very few younger people like under 40 or even 50 that are fluent in their Native tongue.  

KAREN:  I was wondering if in terms of the training and when the Native language was more dominant, how they learned some of this very complicated medical terminology and techniques and things, that if that was an issue?  

DAN:  From what I've heard, it isn't any harder to learn two languages as it is to learn one.  So I don't think that's an issue.  I don't think that that would be a problem.  

If you're fluent in one language, that makes it easier for you to be fluent in another language.  That's the way I've understood it.  

KAREN:  Okay.  

DAN:  So I think that people today probably struggle just as much learning the medical terminology as the other folks did, except that I think that our training is more intensive now.  And they may have more academic skills because they just went further in school.  

Our health aides are, you know, almost always high school graduates or have their GED, which is probably different than it was in the early days. 

KAREN:  Yeah.  What about the role of traditional healers?  Is there any of that going on?  

DAN:  You know, in our region, in contrast to, say, Kotzebue where it never really died out, it kind of died out here.  

And our corporation has been, in the last few years, hiring kind of apprentice Native healers who didn't have any training in that area, who have been trying to train into the position.  So they go and kind of act as apprentice with the folks up in Kotzebue and try to get their own practice going on down here.  

But it's a struggle because you're starting from scratch.  And that's a hard thing to start from scratch on, I think. 

KAREN:  And I'm wondering if -- how that works or used to work, tradition -- when traditional healing was more dominant between Western medicine coming in and traditional healing and how that balanced out. 

DAN:  Well, I think that, you know, the midwives were accepted and continued to do their thing up until they were just kind of gradually replaced by health aides that had some training.  

And there are still midwives, well, I think they are gradually dying out.  But I think that the other bone doctors and stuff like that, I think they were -- my guess is that they were pretty well rubbed out actively by the missionaries, that would be my bias there.  Along with the Native language and dancing and stuff like that.  Which varied probably from village to village.  But for some reason, that didn't happen up in the Kotzebue area.  

KAREN:  Yeah.  And it is interesting that the Native health corporation, which is really focused on Western medicine, would also be promoting traditional medicines and healing.  It's an interesting combination.  

DAN:  Yeah, I guess it's -- 

KAREN:  There are other places in the world that wouldn't happen is what I'm thinking. 

DAN:  Well, it's a Native health corporation, you know. 

KAREN:  Right.  

DAN:  It's our -- our governing body is the IRA council, a member of each IRA council from every village.  So you know, they decided that it was important.  

KAREN:  But you say it's a hard skill to go back and relearn.  For sure.  

Well, I think that's about all the questions I have.  I think we've covered what goes on here and pretty extensively and your experience.  And anything else you'd like to say about your involvement and experience?  

DAN:  I guess I would just sum it up by saying that I think that the -- that the training center's portion of the CHAP program is doing very well.  We are very good at policing ourselves and continually striving to improve what we do.  There's very, very dedicated people.  

You know, the only people that last in the training centers and probably I'm sure the field people, as well, the only people that last for long in that kind of a position are the people that really care and really want to do it right.  

And so training centers are doing well.  The field portion of it is what is struggling because of lack of adequate funding, and therefore, lack of staffing and lack of the ability to support and train the health aides the way that they would like to.  

So that's kind of the challenge that faces the program in general, is to beef up the field portion of it.  

KAREN:  And where else are there training centers around the state? 

DAN:  There's one in Anchorage, one in Sitka, and one in Bethel.  

KAREN:  Okay.  And then this one.  

DAN:  Uh-hum.  And there's efforts going on to try to create a distance learning option.  So that's -- that's kind of the new thing on the horizon.
  
KAREN:  That sounds challenging.  

DAN:  Yes.  I would think it would be very challenging, knowing what we do here and trying to do that by distance, that's going to be a tough one. 

KAREN:  And also seeing with medical care, so much of it is patient interaction, you mentioned before, that doing that -- learning those skills or practicing those skills by distance delivery would be very difficult.  

DAN:  Right.  Well, they will have to work out how they are going to go about doing that.  I mean, I'm sure it will be a combination of stuff that is done over the, you know, the video camera or whatever, and then combining that with some hands-on, real patient, touching the patient care in some other spot.
  
KAREN:  All right.  Well, thank you very much for your time this morning.  I really appreciate it.  I'll let you go have some lunch. DAN:  You're welcome.