Where Do Those Twenty Extra Minutes Come From?
Efficiency for Living Medicine
Notes from a Family Meeting is a newsletter where I hope to join the curious conversations that hang about the intersections of health and the human condition. Poems and medical journals alike will join us in our explorations.
For those of you just joining, consider starting here to trace how I’ve been thinking about medicine and technology, a conversation I’ve been returning to time and again.
Dr. Jónsdóttir tapped her foot rapidly, then stopped. She knew it was her anxious tell. This routine visit to discuss Harold Pulliam’s hypertension had spiraled into nearly forty minutes of the large man sobbing about his recently deceased brother. Apparently the younger Pulliam brother had been sick for over a year with some wasting illness that no one could diagnose. “What does that sound like to you, doc?” Harold asked, wiping his eyes, “Cancer? Cancer doesn’t run in our family, but… maybe…” Dr. Jónsdóttir shrugged, making non-committal hums she hoped sounded comforting.
They hadn’t even begun to discuss his blood pressure. Other patients were waiting. Beyond them, documentation. Beyond that, her kids’ bedtime - if she got there. And beyond them: more documentation.
Mr. Pulliam was going to take some extra time. Where was she going to get it for him?
After all my railing on about the problems of efficiency in medicine, you might wonder how I get anything done. I’ve traced a meandering course through my writing here that suggests the Machine is the enemy to good medicine. But what does that mean for the day-to-day work of the clinician? Is the good doctor or nurse one who’s always running behind because they spend as much time with each patient as the patient wishes, they’re late wherever they go because they’re trying to meet all their many commitments, and they carve out the balance from their sleep? Can you be a good clinician and a good parent, or spouse, or friend? Are the claims of being a good clinician so total that, if you’re going to take the time needed to do the work well, you might as well accept that other areas of your life are going to come second (or lower)?
I don’t think it needs to be that way.
I had alluded to as much when I described how good habits can help us practice better medicine. One useful thing about habits is they allow us to do routine tasks more efficiently. That’s good! It’s one way experts do more and better work in less time than a novice. It’s not about the quantity of habits, either. An expert’s habits are connected in important ways to all the other things they know and do so that they’re used at the right time and in the right ways. I know how to use the template I wrote about, but I also know when to abandon the template and veer into the wilderness for a while. Even as I do so, though, I keep a compass with me that directs me back to the purpose of the clinical encounter.
I definitely need that compass. Healthcare bureaucracies impose a top-down, metric-centric approach that leaves clinicians feeling like they’re making widgets rather than caring for people. Efficient through-put masquerades as the purpose of the clinical encounter. The endeavor starts to feel like it’s about seeing more patients in less time. This is an outworking of “technique,” Jacques Ellul’s name for activity that exists merely for the sake of efficiency itself and no greater good. Value collapse, coined by C. Thi Nguyen, aids technique by making our work about the metric rather than the truly important thing the metric measures.
Even if efficiency isn’t the point, it’s not a bad thing, as long as I make sure efficiency remains the means, and doesn’t start to become the purpose of my work. That’s easy to do when I’ve fallen behind and find myself scrabbling for twenty extra minutes. When extra time is needed for a clinician like Dr. Jónsdóttir, where does it come from?
Well, here’s the thing: there is no extra time.
We all get the same twenty-four hours.
Many of those hours are constrained by our bodies. We need to eat, sleep, and tend to some other basic needs. But even then, we use time like many of us use money, living in a state of constant borrowing and debt. Dr. Jónsdóttir’s extra time for Mr. Pulliam comes from her next patient, and the time needed for that patient she takes from the next patient still. Ultimately, she begins to take time from her family and from her sleep. Where else would it come from? In order to meet the demands of her many commitments, she treats herself like a machine.
Technologies like the electronic medical record (EMR) once promised greater efficiency for clinicians. While the EMR does allow us to do some things more quickly (no more fetching paper charts from wherever they’ve landed, thank goodness), that hasn’t translated into greater efficiency for things that matter. Instead, the EMR offers its own menagerie of inefficiencies, roadblocks, and pitfalls. The time spent fetching paper charts has transformed into time spent clicking boxes.
The promises of technology so often spoil like this, as Oliver Burkeman argues:
“Virtually every new technology, from the steam engine to mobile broadband, has permitted us to get things done more quickly than before. Shouldn't this therefore have reduced our impatience, by allowing us to live at something closer to the speed we'd prefer? Yet since the beginning of the modern era of acceleration, people have been responding not with satisfaction at all the time saved but with increasing agitation that they can't make things move faster still.”
Admittedly, the problem with the EMR isn’t that it sped up what was good about the clinical encounter, but it made faster those things that clinicians believed were peripheral or even unnecessary.
The point remains: our minds so intimately associate tools with power that we struggle to fathom how more tools might not yield greater power. Part of the problem is the more we use our tools, the more information we gather. Modern medicine harvests more data from an individual patient than any one clinician can possibly use. Modern clinical research produces more data than any one clinician can possibly evaluate.
In response to these dilemmas, we’ve built a massive bureaucracy that allows for sub-specialization. Many medical trainees no longer choose general medicine, but rather a specialized field like pulmonology. Deeper still, we find sub-sub-specialties having to do with particular problems, like transplant pulmonology or interstitial lung disease. Specialization limits the amount of data clinicians are responsible for reviewing, and silos off their responsibility to a particular organ or set of diseases.
Specialization doesn’t solve the problem we started with, though. Although the lifestyle of the pulmonologist focused on interstitial lung disease might be a bit better than the family medicine doctor (maybe), they still need to contend with this question: when a patient needs twenty extra minutes, where does that time come from?
I don’t have any answers, but I’ve got three responses to that question. I want to try to reframe this idea that time is a resource we use (“I need more time. Where can I dig it up?”). To do that, I want to observe that, first, time and justice are inseparable; second, time management is a mirage; and third, time allows for rest.
Time and Justice Are Inseparable
Burkeman continues his thought about our eventual dissatisfaction with novel technologies:
“The reason that technological progress exacerbates our feelings of impatience is that each new advance seems to bring us closer to the point of transcending our limits; it seems to promise that this time, finally, we might be able to make things go fast enough for us to feel completely in control of our unfolding time. And so every reminder that in fact we can't achieve such a level of control starts to feel more unpleasant as a result.”
We hope this tool will help us push past a limit that’s bedeviled our work for so long. In our haste to move quickly, though, we can also race past the downtrodden, neglect the oppressed, and take on more commitments than we can possibly honor in a timely fashion.
If Mr. Pulliam needs twenty extra minutes, that time doesn’t just come from somewhere else, but someone else. Will the extra time come from the next patient? The patient after that? From Dr. Jónsdóttir’s team with whom she’s working on a project? From her family? From herself? If Dr. Jónsdóttir existed to sit in her clinic and see patients every day (that is, if she really were a machine), there’d be no dilemma: she has one job and she should do it. But no one has one job alone. Dr. Jónsdóttir doesn’t exist to sit in her clinic and see patients every hour of every day.1 How she negotiates among all the different roles she inhabits requires integrity.
Integrity, as Alasdair MacIntyre defines it, is the limit one sets in their willingness to adapt to their roles. Although Dr. Jónsdóttir will act according to the needs of her role at any given time, that role does not finally arbitrate her moral agency as an individual. She might say “no” to a demand because she’s more than her role, or even the sum of her roles.
People without integrity often find themselves forfeiting their agency to the authorities governing each of their roles. If Dr. Jónsdóttir grounded her identity in “physician,” she may very well sacrifice all her other commitments to persevere in clinic. This is the essence of irresponsibility.
If we consider justice to be rendering to another that which is owed them, then to give to Mr. Pulliam the time he’s owed, if he needs more than expected, necessarily means taking from someone else the time they’re owed. Maybe when it’s all said and done, Dr. Jónsdóttir cuts her last patient encounter of the day short so she can pick up her daughter from daycare. Even if she’s able to do that without causing any harm to the patient, the fact remains that she chose to spend less time with them than she normally would have. The decision of whether to give that last patient the time they’re owed, or to give her child (and the daycare workers) what they’re owed, pits Dr. Jónsdóttir’s roles against one another. Will her commitments as a physician or her commitments as a mother win out here?
Our response to this challenge might be to try to manage time (more on that in a moment), but this brief reflection shows that our relationship with time is inevitably moral. Even before the moment of decision, our commitments, chosen moments or year earlier, shape the dilemmas we now face with time. Sometimes a commitment brings us to a conflict between something good and something bad, but often it’s a conflict between two good things. Law is a helpful barrier and teacher for the former, but we need wisdom for the latter. We need capacities to see the moral landscape before us, deliberate on it, and then make a decision for which we’re responsible.
So, what’s the right thing for Dr. Jónsdóttir to do? I haven’t answered the question (I told you I wouldn’t). I don’t think we should rush to answer it too quickly. In the bit of space we’ve marked out here, Dr. Jónsdóttir may be able to make a more responsible choice about her commitments in the moment, and also more responsibly prioritize her commitments in the future (maybe working with her clinic administrative staff to design a more sustainable schedule). In saying this, I’m not saying Dr. Jónsdóttir was irresponsible to have been brought to this dilemma, as if she did something wrong. Rather, as my knowledge about myself and my circumstances is always partial, I grow in responsibility as I gain insight. I could better claim my commitments rather than fly by the seat of my pants. This, in turn, hopefully sets me up to act more justly.
Time Management is a Mirage
We spend time, we waste time, we kill time, we share time. These metaphors obscure reality, for time itself isn’t a resource for our use (or killing). Time is a context in which we make and prioritize our commitments. The hour ticks by whether we’re binge watching television, laughing with our friends, or prescribing an antibiotic. What has been used, well or poorly, isn’t time, but energy directed toward this or that commitment.
If I acknowledge that time isn’t something I manage, then I can see what fills the time in a new way. Back to Burkeman:
“…meaningful productivity often comes not from hurrying things up but from letting them take the time they take, surrendering to what in German has been called Eigenzeit, or the time inherent to a process itself. Perhaps most radically of all, seeing and accepting our limited powers over our time can prompt us to question the very idea that time is something you use in the first place.”
It just is the case that, in order to care well for Mr. Pulliam, Dr. Jónsdóttir will need to sit with him longer than she intended. The absolute amount of time spent doesn’t tell us whether she was compassionate or discerning or kind. In fact, novices might end up spending more time with less overall benefit. That may also happen with those who resist what the moment brings. If Dr. Jónsdóttir did that, trying to push past Mr. Pulliam’s grief, she might speed up the encounter, or she might frustrate him and make him argumentative, taking even more time than if she had just slowed down to honor what was going on.
Efficiency should serve the purpose of the clinical encounter, not vice versa. But what about when two commitments clash? It would be silly to say that the clinical encounter should serve the needs of Dr. Jónsdóttir’s family (though it does, indirectly, because of the money she earns). Likewise, it would be silly to say that Dr. Jónsdóttir’s family serves the needs of the clinical encounter. These are two disparate commitments that meet in the person of Dr. Jónsdóttir. In any given moment, she may prioritize the needs of her patients over those of her family or vice versa. That’s inevitable. Weighing which commitments she takes on, though, and the judicious sharpening of efficient habits in service to a greater good, will hopefully minimize those dilemmas.
Before you go off and do something, though, Burkeman first wants you to remember your finitude:
“...the more you believe you might succeed in "fitting everything in," the more commitments you naturally take on, and the less you feel the need to ask whether each new commitment is truly worth a portion of your time-and so your days inevitably fill with more activities you don't especially value. The more you hurry, the more frustrating it is to encounter tasks (or toddlers) that won't be hurried; the more compulsively you plan for the future, the more anxious you feel about any remaining uncertainties, of which there will always be plenty. And the more individual sovereignty you achieve over your time, the lonelier you get. All of this illustrates what might be termed the paradox of limitation, which runs through everything that follows: the more you try to manage your time with the goal of achieving a feeling of total control, and freedom from the inevitable constraints of being human, the more stressful, empty, and frustrating life gets. But the more you confront the facts of finitude instead-and work with them, rather than against them-the more productive, meaningful, and joyful life becomes. I don't think the feeling of anxiety ever completely goes away; we're even limited, apparently, in our capacity to embrace our limitations. But I'm aware of no other time management technique that's half as effective as just facing the way things truly are.”
Time management is a mirage because time isn’t a resource we manage. Instead, we choose and prioritize our commitments within the constraints of our human limits. We don’t choose between commitments when we’ve done something wrong. We choose between commitments because we’re human. Time is a limit, not our enemy.2
Time Allows for Rest
Under significant constraints and pressure, I may still try to manage time. Dr. Jónsdóttir probably feels like that too. She and I might even sneer at time’s scarcity, as if others have “more time.” I don’t know how common this is, but even when I have “time off,” I’m acutely aware of the time passing. I need to use it well. I developed this sense with the birth of my children. I now measure time not just with the ticking of the clock, but with childhood milestones and discarded toys. The irony is that the more I try to hold on to the moment (particularly by photographing it), the more acute its ephemerality becomes, and the less restful it all feels.
Among the various approaches to rest I could take, the worst is probably that I start to see time away from work as “self-care.” Embedded within that terrible little phrase is the suggestion that on the one hand, work somehow injures or degrades us (thus we need care away from work, like our patients in the hospital need care). That need not be the case, though there is a toilsome facet to most work. On the other hand, it suggests that time away from work is meant to restore us for more work, as I wrote about here:
“Playing with your kids is no longer an end unto itself but “self-care” to get you back to work on Monday. Kite-flying should aim for your renewed vigor in clinic. Woodcarving should reinvigorate you for rounds. The fact that these things often do restore us for work make it all the more insidious. “Self-care” hides a revolutionary power.”
But even if I don’t fall into this self-care trap, I might still try to fill my time away from work with as much “rest” as possible. I approach time the same way whether I’m resting or working: it’s a resource to be managed, and I need to do more, even it’s just rest more.
Byung-Chul Han warns that this is not the way. He describes the harried lives of many modern people, some of which are surely clinicians:
“The idea is that whoever lives twice as fast can enjoy twice as many life possibilities; the acceleration of life multiplies life and thus brings a person closer to the goal of having a fulfilled life. But this is a naive calculation which rests on a confusion of fulfilment with mere plenitude. A fulfilled life cannot be explained on a quantitative basis. It does not result from a plenitude of life possibilities, just as a recounting or listing of events does not necessarily amount to a narration or account. Rather, the latter require a special synthesis to which they owe their meaning. A long list of events does not produce the tension which characterizes a story, while a very short story may nevertheless possess a powerful narrative tension. And, thus, a very short life can also achieve the ideal of a fulfilled life. The acceleration thesis does not recognize that the real problem today is the fact that life has lost the possibility of reaching a meaningful conclusion. It is this fact that leads to the hectic rush and nervousness which characterize contemporary life. One begins ever anew; one zaps through ‘life possibilities’, precisely because of an inability to bring any single possibility to a conclusion. The individual's life is not informed by a story or meaningful totality.”
Because of that lack of cohesive story, that lack of vision of the point of human living, that telos, Han argues that we have lost the capacity to linger over our moments. This induces the sensation of the rapid passage of time:
“When we are constantly asked to begin anew, to choose a new option or version of something, we may get the impression that life is accelerating. In reality, what we face is an absence of any experience of duration.
…
The impression that time moves considerably faster than before also has its origin in the fact that today we are unable to linger, that the experience of duration has become so rare. It is mistakenly assumed that the feeling of being rushed is the result of a fear of missing out … But in actual fact the very opposite is the case. Whoever tries to live faster, will ultimately also die faster. It is not the total number of events, but the experience of duration which makes life more fulfilling. Where one event follows close on the heels of another, nothing enduring comes about. Fulfilment and meaning cannot be explained on quantitative grounds. A life that is lived quickly, without anything lasting long and without anything slow, a life that is characterized by quick, short-term and short-lived experiences is itself a short life, no matter how high the 'rate of experience' may be.”
I don’t think it’s a matter of merely doing less. In the vacuum left behind when we stop our frenzied activity, we fidget. We need something else, even as we abstain and rest.
Han puts it this way:
The Chinese poet Hsieh Chin (c.1260-1368) writes about the rising smoke of the incense seal:
“Smoke from an incense seal marks the passing
Of a fragrant afternoon."
The poet does not lament that a beautiful afternoon has passed, because every time has a scent proper to it. Why should one lament the passing of an afternoon? The scent of the afternoon will be followed by the pleasant smell of the evening. And night, too, exudes its own fragrance. These scents of time are not narrative, but contemplative. They are not arranged into a sequence. Rather, they rest in themselves.
Han’s exhortation to contemplate finds good company with the words of Abraham Joshua Heschel, a rabbi writing in the mid-20th century. People who don’t share Heschel’s tradition might find it fits awkwardly with their rhythms of life. However, I think there’s something here for anyone who finds they’ve fallen into an adversarial relationship with time:
“All our life should be a pilgrimage to the seventh day; the thought and appreciation of what this day may bring to us should be ever present in our minds. For the Sabbath is the counterpoint of living; the melody sustained throughout all agitations and vicissitudes which menace our conscience; our awareness of God’s presence in the world.”
The “seventh day” about which Heschel writes is the Jewish Sabbath, later adopted and honored in their own way by Christians. This is a day set aside as sacred, honored by ritual and abstention. It doesn’t exist to restore someone for more work. If anything, work honors the rest. It creates an anchor in the week, a rhythm of life, that affirms people aren’t machines or animals. Time isn’t a resource. Instead, it’s the context in which we can receive our lives as given, to appreciate the scents of time. Time allows for rest.
So, uh, About Those Twenty Extra Minutes?
Where have our ruminations left the alleged time-thief, Dr. Jónsdóttir?
In the moment, she’ll need to do what she can. But one of the great things about being human is we’re not bound to relive the same moment over and over. We can learn and grow. Efficiency can help as much as hinder. She might come to see how the commitments she’s made shape the dilemmas she now faces. They’ve brought her to this moment of wrestling with what it means not just to be an efficient physician, but a just physician. She’s not some unaccountable robot, and so she can choose what to do in this time.
Efficiency might help her, but only as a means, not as the goal. She might, later, see that time isn’t something to be managed, but a boundary within which she must choose what to do in this time.
Eventually, she might rest. This wouldn’t be merely for renewal. In resting, she might find the time she so often clutches, claws, and wrestles can instead become a friend. Will this provide the extra time she needs? No, but she may find what she needs instead: new eyes to see not only Mr. Pulliam, but her whole life. She might receive the time for what it offers.
In an age when many physicians don’t get to build their own clinics, administrators and clinic managers may set their schedule for them, seemingly with the expectation that all they’ll be doing is seeing patients. Somehow, documentation and, oh yeah, life are squeezed in at the margins.
Easy for Dr. Jónsdóttir and I to say as we struggle to just get out of clinic on time. A trauma surgeon might really see time as the enemy, as every second threatens their patient’s life. I’m no surgeon, so I’ll rely on others to disabuse me of any false notions here, but I think the situation is the same for the surgeon as it is for Dr. Jónsdóttir: time is a limit. Yes, the trauma surgeon must work efficiently to save this person’s life, but even at peak efficiency they cannot save all lives. Even a team of trauma surgeons will reach their limit. The tragedy isn’t time nor the limit; it’s the reality of injury and death.