I have held most of the seats this system has to offer. Dialysis technician. Outpatient hemodialysis nurse, then charge nurse, then nurse manager. COVID broke something in me while I was managing an outpatient unit — the death at the bedside, the fear, the goodbyes I was never supposed to hear, said over iPads to intubated and sedated patients. I went numb for a while, and I stepped away from direct patient care. A contract management role put me in front of the device I would later sell, and the industry side of the curtain opened: clinical sales rep, taking a dialysis machine into acute hospital programs and then into the ICU, where it could run a form of continuous renal replacement therapy. Then clinical sales manager, walking hospital after hospital, listening to nephrologist after nephrologist describe what was breaking in front of them. The pivot wasn’t a detour. It was recovery, and it handed me a vantage point almost nobody at the bedside ever gets. And underneath every one of those seats is the one that matters most — the patient’s, trying to navigate all of it from inside a body that is failing.
From every seat, the same thing is true: the system is too big to see from where you sit. The clinic manager is putting out fires — a patient bleeding past their time while the next patient waits for that same chair. The acute nurse is on call without knowing the day’s census: heavy, light, empty, or a wave of add-ons coming up from the ER, on no schedule at all. The nurse manager is holding staffing together, keeping the unit calm, and tracking a binder of metrics — forms filled out faithfully by people who were never shown the depth or the gravity of what those forms feed.
My seat now is the one that finally forced the question. Piecing together where the regulatory floor ends and best practice begins. Deciphering what each year’s updates actually change. Watching medical directors wrestle the edge cases — a patient who enters hospice care: does that count against the clinic? And over all of it, Goodhart’s Law, quietly turning every measure into a target. All of these views are real. All of them are happening at the same time. And the machinery asks each of us to organize the data, categorize for reimbursement, and still deliver individualized care — while science moves faster than the regulations that encode it. There are so many different moving pieces to this, and that is why I’m trying to draw the map.