Tuesday, October 03, 2006

Detail Management

Detail management is the name of the game when faced with the daunting task of keeping track of so many individual lives. I often wonder if I'm doing enough, and whether my processes for managing such information is useful and efficient. They didn't really teach us such things in nursing school, so creative seat-of-the-pants creativity is often the modus operandi.

On a daily basis, I use a printed spreadsheet to track my contacts with each of my 80-some-odd patients, whether it be an office visit, home visit, or telephone call. This list, which I carry in my bag, gives me a snapshot of who's in touch, who's on the ouskirts of my orbit, and who is apparently MIA. I also have another spreadsheet which tracks whether I have had contact with each patient on a monthly basis. When I see several blank spaces in a row for a particular patient, I know that a few months have passed my by without my having lay eyes on that person, or at least checked in by telephone. I am not expected to see every patient every month, but I'm expected to make attempts at contact, and document each attempt accordingly for the patient's chart. As all nurses have drummed into their heads during nursing school, "if you don't write it down, it never happened". So, I record every disconnected telephone number reached, unanswered call made, or other attempt at finding the ones who got away.

Looking at these crude devices which I have devised for my own obsessive-compulsive purposes, I can see in a glance who the freqent flyers are, who is avoiding me, who might be dead, or who perhaps is just under the radar. Unfortunately, there are a few who have a string of blank spaces on my log, demonstrating the fact that if they truly are out there, they just cannot be found without hiring a detective. Perhaps they like it that way. Perhaps they don't care.

Just recently, I learned that one patient who I have never met is now in jail. Over many months of trying to find her, I ran into dead end after dead end. (Did I say this would take a private eye?) When I would check the hospital computer system periodically, I would learn that she had been in the ER, and I would consequently scour the electronic medical record for an updated address or telephone number with which I might contact her. These leads would generally fail, but one eventually led me to this patient's grandmother, who informed me that her poor misguided grandchild finally ended up in jail. "At least we know where ______is. S/he's fed, clothed, and taken care of medically", she said. I empathized with her and promised to contact the jail (where our doctors run the show) and follow up on her family member's condition. At least I found him/her and my colleagues over at the "Big House" can check in.

Trying to follow eighty people relatively closely and keep them straight in my mind is a challenge. Of course, there are a number of patients with whom I have worked for more than five years, and these are especially well-known to me from the salad days of our organization when we had the luxury of miniscule caseloads of thirty. What luxury that was! We had the time to really build relationships then, holding our patients' hands through every twist and turn of the healthcare rollercoaster. Now, in our current iteration, I still do my best to provide personalized care, but there is just not enough time to do it justice. As much as I liked my old way of practicing, it just is not sustainable. The up side of such a change is that more responsibility is put on the patients' shoulders where it really should be, although many simply fall under the weight of their own myriad needs. How to find that balance of empowerment and assistance? A good question to which I have no answer.

So, this very tired and overworked nurse tries his best against long odds, and I watch my colleagues do the same. We go to extraordinary lengths---often disappointed, manipulated, and otherwise thwarted, but some rewarding moments sneak through almost daily. The chaos is sometimes overwhelming, as is the chaos of having 19 clinicians in a relatively small space all talking on phones, sending faxes, emailing, dashing for medical records, and catapulting in and out the door to and from home and office visits to our hundreds of patients. It is a perplexing exercise, often quite frustrating, and I often long for simplicity and quiet, something which is rarely seen and would probably feel somewhat pedestrian and boring compared to the general maelstrom with which I'm acquainted.

It's 8:30pm, I just finished my notes after having dinner with Mary, and now I write about my work to exorcise it from my mind so that I can move on with a relatively clear head to the rest of my evening. This is a frequent practice, the office frequently being a place where paperwork just cannot be finished in peace. I look forward to moving on to laundry, bills, perhaps some reading, some emails, and then the big reward---seven or eight hours of sleep---which will allow me to get up and do it all again. With "retirement"(is that even possible these days?) perhaps several decades away, most likely, I know that a change of pace will be needed soon. Such ongoing stress takes its toll, and there will come a day when it will be time to leave this harried rat-race behind. Til then, this rat will get back up on that wheel tomorrow, nose to the healthcare grindstone.
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