If It Isn’t Documented, It Didn’t Happen. (Yes, Even With AI.)

AI Is Confident. I’m Accountable

AI can help me move faster with confidence. It can also be confidently wrong.

And here’s the part people may miss: whatever AI produces becomes my responsibility the second I use it. Not the model’s. Not the tool’s. Mine.

That mindset isn’t new. In high-reliability work, you don’t get to outsource accountability.

So this is my “professional cover-yourself” version of AI governance—practical, lightweight, and designed for real work.

Garbage in, garbage out

AI does not fix messy inputs. It scales them. 

Decisions pile up. One small assumption can get lost in a long string of decisions.

Rationale: If you don’t document what you did and why, those stacked assumptions eventually implode—usually at the worst possible time.

Guardrails:

Programmatic guardrails

• global guardrails (always true)

• project guardrails (context-specific)

Rationale: This prevents “helpful shortcuts” from quietly becoming bad defaults. 

Guardrails in action: Trust, but verify

AI outputs are hypotheses until proven, because confidence is not correctness 

I challenge every notion: Prove it. What could disprove it?

I periodically test the AI against the guardrails to make sure it still conforms. If it drifts, I correct the prompt, tighten the format, or reduce the scope.

Rationale: AI is not perfect (just like humans) and small tests are investments in avoiding larger future failures

Category guardrails: 

I use AI to:

• summarize

• identify patterns (especially in large data sets)

• drafting / formatting documents 

• discuss, suggest options

I do NOT use AI to:

• make final calls

• declare root cause

• “certify” anything without evidence

Rationale: Decision support is not decision ownership. 

Standardize the communication

I don’t want paragraphs. I want a clean hand-off.

So I standardize the format:

what happened → evidence → next action

Rationale: Closed-loop communication beats interpretive storytelling every time.

Keep a document trail as you go (because you will sleep between now and remediation)

“If it isn’t documented, it didn’t happen.”

And in AI-assisted work, documentation is not the conclusion.

I document the rationale in a lightweight way—because I have slept since then is a real thing.

My preferred framework documentation trail:

• what I asked

• evidence I reviewed

• decision

• rationale for above decision

• what might change the decision

• next steps

• confidence: high / medium / low

Rationale: This makes remediation faster, hand-offs cleaner, and mistakes easier to unwind.

The cost of doing this business this way: 

At first, this might feel like it slows you down.

Truth told - briefly.

But it builds something you can trust. And once the guardrails + trail + standard hand-off are in place, you stop re-learning the same lessons and start scaling outcomes.

Rationale: Fast is fine. Defensible is better.

Spoon-feed the judge

 

"Spoon-feed the judge" The best personal advice I ever got about high-stakes work. It became part of my professional practice: don’t make the decision-maker swivel their chair, open another book, or go hunting for context. Put the proof next to the claim. Make it one-and-done.

In regulated healthcare software, the “judge” might be an auditor, security reviewer, change approver, incident responder, future-you at 2 a.m., or future-you three years later in a deposition—but the rule stays the same:

If it isn’t easy to verify, it isn’t easy to defend.

I didn’t fully appreciate how universal this principle was until years later, when my roles included conducting audits and being subject to them.

As an auditor, “spoon-feed the judge” is exactly what I want. I trust, but verify. This is transparency at its best.

As the person under audit, it makes my position easier to defend because the evidence travels with the claim.

Bonus (worth its weight in gold): over time, this approach has kept me out of many audits entirely - because the work was naturally verifiable without a live explanation. More than once I’ve been told: “No—this answered all our questions. We don’t need to call you.”

What “spoon-feeding” looks like in systems work:

1. Make it readable

   Short, structured, and complete. If verification requires a scavenger hunt, you did not spoon-feed your judge and your risk rises.

2. State assumptions upfront

   Identifiers, timing windows, source of truth, and what “acceptable” looks like.

3. Locate proof next to the claim

   Your claim was clear. Now provide the proof right next to it. If proof cannot be adjacent, keep the ordering parallel and easy to follow.

4. Make cross-system truth explicit. For transitions, prove each of the following:

   • Sent
   • Received
   • Applied

   Acknowledged is not the same as true.

5. Leave an audit trail that survives time

   Links, IDs, timestamps, and artifacts that let anyone re-verify without tribal knowledge.

This is not “more documentation.” It’s high-quality evidence—delivered where it’s needed, when it’s needed.

Where do you still see scavenger hunts in your high-stakes work? Consider how you, too, can "Spoon-feed the judge".

The most critical defects often exist between systems rather than within them

 

 

Would you like to quickly find where some of your most critical system defects? 

Take a lesson from healthcare: transitions in care are well-documented high-risk times. This is not a one-off issue but a repeatable pattern.

Software systems exhibit the same pattern during transitions:

• You might say, “System A did its job,” but “System B holds the truth.” It's essential to prove it.

Consider this real-world example:

Your doctor says they sent the prescription. The pharmacy claims they don’t have it. Ultimately, you still don’t have your medication. The gap lies in this hand-off: sent ≠ received ≠ applied.

To address this, lean into testing transitions:

• Define what “done” means on both sides of the transition.
• Trust, but verify: don’t stop at “sent.” Confirm it was received and actually applied.

Test both acceptable and unacceptable outcomes:

• Acceptable: slowdowns, retries, short delays.
• Not acceptable: missing, wrong, late, duplicates.
• If you exceed a limit, log it as beyond tolerance - don’t mask issues behind a green check.

Why is this important? Testing these hand-offs provides evidence where it matters most and can make the rest of your test suite feel surprisingly simpler. Your customers will thank you for it.

I now do accessibility testing. I tested my own blog. I am not impressed.

 

My blog has health care information but it will begin to include what I learn as an accessibility tester. I think I can set the content up with proper heading levels and in a way that is consumable if I have a tool that conforms to WCAG standards.

Unfortunately, I keyboard tested a piece I published and I had too many findings despite the fact that I used heading levels, alt text, etc.

I looked at the company's help pages to see if there was information on making it accessible, a VPAT or ACR or anything about WCAG conformance and got nothing. I am now looking to change the tool I use to publish my website, and remediate my content with a more inclusive design.

The favor I am asking for is which mediums might be able to do that, so I can get down to business and remediate my content, because I can do better.

[Congestive Heart Failure] When the ol' pump ain't what it used to be

This is a repost of my response on Reddit about how someone was going deal with a new sodium and fluid restricted diet after being hospitalized for heart failure. They loved milkshakes and had met with a dietician who really did not have a good therapeutic connection.

Trigger Warning - Below I'm going to talk about what I saw taking care of heart failure patients on a hospital cardiac unit. Someone who has had a heart failure episode may become anxious when I describe the early parts of their admission.

 

This discussion barely scratches the surface of the complexity of this condition. Most people are not admitted every week or two - but the advice I learned to reduce admissions for these patients helped to curate the discussion and education I provided to patients in the clinic and helped them have much more control over their own health and disease.

 ---------------

Day 1: I have had patients who were admitted about every 10-14 days like clock work. The ER gave them diuretics, the ER would take off 1-2 liters of fluid. By the time they get to my unit, they were still afraid from being short of breath and it being hard to breathe and this was the new and improved version. There is a look in a scared person's eye that doesn't leave you. I know that look from across the room.

Day 2: Less panic, still feeling very drained. We continue to remove fluid.

Day 3-4: Start to perk up, feeling a bit better. Better enough to be irritated with us, and complain about being hungry and don't like the food we're bringing because not enough salt/fluids. Sometimes they ask family to bring food - like fried chicken.

I cannot believe my anecdotes came about because I had so many patients who would come in and say how we didn't take care of their heart failure, but by day 3-4 they were having family bring fried chicken. #ffs #nurselife #we'veseensomeshit

Now let me get to the advice I found worked the best to stop repeat admissions:

Of all the dietary restrictions, salt+fluid can be one of the hardest.

Accept this is a difficult thing. I don't love people who treat it like it is easy like dieting and losing weight. *just* change your diet and the things you eat multiple times a day, every day for the rest of your life. Yeah bud, *just* is a 4-letter word. It is okay to have grief over this.

This person discussed a having dietitian who did not connect well with them: 

If you feel like you and the dietician aren't connecting, consider finding one who has empathy. I have seen great dieticians (they are part of your healthy team and they find ways to help you feel satisfied while having to change something you've been doing your whole life) and ones who just tell a grown adult patient what to do. I have no use for someone telling adults what to do like they are children.

Intake is all choices. You can absolutely eat all the fried chicken and drink all the ice cold milk shakes (or whatever items you love). Be prepared to spend an increasing amount of time in the ED and in the hospital as that taxes a heart that has had an injury.

Basically, the heart is a pump that is with you your whole life. That pump got hurt somehow. Maybe a heart attack or some other type of an injury but at the end of the day, the ol' pump ain't what it used to be. It can't pump like it used to. Your body has tried for a long time to help it - but it just can't do all it used to do. 

What happens when you try to use the pump the same way and it can't do it? These are the chains of events that bring some people to the hospital with a worsening of their heart failure enough to be admitted.

If you are committed to liquid, consider eating foods with less fluid - since the liquids add up you can trade off. Now if less liquid-y foods are dried (e.g. beef jerky) - mind the sodium.

I don't know how you are managing your HF, but daily weight is the gold standard.

Wake up, eliminate any stuff from your body and weigh in the "same clothes" (e.g. naked = same clothes) every day. Write the weight down. If you gain more than 3 pounds in a day or 5 pounds in a week, it is time to call the doctor as that is the best indicator of water weight.

What are the other upsides to daily weights?

Just for a bit of context - our patient often didn't get admitted with a 3 pound weight gain. They were frequently admitted with a 20-30 pound weight gain and often didn't detect it until they were short of breath (height and weight can change these numbers). Watching these numbers lets you know in short order what is going to cause more fluid retention. Daily weights give you insight about your intake from the day before and if it affected you, you can make adjustments.

This is great info for the doctor too. Your doctor can have a much more informed discussion with you over time when you can bring that one bit of data for daily weights to your PCP or Cardiologist.

I don't know your situation, but if you are a Veteran, they actually have a heart failure line where Veterans can call. The line has clinicians who can advise on medication adjustments if needed on the fly. I personally believe it should be an industry standard. The concept is simple, they can manage you at home to reduce admissions. Less cost for them and more convenience and quality of life for you.

The unappreciated choice

 

You have a decision to make. You weigh the options in hopes of making an informed decision (or informed refusal). 

• The decision can be difficult
  
• Maybe you don't like the answer or outcome
  
• Maybe you feel like you don't have enough information to render a decision yet
  

Enter analysis paralysis

Consider this: *Not* deciding is also a decision. 

Why? There will always be an outcome. The absence of a decision is often the unappreciated choice in a scenario.

Consider this when you might come across time when analysis paralysis sets in:

No decision is a decision in and of itself

Why you want to interview a nurse, whether or not you are in the healthcare sector

 

Nurses are limited in their career only by their own imaginations. 

If you are a nurse thinking about changing roles or if you are an employer looking for that next employee to round out your team, let's discuss the things a nurse brings to the table:

1. Nursing is a profession - we teach each other

2. Safety first - Our license is to demonstrate that we know how to keep folks safe - it is a privilege not a right

3. Prioritizing - we have to get ahead of the thing that may kill you first; then we'll get to the second thing that might kill you (see # 2)

4. Learning - evidence based medicine is ever changing, and we have to stay up to date, so we are expert learners (also see # 2)

5. Delegation - we are trained to lead because we know we can't do it all. We learn to leverage the power of a team and the strengths of the many (See # 3)

6. Resourceful - we don't always have everything we need on hand, yet we still manage to get things done (see # 3, # 5)

7. Teachers - we have to teach medications, treatments and healthcare to folks who may not know much about medications, treatments or healthcare (also see # 1, # 3)

8. All comers - we treat everyone because we are everyone <3

9. Compassion - We see people at their absolute worst and we learn to help them maintain their dignity and autonomy as much as possible (see # 2, # 3)

10. Practice - We know how to work toward improving things "That's why we call nursing a practice, not a destination" (See # 2)

11. Pattern recognition - Nursing and healthcare are algorithmic in nature. There is math in humans and we still treat them like humans

12. Soft skills - we are consistently the most trusted profession while doing all of the above things in any given situation (See # 1, # 2, # 3, # 4, # 5, # 6, # 7, # 8, # 9, # 10, # 11)

Universal Truths

 The Distillation Process

 

These things. They happen over and over. They prove themselves at every opportunity. They are Universal Truths.

How do you recognize a Universal Truth? Well - it isn't always easy. Think of distilling a fine spirit. You boil off the impurities and what is left may be the Universal Truth you are seeking.

If something happens over and over - it may be true, from your perspective. Consider though, you are one of over 7 billion people on the planet. What is true for you, may not be true for everyone else. Try to see someone else's perspective. Challenge your own thoughts on the thing. Observe the world around you. Does it change when you changes these variables? If it does, it may not be a Universal Truth. Does it stand the test of challenge? Then you may have a good candidate!

I encourage you when you think it is a Universal Truth - don't declare it, you still may be wrong or the thought may still need further distilling and removing of impurities. Instead, try floating the thought out there, "Wow, this may be a Universal Truth" or "Do you think this could be a Universal Truth?" Have this discussion with folks. Welcome the discussion and challenge. You aren't married to it, you are working on it. 

Some Universal Truths have taken me minutes to find and years to challenge. Others take me years to find and minutes (or seconds) to say...yup...that may be a Universal Truth. I like them because these truths are the things we share with others in life. How we can connect and know each other. How we see eye to eye. How we learn and get better. Remove the impurities, retain the true spirit.

Sit with me by the fire

Imagine you and I are camping. We are sitting around the campfire, you on one side - me on the other. We are discussing things. I am telling you what I see from my perspective. I see the fire, you and the stars. It is beautiful. You, on the other hand see the fire, me and a grizzly bear approaching. 

 Stop time

If you came over to my side of the fire, you would see my perspective and you would not appreciate the danger. 

If I came to your side I would see your perspective and I would see the danger. 

There are at least three hundred and sixty seats around this fire. We may share views, we may not. They are all a little different. 

When we interact with folks, we are at a campfire. I always strive to mentally slide around to their side and try to see where they are coming from so I can understand their perspective.

I also work to help them slide to my side and see what I see. 

This brief stopping of time and mentally putting yourself on the other side of the campfire is the easiest way I know how to explain both perspective and how to promote empathy. 

During a pandemic we are both isolated and we interact in ways that are both social and anti-social. I still remember when working with folks - we all share this campfire.

Walking down the spiral staircase versus jumping off of it

"My blood sugar doesn't like to be less than (200-250) so don't give me that damned insulin!"

Have you ever met that patient? The one who fusses when you get their blood sugar "too low"??

Here is how I teach to that:

First, I have visual printouts of what the symptoms look like for Hyperglycemia (high blood sugar) and Hypoglycemia (low blood sugar). Patients benefit from pictures, not words. I set something like this on the table.

"Here is the deal. Your body likes this state we call "homeostasis." In a nutshell, it means your body wants to be at all times. Sameness. If one thing moves - other things have to move too" I draw this on the whiteboard:

What that looks like: (Pointing to the hyperglycemia chart) "Your blood sugar begins to rise and other systems compensate to keep adapt. Around sugars of 250, your body starts pulling water from here there and everywhere to push that sugar off by your kidneys. You get thirsty, you might be peeing all the time, you may be constantly hungry or you may be tired all the time and feel like you just can't get stuff done."

Patient agrees or disagrees with these statements. I adapt my approach to the ones they identify. 

"Also, you can have trouble seeing things and you might have a small wound that just won't heal - or worse yet gets infected like crazy! Why? Because bacteria like to eat sugar so your body is like Daytona Beach during Spring Break!"

Patient usually laughs - then becomes a bit uncomfortable.

"You didn't get this way over night. You aren't going to have "normal" blood sugars overnight either. We need to walk your blood sugar down, like walking down a spiral staircase to a less dangerous level of blood sugar."

Patient may argue about how their body doesn't like below ___ blood sugar. 

What are we worried about? (Pointing to the hypoglycemia chart) "Your body has gotten USED TO these blood sugars. If we immediately try to bring you down to "normal" your body doesn't have time to adjust. You will have the SYMPTOMS of low blood sugar, even though your blood sugar IS NOT LOW. So, when you hit 250 (down from 500) you feel like crap! You're shaking, your heart is beating, maybe you are sweating and you feel like you're going to fall out. You are starving and ready to chew off your own arm, you have a headache and you are ready to kill the first person who looks sideways at you. Sound familiar?"

Generally the patient is nodding emphatically.

"Well, this is not ACTUALLY hypoglycemia - but it feels that way. If your blood sugar was...say...under 100 - I'd be getting you a full meal together. If your blood sugar is, say 250 and you feel like this - I'd say you are not in immediate danger - but I also know you still feel like crap. For that, I'd get you a small snack, to help you feel better, but not to jack your blood sugar right back up through the roof."

A glimmer of understanding begins to fuel itself. 

So, think about bringing your blood sugar like walking down a spiral staircase. We want to take it one step at a time. You would feel a lot better walking down that staircase, than jumping off of it - wouldn't you?

Planning the new diabetic regimen begins. 

PS: If any of this works for you - please use it! The talk about homeostasis and "feeling" crummy when we overshoot our mark can be adapted to talking to a patient about their hypertension medications as well. 

Why you want to work with the most difficult patient on the unit

I talked about the concept of "othering" and how I would work with this as a nurse or charge nurse on a unit to tighten our team and help us all work together better. The same concepts are true when I apply them to the patients.

First of all, think about the following two questions:

What does the "other"do poorly?

What does the "other" do well? 

Find me a "familiar face" or "frequent flier" and please - oh please - let them be a loud troublemaker! These are so frequently our folks who are misunderstood. Of course, the more loud someone gets, the more I wonder about their underlying motivation, but I usually assume it is some sort of fear. When this loudness is in process, be quiet, listen. You are looking for subtext. Hear the fear, worry, frustration or motivation.

When I hear the subtext, personally, I often find myself tell them how much it sucks or how difficult this all must be. I don't have to agree with them. I don't have to feel that way. I often know I wouldn't necessarily have reacted that way. I just have to hear how they feel at this moment that brought them to this place, and they need to feel that I hear them.

I operate on the precept that when someone is mad 1) you aren't teaching them anything and 2) they can only rage for so long. Acknowledging how difficult this can be for them shifts gears or at least puts their transmission in neutral. This is a great place to be. In neutral, they may need some more time to vent - but you are helping the patient feel heard. The more they feel heard, the more they'll be more likely to tell you the worries on their mind. Don't be surprised if it does or does not perfectly fit your clinical scenario or what you are trying to accomplish - humans aren't always rational but you have to hear this if you want to cease the disruptive behavior.

Next helpful hint: If you really want to de-escalate this quickly, you have to let someone have an easy way to escape the corner they've backed themselves into. A scared, worried, frustrated person can make a real ass of themselves. They can say some nasty stuff. Once they are less screamy and more listeny, my response goes something like this:

"Hey, you were just having a MOMENT. It doesn't define you. This is all pretty stressful and you were upset. Everyone has a MOMENT, including me at times. We're past it now. I don't take it personal. Now let's try to do something that gets us where you are trying to go."

Then I focus helping develop a mutual plan of action. Why? They are engaged and they are open to what we are doing and need to do. I am pretty candid about what we can't do too. Patients don't hear the limits of our treatments, systems or facilities enough, then clinicians wonder why the patients have these unrealistic expectations.  This candid explanation of the limits of the system helps patients be more reasonable - more patient.


Bonus skill: 
Once you learn to speak to what someone does well and what they do poorly you can improve your game with your patients who are as sweet as pie. Why? because pleasant demeanor merely means they haven't gotten sideways of you or everyone else. It does not mean they are having their needs met. They still may not have revealed their fears or frustrations to you. I have learned that actively seeking my patients strengths and weaknesses helps me prepare them in ways that set them up for success and not failure (e.g. no unexpected re-admits).

If you can't say something nice about someone, then you're not done looking

‪On a floor of nursing staff, there will be personalities who conflict. It is not good for the patients or the staff. 

I wanted people to tell me what frustrated them (their barriers). Their feelings about this are real and need to be acknowledged. Often they would tell me something about a coworker that “drove them crazy." I would respond, "Ok, I know what they suck at, now tell me what they do well?" Rarely could they answer it. 

I would point out, this was a skill I had to learn myself but it was very useful. I'll admit, some days it was tough for me to find something nice about someone. I think there is value in having a place to admit that too.  At that point, I could suggest something minor that the "other person" could do well. No matter how minor the good thing was, my hope was it would be undeniable - even for the person complaining. Then I say, "If you can't say something nice about someone, then you are not done looking." 

My challenge to find more is because I've learned there is always more. I promise them if we know what they do well AND what they do poorly, then we can forge a more functional work day with them because we all can play to each others strengths and weaknesses.

I say all this because our team functioned more and more seamlessly on the floor after we all began to practice at this. It gave me some pride to hear the snarkiest of nurses asking another nurse "so, tell me what they do well?" from around the corner. 

This applies to your most difficult of patients. Find out what they do well and what they do poorly. Similarly, for your "sweet as pie" patients, you may find out what they do poorly and also reaffirm what they do well. I have found out this assessment of others resulted in more prepared discharges (read - reduced risk of unplanned re-admit). This whole exercise is one of assessment, and of meeting needs - plus it makes the workday suck less.

Bomb disassembly 101

As the story goes in my husband’s family his brother was sent by his employer Uncle Sam to go help write or edit a bomb disassembly manual. Why? Because he knew nothing about the assembly or disassembly of bombs. He finds himself observing the process of disassembly while trying to follow the manual in its current incarnation. He finds the experts to have missed steps (e.g. disconnect the red wire only after ensuring...) Steps that matter when the expert isn't there to do the thing.

I often think of this when I send patients home with teaching for...whatever. My mind goes to the high risk things. Medication teaching. Wound care. How to know when something is okay versus when to call the clinic versus when to go straight to the ED, do not pass go, do not collect two hundred dollars. If my eyes aren't there, theirs needs to appreciate what is important.

"Just" is a four letter word

I sit in any random training and I throw out the concept that for all the cuss words I know, "JUST" may be the nastiest of the four letter words.

I look around me and I see good clinicians becoming increasingly burnt out. I have a theory that Electronic Health Records (EHR) should be click neutral (if you add clicks, you should subtract clicks elsewhere) otherwise you fall into the trap I call "Just is a four letter word". 

Technology has been brought to the bedside - but there really hasn't been proper time or space made for it. Of course back in the day, there was angst and gnashing of teeth about paper charting. Still, it seems to be worsening. 

Often in training we hear a feature was added and you "just" have to click this box, bar or link and you can find the order set and you "just" need to complete these _______ things. No one capped the click burden for people giving care at the bedside. No one thought to remove anything when they "just" added these extra boxes.

 
The increasing requirement for more and more standardized tools does not provide additional time to complete all the standardized tools.

In the sphere of value based care and tracking metrics, payers also seem to add requirements without taking other things off. It seems no one sees keeping screen time capped as a priority. As screen time increases, patient time decreases. How can this be good care?
 
I think the healthcare industry is racking up a tremendous technological debt. I think it is going to take an effort from payers, electronic health records manufacturers, hospitals and clinicians to prioritize and clean up the workflow. Of course, who do you convince of this? Likely most people working directly with patients agree. If you hear patients complain about how clinicians were "looking at the screen and typing" you know the patients would appreciate more face to face interactions.

I think the system has bandwidth to permit clinicians to get back to doing what we expect them to do - provide care. Someone "just" needs to see that as a priority.

Learn one, do one, teach one.

 

As nurses we are often taught "Learn one, do one, teach one." I learned it. I practice it now in my profession, however teaching isn't really the end. I want to make sure my patient or their carer can also do the thing safely and with good practice without me there.

This comes to the idea of demonstrating competency or "teach back." The higher the stakes the more I want to have my patient or their carer teach me how to do the thing. It is imperative they can do the thing successfully. It gives us opportunities to iron out the areas that matter, but also to build confidence that that can take the thing home and be successful.  I also find I learn a lot. In nursing we need to hold some things to a certain standard but other stuff is what I call "style points." I learn a lot by looking at different people's styles and it makes me a better nurse as I have adopted their techniques because they are legitimately good.

Look around at the folks around you. They have a lot to teach and when you think you know something - don't say "Oh, ok" or "I know" say "Teach me how you do that."  I promise you will be amazed at the things you learn!

Sometimes second-best is number one

I had a patient who kept being admitted for high blood sugars. They were known to the hospital. They would routinely be admitted with blood sugars from 800-1,000. The term “noncompliant” rakes over my last nerve and this patient is one of a list of reasons why.

Through the day, I learned the patient had housing insecurity (no home). They lived in their vehicle. They said they tried to manage their diabetes, but they couldn’t. People under stress have different reactions. This person’s reaction was to the problem completely. I looked at the chart. The diabetic regimen given to this patient after multiple admissions had them visiting their diabetes SIX TIMES PER DAY across multiple insulins. Think about that.

In my mind, I thought the patient may have lacked education or understanding. What I found was that the system was busy providing the “best” care with the most current protocol – despite it being unsustainable for the patient. One of the insulins prescribed was probably the most susceptible to temperature changes. Not great for someone who has no home to put it. Can you imagine carrying around supplies to check your blood sugar and medicate yourself six times through the day while you are trying to merely survive? Me either.

I asked the patient how often they may be able to reliably visit their diabetes? They said they could visit it twice. We could work with that. I called pharmacy. I explained the situation. I didn’t want to upset anyone, but maybe we could consider what would be the second-best treatment for this patient? We got buy in from the team. We updated teaching and I had them teach me how to draw and inject their insulin.  They benefited from the practice. They also suggested they could get a small cooler for their glove box to help protect the insulin from the temperature fluctuations in their vehicle. Wow! The patient who’d disengaged from their treatment is back in the game! Ultimately, prescriptions were reduced from 90 day to 30 day to protect the integrity of the medications. The patient could get to the pharmacy. This process delayed discharge by one day. It also stopped the readmissions for hyperglycemia immediately.

This is why I appreciate the value of the second-best treatment.

Healthcare is racist and not serving those who need it most. We can do better.

Harriet Tubman, nurse, spy, bad ass <3

The Tuskegee experiment was coming to light and being ended around the time of my birth.  I have deep gratitude to have worked for a nurse researcher (before I was a nurse) who helped open my eyes to disparities in care. 

Still, in the past year we hear news about racial bias in healthcare algorithms. This is unacceptable.

In my own practice, I see how the system is not fair for people every single day. People of color, people who are poor, people who have mental illness. People with disabilities (visible or not visible). Anyone different.

At the end of the day, I can only be transparent in my own behavior with patients and be accepting that patients may still harbor mistrust for me. I continue to educate my patients in the ways that work for them and I continue to advocate to keep the system from losing the folks that may be under served. The faces of the people who are under served, I can tell you they are beautiful, brilliant, resourceful and kind. We can do better.

Anecdote: How to get (then keep) a research department from being shut down

I took a job in 2004 where the federal purchasing was so out of compliance, they were threatened with shut down and mandated to create my role. My job started off with a deposition early and I was asked how I was going to address the problems.

BTW: Don't ever read your own deposition. Just take my advice on this. I know they want you to read it for corrections and you should do that, but if you can separate your emotions from how bad you sound - do it. 

It was federal purchasing - so much had been done incorrectly. For a long time. No more than $2,500 per transaction. Hundreds of thousands of dollars (or more) were insufficiently accounted for.

The system provided to researchers was DOS based. This system required entry of a proper purchase order and later reconciliation in that DOS based system.

Well duh! They handed credit cards to researchers and trusted they would be able to enter a purchase order and reconcile in DOS. Oh, this also had to adhere to all federal purchasing regulations.

These were researchers doing cellular level research. Purchasing was not in their skill set, purchasing was the necessary evil to get the supplies and equipment they needed to do their science. For me, it was a straightforward fix. No, I didn't know all the rules or the system but I was able to figure it out.


Hell, after digging through all the ways someone could inadvertently do something wrong it was easy to forge a system to get and keep them in compliance.  Added bonus, I found ways to purchase on and off contract that saved obscene amounts of money and still followed all appropriate rules. 

I worked with the individual researchers, helped get all the prior financials reconciled and set up a centralized system that was still being used 14 years later. It was simple, it worked. I like stuff like that.