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Temporal dynamics in the lives of health practitioners

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Temporal dynamics in the lives of health practitioners

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Content 1
Temporal Dynamics in the Lives of Health Practitioners
Cynthia Wang
Annenberg School of Communication
Submitted in accordance with the requirements
for the degree of
DOCTOR OF PHILOSOPHY
at the
UNIVERSITY OF SOUTHERN CALIFORNIA
Committee Members:
Larry Gross (Chair)
Manuel Castells
Mike Ananny
Faculty of the USC Graduate School
Degree Conferred August 2016
2
Table of Contents
Acknowledgments.............................................................................................................................3
Chapter 1: Introduction.....................................................................................................................5
Chapter 2: Time and the US Health Care System...........................................................................25
Chapter 3: A Day in the Life...........................................................................................................68
Chapter 4: Negotiating Weekly and Monthly Schedules...............................................................109
Chapter 5: Health Practitioners' Use of Communication Technologies........................................159
Chapter 6: The Long Game - Work-Life Balance and Long-Term Career Considerations...........211
Conclusion.....................................................................................................................................260
References.....................................................................................................................................269
3
Acknowledgments
I owe the greatest measure of gratitude to the continued support of my advisor, Larry Gross,
whose generous guidance, insightful comments, and timely advice was invaluable to the
completion of this work. He took me under his wing and helped me take all of these half-baked
ideas and turn them into, well, maybe not fully-baked, but at least they look a little bit better
coming out of the oven. And it’s not just the projects that I had worked on or the dissertation
itself. Some of my favorite times have been just sitting in his office shooting the breeze about a
wide and sometimes random range of topics. Whereas his guidance with my dissertation molded
me into a better researcher, it was our ongoing conversations and tangential musings that shaped
me into a more knowledgeable scholar and person.
Similarly, deep appreciation goes to to my other committee members, Mike Ananny, who pushed
the boundaries of my theoretical work and challenged me to reach out and explore a wide breadth
of disciplines on which to build my framework, and Manuel Castells, who took all of the messy
aspects of my theory and methods and elegantly weaved together a coherent narrative around the
meaningfulness of the use of time that ended up being a major theme in this project. Additionally,
Sandra Ball-Rokeach, Alice Echols, Yu Hong, Doug Thomas, Francois Bar, Tom Hollihan, and
Alison Trope have all helped mold my professional trajectories that are intertwined with this
dissertation project. Much credit also goes to Aram Sinnreich, Marita Sturken, Susan Fox and my
other NYU mentors and professors who gave me a solid foundation in critical cultural theory
upon which I was able to build this project.
Many thanks go to those who gave me insight into the issues with the US health care system,
particularly Allen Miller, Vanessa Alvarez, and their team at COPE Health Solutions, Jenn
Duquette for being my partner-in-crime during critical development years at COPE, as well as my
many friends who work in different sectors of the health care system through our conversations
over meals and drinks. Most importantly, this project flat out could not have been conducted
without my informants who generously contributed their precious little time to share their
experiences, challenges, and personal stories with me.
To my gradsitting crew: Winmar Way, Veena Hampapur, Preeti Sharma, Alejandra Priede-
Schubert, Ashish Vaswani, Talia Stol, and a lifetime's worth of eaten samosas. My Annenberg
colleagues and friends who have been intellectual sounding boards and companions through this
process: Andrew Schrock, Aaron Trammell, Tisha Dejmanee, Nancy Chen, Chi Zhang, Ioana
Literat, Ritesh Mehta, Samantha Close, Francesca Marie Smith, Emma Leigh Waldron, Andrea
Wenzel, Katie Elder, Allie Noyes, Robby Ratan, Nikki Usher. My future colleagues at Cal State
LA, thank you for giving me a light at the end of the tunnel. Others who have kept me sane and
well-fed both in belly and soul include: Emily Methangkool, Raymond Lee, Dawen Wang, Cris
Ledon-Rettig, Juliana Moreno Patel, Elizabeth Pan, Barry Neely, Cynthia Yeung, Jacky Goh,
Sherry Ho, Grace Chiou, Sarah Bishop, Vicky Hsu, Ross Cheung, Pin Chen, Becky Tsai, Alfa
4
Garcia, Michelle Bloom, Callisto Hirschey, Laurian Flint. A special shout-out goes to Richard Yeh
for entering into a writing pact with me, directly resulting in the first draft of this dissertation. And
most importantly, much appreciation goes to ______(insert your name here)_____ for all you do.
All my love goes to my family, both immediate and extended. Baba, the first Dr. Wang, who
always had unconditional faith in me, reminding me that research must be grounded in ways that
seek to benefit people. Mama, who may not know much about grad school, but knew exactly
when to check in and when to let me be and to make sure to let me know I am always loved and
supported and cheered on. My brother Kenneth, littler but taller than me though he may be,
always held my best interests next to his heart, and whose part gentle and part snarky jibes asking
why the heck I am doing a doctorate helped me clarify and ascertain exactly WHY I was. To
Pepper, whose entrance into our lives brought unbounded joy and delight –- good girl, wanna go
for a walk? Also thanks to her bladder, which made sure I got fresh air and exercise at least two or
three times a day. Finally, to Jenny Chen, who has been long-suffering, patient, supportive, and
loving throughout this long endeavor, thank you for walking this path with me these past four
years. Your presence in my life continues to be one of the most rewarding and treasured things I
have and will ever experience.
5
Chapter 1: Introduction
When I first started dating my partner, she had just graduated medical school and was
starting her residency in ophthalmology. I was entering my third year in the PhD program. I was
interested in looking at the world through the lens of time, but was having difficulty figuring out
what my site of inquiry was going to be. Time had always been a source of unending fascination
for me. Spending most of my life in some state of being a student, I have, for the most part, found
my time to be more flexible than that of my friends who got 9-5 jobs. The sense of relative
freedom and temporal autonomy that I experience in my life was exacerbated when my life with
my partner became increasingly entwined in the first two years of our relationship, and I observe
her absolute lack of free time throughout the day. It was this comparison of our different lived
experiences of time (and how miserable the constraint and limitations of her time often make her)
that led to this inquiry about time within the health care field, particularly how it pertains to the
lives of health practitioners.
This dissertation project explores the framing of time as a resource that depends on a
multitude of social, cultural, political, institutional, and structural factors, while placing it within the
urgent context of the US health care system. By looking at the temporal organization of health
practitioners at and away from work, this project highlights the affective aspects of practicing
medicine or nursing, the impact of temporal patterns on quality of life, and the meaning of work
based on practitioners' position within the health care system. Moreover, it examines the ways in
which communication technologies affect organization and perception of time, and how the
aforementioned elements are subsequently impacted.
6
While health professionals are popularly perceived as infallible, authoritative figures,
1
they
face many challenges, both work-related and personal. Physicians have an astronomically high
suicide completion rate – 1.4 to 2.3 times that of the general population, “[p]erhaps in part because of
their greater knowledge of and better access to lethal means” (Andrew, 2015). Similarly, depression is
common amongst medical students and residents at rates higher than seen in the general population
(Andrew, 2015). Meanwhile, the nursing field also recognizes a need for better work-life balance,
given the long shifts and the emotional exhaustion of the job.
2
These individuals constantly deal with
the stresses of catering to patient needs while practicing defensive medicine in order to inoculate
against a malpractice-happy culture. At the same time, they face increased pressures to see greater
numbers of patients with the adoption and implementation of the Affordable Care Act. Therefore, the
tensions that come from having limited time that health professionals face are multifactorial, resulting
from individual actions to institutional procedures and cultures.
Warrant – Filling a Gap in Knowledge
A vast number of studies focus on patient experience and outcomes, and the effect of the
health system and practitioners on patients. Much of communication and medical research, as
well as news media, focuses on patient-facing issues. Questions that address how information is
communicated to patients, as well as how procedures and policy changes are beneficial or
detrimental to patients, often without considering the cost or impact on the practitioner,
1 Interview subjects suggest that many health professionals protect and perpetuate this perception in order to
maintain a patient's trust in their abilities and medical skills.
2 Because of the plethora of sources addressing the need for a work-life balance for nurses, I will simply list a few
here. Susan Simmons wrote about this in American Journal of Nursing (Simmons, 2012), a study of over 95,000
nurses by Matthew D. McHugh and his team found that nurses who care directly for patients have high rates of
dissatisfaction, which can lead to risks for patients (McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011), and
the Royal College of Nursing has an entire booklet on the subject (“Spinning plates: establishing a work-life
balance,” 2008).
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overshadow the same conversations that should happen on the side of the practitioner.
3
On the
other hand, there are also studies done on system procedures, proposing how to make processes
more efficient, particularly in light of the increased number of insured Americans, and hence
patients, due to the implementation of the Affordable Care Act. For example, one study by Eugene
Litvak and Maureen Bisognano (2011) proposes that, rather than increasing resource and staff,
hospitals think of ways to increase “throughput,” or the number of patients served given a fixed
amount of time. An important way to do this, the authors suggest, is to increase bed occupancy to
as close to bed capacity as possible. Studies like these assume 100% compliance from the health
practitioners in the implementation of these changes, without understanding the potential, often
temporal, limitations.
There are a number of studies in other fields - namely human resources, medical
education, and nursing - that address the challenges of residents, duty hours, scheduling, work-life
balance, job satisfaction, and burnout. For example, Shanafelt et al (2012) highlight the dire
situation that physicians face, noting that 1 in 2 physicians experience at least one symptom of
burnout, with high rates of depression and suicide. Another study done on medical residents in
North Carolina, found that “70% of residents met the criteria for burnout” (Anderson, 2015). This
particular study disaggregates burnout and depression, finding that depression and burnout are not
necessarily directly correlated. Yet, the study also finds that most attempts to address this issue
lies with the individual physician with stress reduction training, rather than interrogating the
institutional and organizational system. And finally, as mentioned earlier, it is well-documented
that physicians have a far higher suicide completion rate than the general public, with an
3 For example, a recent NPR article summarizes the findings of research studies that showed no significant impact
on patient care with the restriction of resident duty hours (“LineAngel,” n.d.). While the end of the article makes
allusions to the quality of life of health practitioners, it is clearly as an afterthought.
8
estimated 400 physicians committing suicide per year (Anderson, 2015; Sinha, 2014), which is
the equivalent of about two entire medical school classes. So while there have been practitioner-
facing research studies conducted, they have largely been confined to medical publications, which
rarely employ critical perspectives in thinking about the implications of these issues within the
sociocultural context that situate the challenges practitioners face. Therefore, the purpose of this
dissertation is to bridge this gap by looking at challenges and issues from the perspective of the
provider by using a mix of social science and critical cultural approaches through the lens of time
and temporality. At the same time, this research considers how capitalistic priorities of health care
institutions intersect with the lives of practitioners by examining how tensions and struggles
around control over time, and hence power, are negotiated.
This project highlights the experiences of physicians and nurses in order to develop a
nuanced and complex perspective of the temporal factors that shape the cultural practices and
affective experiences of health practitioners. Because of my cultural studies and critical theory
background, my work is situated within discourses around power and institutional structures, and
social relations. The strong qualitative aspect of this research allows me to retain the significance
of individual accounts while also drawing out trends and patterns across the experience of many
individuals. These real-world experiences are then put in conversation with theoretical work
around temporality, society, culture, difference, and power. As a communication piece, this
dissertation focuses on the ways in which the control of time – both one's own time and others'
time – communicates and reinforces structures of institutional, social, and cultural power.
The changing landscape of health care not only has an effect on the patients' hospital
experience, but also greatly affects the ways in which health professionals practice, especially as
they negotiate a number of factors in their work and personal lives. This is not unrelated to patient
9
care. On the contrary, the happiness, satisfaction, and well-being of health professionals
ultimately have an impact on the quality of patient care. As time is an “omnipresent dimension of
the world” (Zerubavel, 1979, p. xi), the implications of temporal structures and patterns both of
the health system and of the lives of the individual actors within it, is a crucial perspective to
consider. By understanding the temporal dynamics in the lives of these health professionals, we
will better be able to identify the problems of the system, and where systemic procedures and
institutional regulations break down. By doing so, we not only work to humanize our health
practitioner population, but also potentially pave the way forward for solutions and policies that
can ameliorate the current situation and ultimately impact the quality of patient care for the better.
A Capitalistically Temporal Perspective
Building upon my previous work that examines the ways in which the amount of time
under an individual’s control, or temporal capital, varies between individuals based on his of her
position within the social class hierarchy (Wang, 2013), this dissertation aims to further explore
the power structures related to the use and control of time in context of health care, specifically
looking at how practices of time management on both the individual and the systemic levels
contribute to and are shaped by relations of power in health care systems. It also addresses the
influence that communication technologies and a constantly connected society has on individuals'
values and use of time, which Judy Wajcman (2015) discusses in her fantastic book, Pressed for
Time. One of the interesting points, among many, that Wajcman makes in the book is that the
“'always-on' character of digital technologies provides new opportunities for flexible
coordination, counterbalancing any uncomfortable increase in time pressure” (Wajcman, 2015,
Chapter 6, sec. “Patterns of Mobile Phone Use”, para. 11), which pushes back on the notion that
10
the acceleration of life through the ubiquity of communication technologies correlates with higher
levels of stress and decreased time for self reflection, an argument that Ben Agger (2004) makes.
In a sense, technologies potentially enable more temporal autonomy through its ability to allow
people to resolve issues and communicate while on the go.
As control over one's own and others' time communicates and maintains dynamics of
power, temporal capital is not evenly distributed amongst all individuals, nor is it evenly
distributed across all moments of an individual's temporal landscape, and works as a framework
with which to think about patterns of social power through temporal colonization. As such, a
discussion of temporal capital necessarily builds on scholarship that have come before, which will
be discussed in more depth in Chapter 2. Most notably at the intersection of temporality and
power, David Harvey takes to task the implications and ramifications of a society steeped in
capitalism's intersection with ideals of neoliberalism as well as the ways in which “in a capitalist
society in particular, the intersecting command of money, time, and space forms a substantial
nexus of social power that we cannot afford to ignore” (Harvey, 1989, p. 226), providing a useful
springboard from which to think about how a mentality of neoliberal capitalist functions to
govern individual temporalities and discipline individual bodies and behaviors. Through the
process of neoliberalization as “[bringing] all human action into the domain of the market”
(Harvey, 2005, p. 3) and keeping in mind Marx's seminal texts on the time of social labor (Marx,
1867), in which the value of labor and the ensuing economic income of the laborer is measured by
the amount of time labored, we must consider how time as capital varies according to the patterns
of social power, and how laboring bodies are interpellated as neoliberal subjects into a perpetual
capitalist logic. As such, Sarah Sharma calls for a broader discussion around the political
economy of time, wherein time is "understood as multiple, relational, and deeply uneven"
11
(Sharma, 2013, p. 1). My dissertation intends to participate in this discussion by examining the
ways in which relations of power function for health practitioners through the management and
control of time. Within this discussion, temporal capital is used as a way to discuss differing
amounts of time over which individuals have agency, given the broader dynamics of social
relations and individual's positions within the hierarchies and power structures present in the
specific health care system.
Temporal capital is broadly defined as the amount of time individuals have at within their
control to pursue whatever they want in an attempt to generate additional capital (economic, so-
cial, cultural, etc) or a meaningful existence. This concept builds on theories of how control of
time communicates dynamics and structures of social power. Through using the health care sys-
tem as a site of inquiry, and health practitioners as the research subjects of interest, I explore prac-
titioners' ability to invest the limited time one has to perform activities that one may or may not
choose to do autonomously, using the framework of temporal capital, wherein the amount of not
only free or autonomous time, but also the ability to exchange the amount of time into meaning-
ful, self-actualizing activity, is necessarily differentiated given one's position within the relevant
hierarchy, and co-opted by institutionally mandated policies and rules and culturally influenced
norms (Wang, 2013). When the institution imposes temporal constraints on individuals, co-opting
their temporal capital, individually differentiated temporal capital through negotiating within the
bounds of the cultural norms of the relevant group of practitioners work to resist the totalizing
power of the institution. Hence, as health care providers are increasingly functioning at the whims
and demands of a capitalist society, they negotiate (often unknowingly and subconsiously),
through the use and control of time, their agentic temporality as neoliberal subjects. Foucault's
work on neoliberal subjectivity is useful here, wherein society bends to the “regulatory principle
12
[not so much as] the exchange of commodities as the mechanisms of competition” (Foucault,
2008, p. 147). Such competition, of course, is in the service of capitalist market profit. It is this
competition that saturates doctor's offices with more patients than they can presumably see in a
day in order to merely keep up with the rapidly changing landscape of health care. It is this com-
petition that makes patient visits shorter and physician's days longer as regulations cut into physi-
cian's reimbursements for patient care, forcing them to see more patients to make the same
amount of income, disciplining their bodies to an accelerating logic of capital.
There have been roughly two frameworks of the relationship between time and money. On
one hand, there is the time rich/money poor, or time poor/money rich paradigm, to which Barbara
Adam (2006) refers, in which an individual who has a lot of money has to spend that time making
money, and therefore has little free time, and vice versa. This is, however, a flawed assumption. It
assumes a singular relationship between time and money, without considering the sociocultural
contexts and complexities that govern temporal capital. It also assumes that the relationship
between money and time is a causal one, which is reductive. The other framework is a bit more
nuanced: time rich/money rich, and time poor/money poor. Perhaps the more accurate comparison
would be the correlation between temporal capital and money. As scholars like Castells (1996)
and Sabelis (2007) point out, more money does not always correlate with more time, given the
constant connectivity to work that communication technologies enable (and mobile devices to an
even greater extent). However, if one is rich(er), one can outsource one's temporal obligations and
purchase another's time. For example, people paid others to sit outside of the Apple store to wait
for the newest iPhone.
4
That means, in order to free up the time one would would otherwise spend
4 When the iPhone 6 came out in September 2014, people lined up outside of the stores more than a week in
advance to ensure they get their hands on the newest Apple product (Granger, 2014). Similarly, there is now an
application called LineAngel (with the taglines like, “Make the Most of your Time” and “Never Wait in a Long
Line Again!”) which allows users to hire a “line sitter” to wait in line for them, demonstrating that one can indeed
13
sitting outside of the Apple store, one needs to have enough economic capital in order to hire
someone to sit outside of the store for them. In a similar dynamic of power, people lower on the
relevant social hierarchy have their time controlled by those at the top. As we will see throughout,
attending physicians often delegate tasks associated with patient care to their residents. Therefore,
those who stand to gain more economically, have the potential to control the time of those poor
peons below them, expanding their temporal capital by co-opting the time of others. In simple
mathematics terms, if I can buy someone's time to transcribe my dissertation interviews for me, I
can use the time I would otherwise be spending transcribing doing something else that may be
more valuable or meaningful.
Temporal capital provides a useful framework here to reconcile these two perspectives. An
individual may be doing constant and unending labor for the purpose of, for example, flourishing
one's own company or advancing one's career, but the temporal labor and the temporal investment
into that endeavor is meaningful and willingly done for more than simple economic exchange.
Therefore, temporal capital is not simply “free” time, but also temporally quantifies (abstractly)
the ability for a person to ascribe meaning in their life through the exchange of time. Non-paid
domestic labor is another example where temporal capital may be enacted outside of traditional
economic capitalist frameworks as well. Temporal capital does not only define the CONTROL
that one has over time in the most immediate sense - “I want to play video games right now”, but
a framework of temporal capital also pertains how choice and personal meaning through temporal
investments are enacted - as for example, decisions made about one's career that may have long-
term ramifications. This is all keeping in mind that the argument of temporal capital as a way to
measure the ability of one to generate meaning in one's life is situated within a Western context
pay for more time (“LineAngel,” n.d.).
14
that is framed within the logics of productivity, in that time spent should be used in a way that
increases one's economic, social, cultural, and other forms of capital. Productivity as a measurable
exchange of temporal capital, and the moral policing around what type of labor and activities are
considered “productive” is problematic, as it narrowly defines and legitimizes only certain types
of labor and activities embedded in a certain (usually politically, socially, or culturally dominant)
normative perspective.
Autonomy and Quality of Life
The alienation of timed labor and the co-optation of temporal autonomy warrants some
discussion here. Marx famously demonstrates how, within a capitalist society, through capitalist
modes of production, which maintains stratification of the social classes, timed labor –
compensation based on how long one works - makes it so that the proletariat worker labors in the
service of the bourgeoisie, and his labor is mechanized and dehumanized by the measurement of
time. The worker himself is alienated both from the product of his labor and the process of labor,
estranging him from his humanity, making him lose control and autonomy over his life (Marx,
1932). Autonomy, and in particular, temporal autonomy in the framework of the capitalistic
modes of production that deny a worker's control and ownership of his labor time, is a way of
realizing and maintaining one's humanity and meaning in one's temporal investment. In one of the
many tense discussions I have had with my partner about the constraints of temporality on her
time versus my time, she remarked, “I don't think you understand what a privilege it is to be able
to have flexible time (J. Chen, personal communication, 12/5/2015).
Autonomy has long been correlated with life satisfaction and happiness. Wajcman (2015)
discusses extensively the importance of autonomy, especially temporal autonomy and the control
15
over one's time as a factor in determining the quality of life. Yet, the situation cannot be discussed
as reductively as such. Not having a framework in which the wielding of one's temporal
autonomy can be embedded is also not helpful (Salmonsohn, 2011). Sleeping too much, watching
too much TV, and not setting internal deadlines, despite the seemingly infinite amounts of
temporal capital, is negatively correlated with life satisfaction. This follows Ryan & Deci's (2001)
description of two perspectives of well-being – the hedonistic and the eudaimonic. Hedonism
“reflects the view that well-being consists of pleasure. The second view, both as ancient and as
current as the hedonic view, is that well-being consists of more than just happiness. It lies instead
in the actualization of human potentials” (Ryan & Deci, 2001, p. 143) The same authors, in a
previous study, posit that autonomy is one of the three basic psychological needs for achieving
self-determination, which is the cornerstone of eudaimonism (Ryan & Deci, 2000). Atul
Gawande, a surgeon and writer, uses different words but similar themes as he criticizes "free
action...living completely independently, free of coercion and limitation" (Gawande, 2014, p. 140)
This is that idealistic, hedonistic way of thinking of autonomy, as he goes on to say, "Out lives are
inherently dependent on others and subject to forces and circumstances well beyond our control.
Having more freedom seems better than having less. But to what end? The amount of freedom
you have in your life is not the measure of worth in your life. Just as safety is an empty and even
self-defeating goal to live for, so ultimately is autonomy" (Gawande, 2014, p. 140). He references
Dworkin's work that indicates autonomy as a way for one's own story to be written, to control
one's life narrative. As with the research in this dissertation, possession of temporal capital allows
for an individual to take "[responsibility] for shaping [one's] own life according to some coherent
and distinctive sense of character, conviction, and interest" (Gawande, 2014, p. 140).
While autonomy is perceived as a measure of freedom (Goodin, Rice, Parpo, & Eriksson,
16
2008), work itself is often positioned as oppositional to the freedoms of human nature, with the
connotation that suggests people would rather be doing something else. There is a sense that work
colonizes the worker's time, alienating a worker from his or her labor (Marx, 1932). However, as
we saw, work and labor does not have to be undesirable or devoid of meaning. Rutger Claassen
(2012) suggests that when people are given “free” time, they will either do labor or leisure
activities, depending on if they are labor or leisure oriented, rupturing the notion that work is
undesirable and temporally controlled. His discussion suggests that ascribing meaning to one's
investment of time does not have to exclude work time. Conversely, leisure, which has
pleasurable connotations, may not be as pleasant or autonomous as one may think. Robert
Stebbins (2012) posits that leisure itself has become a sort of labor which compels individuals not
only to schedule it around their work time, but also spend money on the trappings of the leisure
activity, thereby disciplining both the bodies and the wallets of individuals to logics of
productivity, making the only distinguishable feature the hemorrhaging rather than the
accumulation of funds, and the assumption that leisure activities are supposed to be pleasurable,
whereas work is not. Such an observation ruptures preconceived assumptions of work and leisure
as diametrically opposed, wherein enactment of higher levels of temporal capital is not in the
amount of leisure, but potentially pertains to both work and non-work time.
Hence, there is a balance necessary between controlling life within a certain framework,
with a certain purpose or pursuit of meaning (eudaimonic), and a chaotic, anarchical idea of
temporal autonomy (hedonic). The use of a temporal capital framework works within both of
these perspectives in that temporal autonomy can be present-based (hedonic) or future-based
(eudaimonic), with the meaningful exchange of time as an aspect of self-actualization a critical
aspect in the consideration of temporal capital. Therefore, throughout this dissertation, the ideas
17
of temporal autonomy and individual agency are used to convey higher levels of temporal capital
through the potential for individual self-actualization in exchange for an investment of time.
Autonomy and agency are ways in which practitioners resist their interpellation into a neoliberal
subjectivity, a dehumanized laborer alienated from one's work through capitalist logics that
govern their temporal patterns.
Research Focus
This research project examines the ways in which power dynamics are enacted through
differentiating levels of temporal capital between individuals, and is focused specifically on the
experience of health practitioners both at and away from work. The research concerns itself with
primarily two main dynamics. First, how does the institution colonize the temporal capital of
individuals to the extent that individual practitioners are interpellated into the expectations and
demands of the health care system where their behaviors and actions are locked into place so their
bodies are disciplined to perform tasks at the whim of the invisible force of the health institution?
In this case, “institution” is used to denote forces outside of individual control that stem from
regulations and legislation directly from the government as it bears on the ways in which health
care is delivered and practiced in the United States, or from the governing body of the hospital or
health facility. It also indicates the invisible and unconscious habits and rituals that are expected
of individuals that submits the individual to certain sets of actions, thoughts, behaviors, etc.
Secondly, how does the differentiation of temporal capital between different individuals reflect
established power hierarchies within health organizations and professional
development/training/educational trajectories? Along the same vein, how does this differentiation
of temporal capital based on social power (which is bestowed upon the individual by the
18
institution) allow for more temporal autonomy?
An important variable in this research is the question of well-being and life satisfaction.
Too often, practitioners are perceived as authoritative, yet overly rationalized robots. This notion
is reinforced through the tightly controlled temporal environments in which they work and
function, which serves to dehumanize them and alienate them from the meaning of their labor,
which, in short, often results in frustration and sometimes misery for practitioners (especially
residents). As my research demonstrates, while this may be true in some cases, there are both
moments of rupture and resistance to the strict temporal structures of their lives, as well as
meaning that is found within their regimented time, which is seen as a worthy exchange of their
temporal capital. In this way, temporal capital is not only a measure of power, but is also a way
for individual practitioners to recoup a sense of humanity and self-actualization within an
institutionally imposed system of practice.
Methods
This dissertation used a multi-method approach that includes semi-structured interviews,
participatory observation, and survey data. I conducted 29 formal interviews averaging over an
hour each with medical and nursing staff at a major urban teaching hospital in Southern California
(hereafter referred to as “University Medical Center”). Additionally, informal conversations and
participant observation on additional subjects were conducted in informal, friendly settings. I also
interviewed administrative staff, managers, and directors in order to understand the ways in which
non-practitioners viewed the temporal dynamics within patient care. Finally, I also interviewed
practitioners who were not affiliated with University Medical Center in order to reveal issues that
may be similarly shared between institutions, or uniquely part of the University Medical Center
19
culture. This was also done to get a better general idea of the issues facing practitioners. All in all,
my research data consists of conversations with and observations of over 50 subjects through
interviews and observation over the course of three years. Formal interviews were recorded and
transcribed, and were conducted in person or over the phone and address four main points: 1) The
temporal constraints and flexibilities they experience on a daily basis and how they feel about
them, 2) their use of communication technologies, including personal mobile devices and
Electronic Medical Records (EMRs), 3) how they negotiate a work/life balance and what other
factors in their lives demand their time, and 4) the meaning derived from their work and the value
of the temporal investment put into both the process of training and the temporal dynamics
experienced from day to day.
My research data is heavily informed by and attained through my personal networks and
connections. Clifford Geertz (1973) puts forth “deep hanging out” as a method of ethnographic
research, and deep hanging out is, indeed, an additional way I used to understand the relationships
between individual practitioners and the relationship between practitioners and the health system
institution in which they exist. The humanization of practitioners is key in this research, as
practitioners have often been dehumanized, both within the process of their labor as well as in the
perception of the public. In the course of deep hanging out with practitioners, my subjects often
revealed information and emotions that they would not express in formal interviews. I have also
been influenced by Harold Garfinkel's (1967) approach of ethnomethodology as a method of
research, employing the idea of using how practitioners negotiate their everyday situations,
particularly the temporal aspects, through common sense, rather than rules and regulations that
may govern their job. While these methods necessitate a smaller sample size,
5
they reveal
5 In an extreme case of small sample sizes, Krista Hirschmann (1999) conducted a study in which her data
consisted of examining a single intern's call night.
20
instantiations of temporal capital is enacted, exchanged, and negotiated. As with any study, it is
difficult and unreasonable to extrapolate my finding to any and all similar structures and actors
within health care. Rather, these should be seen as examples of how temporal dynamics intertwine
with the work flow, obligations, and negotiations that fill a practitioner's day, and how a
perspective of temporality can be used, almost like a method unto itself, to reveal complex social
relations, cultural practices, and power dynamics within an institution.
The data gathered was analyzed using qualitative and interpretive methods. The process of
data collection and analysis was iterative, with repeated contact with some subjects. My
acquaintance with many of the subjects, especially those who are personal friends, in this project
is ongoing. For some of the residents, it has spanned their entire residency. I have seen senior
residents and fellows become junior attendings through the course of my research. While this
project was not designed to be longitudinal, my long-term and repeated interactions with these
subjects through different phases of their training give me a uniquely broad perspective to
consider how their temporal patterns and temporal capital may change over time as they move up
the proverbial ladder.
Additionally, I implemented an online survey using Qualtrics asking health practitioners
about their communication technology use. The data from this survey is used only in Chapter 5,
where a more detailed description of the methodology and the survey is found. The survey asked
participants about their use of EMRs, pagers, and personal mobile devices, in order to interrogate
how communication technologies have impacted the organization of time.
Interview data, if quoted, is presented with pauses and fillers removed for easier reading
and comprehension, but with the original meaning and intent of the subject intact. All subjects are
anonymized, as are the various locations and health facilities. Because I collected substantially
21
more data from physicians than nurses, I will be using physicians as an anchor throughout, using
nurses and other types of practitioners as points of comparison to physicians as appropriate.
A final note regarding the locations that will be used throughout. Most of my subjects are
affiliated with University Medical Center, which is an urban teaching health system in Southern
California as well as a designated trauma one regional medical center. Within University Medical
Center is University Eye Clinic, which includes both clinics and operating rooms, both of which
will be referred to through the dissertation. Other associated facilities include an affiliate
Community Hospital, two county medical centers, which I will refer to as County Medical Center
1 and County Medical Center 2, a Veterans Affairs (V A) Medical Center, and other auxiliary
clinics. The specification of the other auxiliary clinics and facilities is not relevant. While the
nursing staff are specific to each facility, attending physicians and medical residents rotate
through different facilities throughout the system. They are all considered part of the University
Medical Center health system.
Chapter Breakdown
This project is broken down into five parts. Chapter 2 situates this project within the
existing scholarship and research done around time and temporality, and provides a review of the
foundational ideas on which my analysis and theoretical framework of temporal capital is based.
It then moves into a discussion about the state of the health care system in the US, considering
particularly how the issues facing health care in the country are related to theories of time and
temporality, and why a temporal perspective is a useful lens through which to examine some of
the challenges.
Chapter 3 examines the daily, organization of health care professionals in a hospital or
22
outpatient clinic setting, exploring the micro-temporal dynamics and instantiations of power
through control of time. Mapping out temporal dynamics between patients and doctors, doctors
and nurses, and attendings and residents illuminates where power over time is located given
particular situations. Through interrogating who holds the power to demand others' time during
working hours, I examine the different work-related factors that place either restrictions or
flexibilities on the time of the practitioner. For example, why is it that an ophthalmology clinic at
the County Medical Center chronically runs three to four hours behind schedule? Why do medical
residents time and again indicate that they are unable to find time to use the restroom during the
work day, and often forgo lunch? Who or what are the factors in their day that hold the power to
controlling these individuals' time?
Chapter 4 takes a closer look at schedules, both work schedules and call schedules, taking
into consideration how the schedule itself is a physical manifestation of institutional impositions
of temporal patterns on the bodies and behaviors of practitioners. In this chapter, we see
differences in temporal capital made clear through the implementation of the schedules between
different practitioners, the implications of shift work and the night shift, and tensions that arise
during the scheduling process itself. Through a closer look at a specific instance of scheduling
within a group of ophthalmology residents, we come to understand the anxiety over and
overprotection of limited time that residents have, and how the attitudes of attendings are laxer.
Chapter 5 enters the realm of communication technology and explores the ways in which
communication technologies have an impact on the management of time for health practitioners.
Communication technologies include both personal mobile devices and institutionally sanctioned
entities like electronic medical records (EMRs), pagers, and in-house cell phones. I consider the
potential for communication technologies to allow for non-work-related communication to
23
happen during work time, and also for work-related communication to happen during non-work
time. Furthermore, I also explore how mobile devices and EMRs impact the temporal rhythm of a
hospital unit or clinic, and how the use between institutionally non-sanctioned devices reveal a
struggle to maximize efficiency and resist the co-optation the health institution has on individual
practitioners' temporal capital.
Chapter 6 takes a macro-temporal perspective. This section recognizes the long years of
training that health professionals endure and places that in conjunction with long work hours and
low temporal autonomy to explore the perceived worth (economically and otherwise) of both the
long-term and the daily temporal investments. I also tackle how the strength of identification to
one's profession intersects with the ability to ascribe meaning to one's time at work. How do
people considering going into health care make their decisions to give a sizeable chunk of their
lives to the training process? What factors motivate future health professional in making this
temporal exchange? Moreover, this chapter also looks at the work-life balance and overarching
priorities that drive health professionals, examining the temporal trade-offs between their work
and personal lives, and how the long-term temporal investments of training, and the decision of
medical specialty paths, for example, factor into their work-life balance and overall temporal
autonomy.
Conclusion
Examining the differing affective experience of health practitioners is not only an
interesting endeavor, but an urgent one as well. As our health system faces increasing levels stress
from the implementation of the Affordable Care Act, and the looming shortage of nurses and
24
primary care physicians,
6
there is a push to make health care more efficient. By understanding
temporal factors within tensions between institutional procedures/regulations and the reality of
practicing medicine, we pave the way to potentially find solutions to a more efficient health
system, but also beneficially affect the lived experience of health practitioners, thereby ultimately
increasing the quality of patient care.
6 The shortage in nursing and in primary care physicians are issues that are well known and discussed amongst
people working in the health care industry, from the clinical to the administrative to the educational sectors.
Rosseter (2014) provides some numbers and data on the nursing shortage, while Petterson et al (2012) presents
data on the demand for physicians, reflecting the urgency to address these issues.
25
Chapter 2: Time and the US Health Care System
Time is an intricate part of our existence, simultaneously invisible and deeply influential
on our behaviors and actions. It is a resource that is both objective and subjective, seemingly lim-
ited and unrecoupable, yet variable under different circumstances. Because of the limited nature
of time as experienced by humans as each person progresses steadily toward the end of life, there
is an impetus to seek meaning and value in the acts that take up time, whether through personal
growth in work and career, memorable moments with family and friends, or reflections while one
is alone. However, the meaning and value of time varies depending on situations in which people
find themselves. As time acts as a form of exchangeable commodity in a capitalist-driven society,
the ways in which time is used is entrenched in power structures of relevant segments of society
or specific frameworks, practices, and circumstances. Moreover the amount of time for which an
individual is given agency or autonomy, or control over, varies depending on the individual's so-
cial circumstance and position.
Time can be used as a way of communicating power across multiple levels of interaction –
between individuals, between individuals and institution, within certain systems and processes by
which individuals must function, embedded in technological artifacts. Moreover, the amount of
time over which one has control varies between difference actors across the power spectrum. In
this way, time can be thought of as a form of capital - temporal capital. Temporal capital, how-
ever, is not a cold rational exchange of time for other forms of capital, be it economic, social, cul-
tural, or otherwise. Rather, because time is necessarily limited (given the limited lifetimes of hu-
man organisms), the ability to choose what one does with one's time is a privilege that is quite
26
outside of its correlation with other, particularly economic, forms of capital. Instead, the ability to
use one's time in a pursuit of a meaningful existence of one's choosing is a priority for many. As
will be seen, temporal flexibility and autonomy are important factors taken into account by health
practitioners when making career decisions.
The health care field is an interesting site for this inquiry into time as a mechanism by
which power structures and social hierarchies are constructed and maintained. Temporality in
health care works on many levels – from the clinical, where how quick a patient is seen may be a
matter of life and death, to scheduling appointments, to contentions discussions around deciding
the schedule for who gets “called” into the hospital when an emergency arises during non-work
hours, to scheduling surgeries, to the rhythm of surgeries, to the frustrations of waiting in the
emergency department. In addition to the individually motivated factors that control the pace and
rhythm of the health care field, institutional or systemic forces also influence the temporal pat-
terns within the lives of health practitioners. Furthermore, the mandated implementation of elec-
tronic health records have further shifted and complicated the daily workflow. Given this, the
health care field is not just an interesting site, but an urgent one to examine as well, given the par-
ticular challenges that health care faces in the US today.
Introduction to Temporal Capital
A useful framework to think about time is through a perspective of capital, especially from
a position within a capitalist framework where time is seen as a resource that is exchangeable for
some kind of capital, be it economic, social, cultural, etc. In fact, our mentality that time is ex-
changed for some obviously meaningful purpose (and that time is not “wasted”) belies the disci-
plining of the neoliberal subject into logics of productivity, wherein each moment of our lives con-
27
stitute some form of labor, whether it is professional, domestic, personal, leisure, social, etc.
Hence, the term temporal capital is the amount of time that can be used to be transacted into some
form of capital (Wang, 2013).
Within the intensely hierarchical organizational structures of health care, power dynamics
from the micro to macro levels (individual to institutional) are maintained and reinforced through
control over time. Who controls whose time, for whom temporal flexibility and autonomy is a re-
ality, and how this differs across individuals and institution actors all contribute to the ways in
which temporality enacts “multiple, relational, and deeply uneven” (Sharma, 2013, p. 1) under-
standings of time. My dissertation explores this complex understanding of time though framing
time as capital, examining the ways in which relations of power function in a Southern California-
based health care system through the management and control of time on both individual and in-
stitutional levels, and considers how the individual interacts with the institutional through the con-
trol of time, and lived experiences of temporality. Moreover, this research parses out the condi-
tions under which variations of temporal capital occur, and the implications thereof, which usually
has to do with the quality of life of the individual(s) in question.
While temporal capital seems to be a quantifiable concept, the capacity to choose and as-
cribe meaning to one's life practices within a temporal framework defies rigid measurement. It is
easy to assume that temporal capital refers to the amount of "free" or "discretionary" time one has.
Indeed, many scholars have tackled the idea of "free" time, as Sebastian de Grazia (1962) refers to
it. Rather, temporal capital is more aligned with Robert Stebbin's (2012) concept of “discretionary
time commitment,” and Manuel Castells (1996) “autonomous time,” both of which indicate a cat-
egory of time over which the individual retains some form of ownership, when they are not at the
beck and call of someone of a presumably higher power status (ie: a work boss), or the impetus to
28
increase capital. The difference between the alienated labor that Marx critiques, and meaningful
labor in which the individual performing it is a) recognized for it and/or b) understands that it has
a more general objective or purpose (Ariely, Kamenica, & Prelec, 2008), correlates with the dif-
ference between lower and higher levels of temporal capital, respectively. Being able to choose to
use one's time meaningfully is a key aspect of temporal capital that will come up throughout this
dissertation. The act of doing meaningful labor,
7
is a form of privilege that ostensibly benefits the
individual in addition to the entity for whom or which the individual labors. In health care, which
is considered one of the most meaningful professions,
8
time spent “working” often goes beyond
the foundational exchange for economic capital. Temporal capital, then, refers to the agency over
one's activities, and the ability to have agency over one's use of one's time. This agency over time
intersects, determines, and is determined by one's position in the relevant social hierarchy. Hence,
the enactment of temporal capital cuts across traditional categorizations of work, non-work, free,
and personal time, and using a temporal capital framework allows us to interrogate the conditions
under which one has agency over one’s time, regardless of the categorization of time.
It is useful to think about temporal capital as conceptualized on two levels - the individual
and the institutional. On the individual level, pre-existing factors, such as economic, social, cul-
tural, class status may determines one’s temporal capital, yet having temporal capital can also os-
tensibly determine the former. Temporal capital is intricately tied to the ways in which people
work, socialize, consume and produce cultural artifacts. To give a crude example, if an individual
7 Speaking about meaningful labor, Dan Ariely states, “On an intuitive level most of us understand the deep
interconnection between identity and labor...'What do you do?' has become as common as a component of an
introduction as the anachronistic 'How do you do?' once was – suggesting that our jobs are an integral part of our
identity, not merely a way to make money.” (Ariely, 2010)
8 In 2013, Forbes put out a list of the top 25 most meaningful careers that are well-paid (Smith, 2013). The top 5
most meaningful careers were all physicians, 4 of which were surgical specialties. 9 of the 25 were health care
related – 10 if veterinarian counts. Teachers are alarmingly not on this list, indicating that, even if they find their
jobs meaningful, they are probably not considered well-compensated...
29
is of a higher socioeconomic status, he or she can pay for a housekeeper rather than taking the
time to clean his or her own apartment.
9
The time that is freed up can then be used for whatever
other pursuit the individual wants or needs to do, which is often “time for extra leisure” (Rau,
2016). On the other hand, if one has an abundance of temporal capital to begin with, one can ex-
change that into social, economic, cultural, or other forms of capital. Graduate students are an
easy example for this dynamic. As a graduate student, I have, in many cases, found myself free to
meet up with other graduate student friends in the middle of the day, taking advantage of restau-
rants or museums that would otherwise be busy during the evenings or weekends. Because of my
own flexibility of time, I am hypothetically able to exchange that time for social capital (maintain-
ing my relationship with friends or colleagues, doing community work, etc), cultural capital (vis-
iting museums on days where entrance is both free and free of long queues and crowds), or eco-
nomic capital (picking up an extra teaching gig at a local community college).
Individual temporal capital, then, is both a function of existing social relations, as well as
a factor in determining one's position within a social hierarchy. On this individual level, temporal
capital is conceptualized as the amount of time an individual has in their control in contexts that
include work and leisure, usage of technology, and digital labor and media consumption. Robin-
son & Godbey's (1997) work on the time diaries and time usages examine how Americans budget
and split their time between and within different categorizations of activities, such as work,
leisure, and personal maintenance. They also address the impact that class, occupation, and educa-
9 Judy Wajcman gives this example as well. She states, “Many domestic workers are employed not because people
do not have the time to do their own domestic work but because they want to avoid doing the chores themselves
and therefore gain the time for extra leisure” (Wajcman, 2015, Chapter 5, sec. “Is Outsourcing the Solution?”,
para. 4). Pei-Chia Lan (2006) similarly demonstrates, in her book on Indonesian and Filipino domestic workers in
Taiwan, that domestic workers help offset labor time spent on domestic chores and childcare or elderly care in
order for the employer (the parent or the child, respectively) to have a job outside of the home. The importance of
this invisible domestic labor has also entered mainstream media, with a recent article in The Atlantic which
highlights the ways in which non-familial caregivers and domestic workers can be hired, thus “clearly [enabling]
vast percentages of economic productivity in the U.S.” (Slaughter, 2016)
30
tion has on time usage. This discussion of time as a limited resource spent on different categoriza-
tions of activities are relevant in mapping out an individual’s temporal capital dynamics. In this
dissertation, individual temporal capital comes in the form of examining the amount of control
health practitioners have over their time, from the smaller end of the temporal scale in terms of
hours and days, to the larger end of the scale in terms of years and decades. What sorts of deci-
sions are made by these individuals in order to negotiate their temporal rhythms and enact the
greatest amount of temporal capital, whether this enactment is having greater amounts of flexible,
autonomous time, or choosing to use this time, often through labor in the work arena, to generate
the increased amounts of capital? Additionally, the negotiation of control over time on this indi-
vidual level happens through individual interactions as well. Which individuals are able to in-
crease their own temporal capital at the expense of another individual's temporal autonomy?
Institutional control over time is situational and circumstantial, including both institutional
processes and ritualized cultural processes. One's time is not controlled by an individual, but is re-
liant on external forces that dictate the temporal rhythms and patterns of a group of individuals.
These may not even be institutions in the most obvious sense, but also includes ritualistic cultural
processes and unspoken rules of engagement that are outside of an individual's control. On this
level, the relevant institution (be it capitalism, governmental, the concern of one's own health, or-
ganizational systems, etc) commands a great amount of temporal capital, temporarily, of a great
number of individuals. For example, CEOs and janitors alike have to serve jury duty, or wait at
the doctor’s office, or wait for their flight at the airport. Similarly, students from high and low so-
cioeconomic families may sit side by side in a college classroom for a two-hour lecture – a time
when even the professor herself is obligated to give up to the institution of teaching. In terms of
cultural or unspoken rules, this is akin to a medical resident staying late at the clinic to help a col-
31
league with patients even if that is not their direct responsibility, and they would be completely
within their right to go home. In these situations, an institutional power or cultural/social norm
maintains control over individuals’ time. Individuals, when placed within these situations, regard-
less of their place in society, have their time co-opted somewhat evenly by an institutional norm,
overshadowing individual dynamics of temporal capital. There are obvious exceptions to the rule.
Taking to task the long wait times to get health care, the power elite of the world – famous
celebrities, heads of state, hospital board of trustees members, other publicly significant individu-
als, etc – individuals with oodles of social capital and power, would hardly be expected to wait in
a waiting room with the rest of the unclean masses to see a doctor. Indeed, medical concierge ser-
vices, for those people who can afford the steep premiums, provide health care on demand, essen-
tially eradicating the time spent waiting around for a doctor. But for the most part, certain pro-
cesses of scheduling patients or waiting for jury duty apply to most of the individuals involved.
The difference here is how technology may act as a recuperating tool for temporal capital, but
only for those who can afford it, have access to it, and know how to use it. It may also be used
more on a psychological level in that those who perceive that their time own is more valuable may
seek out technologies that will help one be "productive" during moments when temporal capital is
co-opted by external factors.
Borrowing from James Carey's (1989) idea of the ritualistic mode of communication, in
which culture becomes normative not through the overt transmission of messages, but through re-
peated behaviors and expressions, this institutional control over time is ritualistic in the sense that
the reproduction of cultural and temporal practices that create normative social relations and be-
haviors influence one's temporal autonomy. Even if there is no actual individual actively forcing
another individual to be at a certain place or do a certain thing at a certain time, it could be that
32
the need to make more money compels a physician to cram his or her schedule with more patients
than can be realistically seen and treated given that time period, creating a tension between a tem-
poral schedule and the actual practiced temporality (which usually has the physician running late).
Indeed, the economic influences upon temporal rhythms and the framework of capitalist logic un-
der much of Western institutions and individuals function is a powerful form of institutional colo-
nization of temporal capital.
In this chapter, I demonstrate how temporal capital fits in existing conversations around
time and temporality within sociocultural contexts. Moving from a broader discussion of tempo-
rality, I then introduce the general issues surrounding health care in the US related to issue of how
time is felt, managed, and negotiated.
Theoretical Framework
The sociocultural context of time and temporality has been widely discussed, and the ideas
behind temporal capital have been heavily influenced by this previous scholarly work. Time is a
very broad subject to tackle, and there are many perspectives and scales of time. For purposes of
this inquiry, time is considered a socially constructed resource that objectively progresses at a
consistent rate, measured by the standard scientific and mathematical temporal increments of
years, months, weeks, days, hours, minutes, seconds, yet is subjectively variable depending on the
meaning ascribed to how time is used, and how that time is valued for different individuals.
Within this perspective, time has often been considered an unrecoupable resource due to the
“limited amount of time we have allotted to us during out lifetime” (Adam, 2006, p. 140). Indeed,
the “scarcity of time derives from our finite existence” (Adam, 2006, p. 140) and leads to the
mentality of time as a form of currency, with an impetus to spend it wisely, to save it, to not waste
33
it, to budget it. Time itself, then, and the ability to control and access it, becomes a source of
social power (Harvey, 1989). Especially within a capitalist-oriented society, with the compulsion
to minimize “turnover time” in order to generate the greatest amount of profit, time as a resource,
particularly as a resource under the control of the social elite, dictates many social relationships,
especially those of labor and productivity. As Barbara Adam says,
Time cannot be thought about without the processes by which we divide
and measure it...Time, [social scientists] thought, was inescapably tied to
counting, naming and numbering the succession of units of years,
months, weeks, days and their subdivisions. For social theorists this
activity is inescapably social. It has its root in social organization and
synchronization, and in the need to anticipate, plan and regulate
collective existence (Adam, 2006, p. 103).
Historically, scholars have discussed time as delineated between work time and non-work time
(de Grazia, 1962; J. P. Robinson & Godbey, 1997; Rybczynski, 1991; Stebbins, 2012; Zerubavel,
1985). Robert Stebbins (2012) has discussed at great length the nuances of the categorization of
leisure, and proposes spaces in which leisure can also be a form of labor, complicating the idea
that work and leisure are necessarily mutually exclusive. With the expansion of the use of wireless
and mobile technology, the blurring of time categorizations has reached an apogee. Hence, a
discussion about how we negotiate time from within both a broader sociocultural context of
power as well as thinking about how temporal rhythms have been reconfigured in the digital age
is crucial to understanding the impact of time on individual agency.
Temporal Capital and Social Class
The Industrial Revolution, the migration to factories, and the rise of capitalism contributed
34
to the normalization of decontextualized, measured time as a framework of social relations. With
the Industrial Revolution and the proliferation of capitalism came the exchange of labor time for
money. Karl Marx makes the unambiguous class distinction between the capitalist and the laborer,
describing the relationship between the two as one in which the individual of the higher class, the
capitalist, retains control over the time of the worker in which “the time during which the labourer
works, is the time during which the capitalist consumes the labour-power he has purchased of
him” (Marx, 1867, Chapter 10, sec. “Section 1 – The Limits of the Working Day”, para. 8). The
time of the working day, the time of the laborer, becomes the objectified unit that is “purchased”
by the capitalist. The person in a higher social position uses capital in order to seize control of the
worker’s time with the purpose of having the worker’s labor time reap even more capitalistic
awards for him. The laborer, in essence, becomes an object himself. E. P. Thompson
(1967) similarly states, "Those who are employed experience a distinction between their
employer's time and their 'own' time. And the employer must use the time of his labour, and see it
is not wasted: not the task but the value of time when reduced to money is dominant. Time is now
currency: it is not passed but spent” (61). Within Thompson's rendering of the capitalistic
exchange of labor-time for money is the profound implication that time itself, within a capitalist
framework, is reduced to nothing but a resource, something to be exchanged for economic capital,
to be "used" and controlled by the employer in order to generate money.
The objectification of the worker came with the normalization of clock time, and the
necessary “diffusion of clocks and watches” as the “industrial revolution demanded a greater
synchronization” (Thompson, 1967, p. 69). The mechanism of clock time became imposed upon
the lived experiences of individuals within a modern, capitalist society. With the adherence to
clock time, and the desire for faster “turnover rates” in production and consumption (Harvey,
35
1989) to increase and perpetuate the growth of capital, workers became further alienated to their
work, and became seen as machines under the Taylorist regime of “Scientific Management.” The
purpose of scientific management, according to Frederick Taylor (1911), who explicated the first
rendering of scientific management, is to “secure the maximum prosperity for the employer,
coupled with the maximum prosperity for each employee.” Industrialization has alienated the
worker from his work, with the express purpose of using the labor of the working class for
capitalistic gain for the employer/bourgeoisie/capitalist (Marx, 1867). This mentality continues on
today, with workers who are at the bottom of the occupational ladder with less control over their
time.
Pei-Chia Lan (2006) illustrates an extreme example in controlling one’s time in her study
of Filipino and Indonesian domestic workers in Taiwan. During the three years that a domestic
worker is employed as a caretaker, she (this is an overwhelmingly female profession) lives in her
employer’s home. While she does have time off, she essentially is under her employer’s control
all the time, not to mention that she is bound to the agency that brought her to Taiwan through the
debt incurred through the immigration process. In this way, the employer and the agency control
not only fragments of the domestic worker’s day, but three whole years of her life.
Another extreme case of Taylorism in today’s world comes from Marc Linder & Ingrid
Nygaard’s (1998) book, Void Where Prohibited, which looks at occupations and situations in
which workers’ times are so restricted and controlled that it interferes with the natural bodily
functions of voiding (urinating and defecating). A factory worker’s time is so tightly controlled by
a supervisor that his or her natural bodily functions are restricted by the ticking of the clock, and
the authority of the supervisor who uses the ticking of the clock as a tool in order to impose
control over the workers to increase efficiency and productivity, and ultimately, capitalistic gains
36
for the company. Oftentimes, one’s control in time is correlated with one’s class status. In contrast
to factory workers who, clearly without control over their own time, cannot leave their location
even to urinate or defecate, “[w]hite-collar employees who have the freedom to make personal
telephone calls, leave the premises to run errands, or chat with colleagues almost at will can also
excuse themselves whenever nature calls” (Linder & Nygaard, 1998, p. 2). There is a privilege,
even in the workplace, associated with the ability to do something as fundamental as voiding. In
the age of mobile technologies, this privilege to have the freedom to chat with friends, play
games, or check Facebook on company time given one’s occupation and, presumably, class status,
has become more pronounced.
The assumption that the control over one’s time and others’ time is a powerful indication
of class seems very simple and intuitive, and this usually holds true. Pierre Bourdieu (1984)
addresses the tensions that the limitations of time places on one’s position on the social stratum.
He frames time as “one of the most rigorous anthropological limits” despite the fact that there is
the “possibility of appropriating other people's time or of saving time by rationalization and by
exploiting the freedom to avoid the effects of overcrowding by using unusual times and places”
(282). In a way, he implies that someone who has the ability to appropriate another person’s time
will have control of that person’s time to his or her advantage. Already, he acknowledges the
ability for people in positions of power to control others’ time, which follows Marx’s anxiety
about the “regulation and exploitation of labor time” (Adam, 2006, p. 38) in which time itself is
decontextualized and used as a universal measurement for the value of labor. Bourdieu goes on to
state that “the market value of time - more or less directly experienced, depending on the mode of
remuneration (consultation fees, monthly salary or profits) - increases as one rises in the social
hierarchy” (282). While this is not a direct remark about the control of one’s time, temporal
37
capital is implicated here. If a person who is at a high level in the social hierarchy, whose time is
highly valued, could spend less time and make more money to ensure material conditions, that
person would presumably have a greater amount of temporal capital. In this case, Bourdieu
indirectly makes the point for us that temporal capital is correlated with social class.
Similarly, Robert Levine’s (1997) book, A Geography of Time, demonstrates that the value
of one’s time increases as one has more money, allowing a wealthy individual to “buy” time -
either in the form of human capital or time-saving technologies. Real-world demonstrations of
this occurs frequently. When the new iPhone 5C and 5S came out, someone hired homeless
people (for as little as $20-$40 per iPhone) to wait in line at the Apple Store before the store
opened to ensure that they would get dibs on the new phones, which they would then sell overseas
for around $1,000 each.
10
Moreover, Levine found that the value of time and, consequently, the
pace of life increases the more capitalistic and “economically healthy” a place is. Through
Levine's findings, at least economically, we see a correlation between the valuation of time and
economic well-being, or the “classiness” of a country.
Finally, the advent and popularization of mobile technology have enabled workers of a
certain class to work from a variety of different locations. Those who could afford mobile
communication technologies could liberate their work from a geographically-bound location,
maximizing their temporal capital potential. Many scholars (Castells, 1996; Crang, 2007; Eriksen,
2001; Hassan, 2007; Mitchell, 1996; Sabelis, 2007) talk about the ways in which digital
technologies blur the lines between work and non-work time and increase the potential for
10 Several articles reported on this when the iPhone 5 first came out, but the travesty of the situation lies in the fact
that the homeless people who waited in line did not get paid (“Homeless People Hired To Wait In Line For New
iPhones At Pasadena Apple Store, Don’t Get Paid For It,” 2013; Moss, 2013). Moreover, as I alluded to in
Chapter 1, this practice is becoming the norm for new Apple product releases so much so that the app,
LineAngel, was created in order to mediate the process.
38
telecommuting where employees of a certain level can have the freedom to work from wherever
they would like, outside of the immediate control and purview of their boss.
However, one has to be able to afford and access this technology in order to reap the
benefits of its time-flexing capabilities, correlating the ability to control one’s time with a certain
level of privilege. While the bodies of the high-level professionals are not subjected to the
oppressive control of a supervisor, unskilled service workers have less ability for movement. They
are bound to the location where their work is, and no amount of mobile technology will allow
them to wait tables or provide home care to the elderly from a remote distance. Barbara
Ehrenreich (2001), who went undercover in the service industry to uncover the tension between
limited time and the need to make a living that working class citizens in America face, describes
the tight schedule waiters and hotel room cleaners have to keep in order to make enough money to
pay for rent and food. Often, tragically, the time unskilled workers have for breaks are
unreasonably short, and heavily policed by their supervisors, to the point where the natural
rhythms and biological bodily functions like voiding (urinating and defecating) submit to the
tyranny of the clock (Linder & Nygaard, 1998). These unskilled workers ostensibly have very
little amounts of temporal capital, given the conditions and demands of their occupation.
This claim that control over one’s time is indicative of class is also found, and is
sometimes more pronounced, in leisure. Leisure is time that is ostensibly not used to earn a
livelihood - it is time that is “left over after seeing to life’s basic needs” (Stebbins, 2012, p. 23).
Even in Ancient Greece, the pursuit of knowledge or truth was done in leisure, as the “thinker
engaged in this pursuit had to be free from the demands of securing a livelihood" (Stebbins, 2012,
p. 25). Thorstein Veblen (2007) outlines the ways in which industrialization gave rise to
conspicuous consumption and conspicuous leisure, and a leisure class - people who did not have
39
to worry about laboring for survival and had a surplus of wealth and time with which to conduct
leisurely activities. Being financially well-off, these individuals of the higher class could afford to
hire people to labor for them. Middle and lower class individuals who worked in the factories that
the higher class owned, freeing the higher classes to partake in leisurely activities with all that
free time and surplus of wealth that was being produced by the lower classes (whose time was not
as free with which to leisure). Indeed, “[m]anual labor, industry, whatever has to do directly with
the everyday work of getting a livelihood, is the exclusive occupation of the inferior class”
(Veblen, 2007, p. 8). Likewise, Witold Rybczynski (1991) simply says that “affluence is a pre-
requisite for leisure” (88). Stebbins also states that the act of leisure require that an individual’s
time is not occupied by activities that ensure survival, implying a surplus of resources or material
wealth. In fact, the split between work and leisure, and the utility of the “weekend” was unheard
of with the higher classes. The Dowager Countess of Grantham Downton Abbey, delightfully
played by the indomitable Maggie Smith, demonstrates this split between classes when she
questions what a “week-end” is, as she did not “work” and therefore, did not need a set time to be
“away” from work.
11
In this way, the construction of the weekend was a way of regulating and
structuring labor. Hence, we can see that, through the lens the ability to have leisure time, or the
ability to not distinguish leisure from work, the amount of time that would be considered under
one’s control, or more specifically, the amount of time during which one does not have to actively
labor for a supervisor or boss, is correlated with one’s position in society, and one’s access of a
surplus of resources.
11 Downton Abbey, Season 1, Episode 2
40
Even within leisure, control over one’s time is not always a given. Both Rybczynski and
Stebbins outline the rise of productive leisure, in which even leisurely activities need to have a
purpose. This mentality that time must be used for productive activities follows Max Weber’s
discussion of the Protestant work ethic in which not working was a “degradation of human life”
(Rybczynski, 1991: 22), and this mentality of productivity or “work” has transferred to leisure
time as well, thus making leisure another form or labor. Hence, the idea that “free” time had to be
productive was imposed upon the urban working class by middle class reformers in the nineteenth
century, lest the lower classes, with a surplus of wealth and time, would sink into base activities
such as drinking and wastefulness of time. This is in addition to the fact that leisure itself became
a capitalist industry that compels individuals to spend economic capital on leisure activities.
Although this form of control and disciplining of the lower classes was much less obvious, it is no
less potent in dictating, through the organization of time, the morals imposed upon the masses by
the elite.
Cultural capital also cuts through time and class as well. Bourdieu famously correlates
cultural capital, or the ability to have a distinct taste in culture that corresponds with “legitimate”
or “high” class, with educational and economic capital. But in addition to having the education to
41
appreciate and the money to access “high” culture, “building up cultural capital takes time”
(Wang, 2013). Individuals in the working class may not have time to learn how to appreciate
“high” culture, afford to go to the opera, seek out esoteric classical works of music, or choose to
go to an art museum. Rather, pop culture, with its ease of accessibility, ensures consumption with
less temporal investment, and allows those who do not have much time to discover and consume
it.
Contradictions of Time and Social Class
While it seems as though temporal capital, control over one's time, and the value of one's
time is correlated with social class, this is not always the case, especially when it comes to work
time. An individual with higher social status or a higher position within a company many not
actually correlate with higher amounts of temporal capital. The differentiation between exempt
and non-exempt workers provide a clear case in which one's control over one's time, and one's
purported flexibility during the work day is differentiated within an organizational hierarchy.
Generally, those higher up in a company are classified as exempt workers. These workers are
“usually exempt if they have more responsibilities than the average employee, and if they perform
tasks that are more managerial in nature” (Shoener, 2014). They are paid a fixed salary, regardless
of how many hours they work, as they are “exempt” from overtime pay requirements. Non-
exempt workers, in contrast, are paid in accordance to the number of hours worked, providing
them protection from potential exploitation and unpaid overtime. Given this model, it would stand
to reason that exempt workers have more flexibility and control over their time, as they are not
“on the clock,” and the mechanisms of time are not imposed upon their work activities.
Hence, temporal capital is not always correlated with one's position within the relevant
42
hierarchy and one's access to technology. Robert Levine quotes Sebastian de Grazia as stating,
“The more timesaving machinery there is, the more pressed a person is for time” (Levine, 1997,
p. 12). As I mentioned above, transportation provides a good example of this. The faster we can
get to a place, the faster we are expected to get there. Planes allow us to traverse the world in
hours, while cars drive take us further and faster than walking or biking does. Yet, in a tragedy of
commons sort of way, wherein the selfish use of socially shared resources – in this case, the
potential for speed enabled by access to technology – leads to the depletion of said resources
(Hardin, 1968), the more cars we have to potentially expand temporal capital, the more time we
spend in traffic, the more delays at the airport, the more gridlocked society becomes, and the less
time is actually saved, the less control we have over the time we spend waiting (Adam, 2006;
Castells, 1996; J. P. Robinson & Godbey, 1997). The same can be seen with the Internet, with its
increasing speeds and increasing amounts of information that ultimately results in more time
being spend consuming and filtering out information overload (Davidow, 2012).
Adam (2006) frames the relationship between time and money as one that is negatively
correlated. An individual is either time-rich, money-poor, or money-rich, time-poor. This
relationship seems intuitive enough. On a micro level, someone who is unemployed presumably
will have a lot of time on their hands, and a lot of control of that time on an hour to hour basis,
while CEOs at a corporations, or other high-level management executives, will likely spend a lot
of their time working - answering emails, keeping up with the “latest information regarding
competitors around the globe... traveling and teleconferencing on a continual basis” (Sabelis,
2007, p. 262). Sabelis goes on to state that a “paradoxical pattern arises from the accounts of these
executives: communication technologies have enabled them to acquire more contacts, but they are
then expected to maintain such contacts over time” (Sabelis, 2007, p. 263) and that the “intense
43
pace, the continuous striving for efficiency, acceleration of global competition, and the demand to
be online at all times are also colonizing the private lives of executives and managers" (Sabelis,
2007, p. 264). Hence, while a CEO or a high-level executive manager does not have someone
looking over his or her shoulder and cracking a whip, they may actually work longer hours,
giving the perception that they have diminished levels of temporal capital because of the work
they are compelled to do in order to keep their company afloat. However, taking the example of
the CEO, the temporal capital may be recuperated through the fact that they are more invested in
the company, and the work they do to keep the company afloat is likely personal and meaningful.
We will see this dynamic of temporal exchange for a meaningful life more in Chapter 6.
Manuel Castells gives a useful example of how similar amounts of time are contrasted
between groups of different classes: “[L]onger working hours are concentrated in two groups:
high-level professionals and unskilled service workers. The former, because of their value-making
contribution, the latter because of their weak bargaining power, often associated with immigrant
status or informal work arrangements” (Castells, 1996, sec. "The Shrinking and Twisting of Life
Working Time”, para. 3) Similar to Sabelis's allusion above, high-level professionals have
ownership of their capitalistic, corporate, or organizational pursuits, and their time is controlled
by the ebbs and flows of production and capital. Because they are able to afford the technology,
they can be reached at home, resulting in work penetrating into their private space and disrupting
otherwise “free” or leisure time.
Likewise, a medical doctor or a surgeon will likely make a lot of money, and holds a
prestigious place in society given his or her occupation, yet he or she rushes all day from patient
to patient, barely having the time to do anything else. Physicians are also often “on call” for
medical emergencies when they are not at work – meaning if a patient who needs emergency care
44
arrives at the hospital and needs that particular physicians' expertise, the physician must go into
the hospital to handle the situation, and this state of being “on call” is usually called taking “home
call”. As such, while physicians are “on call,” their time at home is intruded upon by pages from
the hospital that necessitates them to deal with emergency cases. What is stressful about “home
call” is that the physician is not technically working, but does not know whether or when he or
she will be called in, leading to an inability to schedule anything during their day, limiting their
options of things to do. This results in ultimately lower levels of temporal capital during times on
call, even if they end up not being called in, and have a lot of free time. This type of free time is
devoid of temporal capital, and devoid of any agency given to the individual.
Domestic workers also present an exception to the rule that temporal capital correlates
with class. While they are considered working class, as long as they have mobile communication,
during downtime while they are technically “on the clock,” they can chat with friends, watch
television, listen to the radio or music. Labor in the domestic domain and stay at home parents
often also complicate the seemingly apparent correlation between control of one’s time and class,
demonstrating that class cannot be the only variable with which to look at temporal capital.
Gender and social roles are major factors when considering temporal capital. Robinson &
Godbey (1997) found that when kids are involved, it is the mother’s schedule that changes the
most. In other words, regardless of class, the act of being a mother (a gendered social role that is
not monetarily compensated as labor) requires the sacrificing of temporal capital. There is a
socially accepted differentiation of temporal capital between genders given the norms of gender
roles that still manifest today. Arlie Russell Hochschild's (2003) book, The Second Shift, discusses
the different attitudes toward uncompensated housework that women do after their day in the
capitalist, compensated work sector, and how it affects their relationships and their mental well-
45
being. Hochschild found three categories of women according to their attitudes – traditional,
egalitarian, and transitional. Traditionally minded women identified with gender segregated roles,
and are content with their domain in a domestic space, while egalitarian women sought out more
equal dynamics within their marriages. The transitional woman is situated between the two
ideologies. Hochschild found that the working class and men preferred the traditional attitude
toward marriage and housework, whereas the middle class and women preferred the egalitarian
ideology. Indeed, this study illustrates that the attitudes toward temporal investment as an avenue
to economic gain differs between both gender and class. Indeed, segments of scholars and
feminist activists have seen this unpaid domestic labor as problematic. Selma James, the co-
founder of the International Wages for Housework Campaign, started the campaign in order to
raise awareness of the uncompensated labor and time that went into raising children and doing
housework that were mostly done by women (“Selma James,” n.d.), highlighting the importance
that unpaid labor, which exists outside of the public exchange of capital, has on the future
workforce. As such, labor in the domestic sphere confounds the simple correlation of temporal
capital and class status, as well as the exchange of temporal and economic capital, complicating it
by inserting gendered factors into the relationship of time and labor, and compelling a
consideration of the value of temporal exchange beyond a simple economic framework.
Despite these exceptions, and perhaps problematically so when it comes to valuable
unpaid domestic labor, the correlation between social status and temporal capital still holds true
on a broader level. Yes, the unemployed individual may be able to have a lot of time to do
whatever he or she would like to on an hour to hour basis, but his or her options of what to do are
severely limited by inadequate amounts of other forms of capital – namely, money. At some point,
that medical doctor or that CEO will have some free time, and the options that she has to do with
46
that time is greatly expanded because he or she has the resources to travel, or take a kick-boxing
class from an expensive gym, or go out to eat at a nice restaurant, or go to a Broadway show.
Likewise, the stay-at-home mother whose husband earns a high income, situating their entire
family in a relatively social stratum, can afford a nanny once in a while and do something for
herself.
12
Hence, while we are talking about whether or not the claim that temporal capital
correlates with class status holds true, we must also consider the unit of analysis that we are using.
Often, our use of time, and the value of our time is situated in a specific culture or a normative
framework. Thus, the definition of temporal capital necessarily changes as well.
The Acceleration of Society, the Tyranny of Speed
In June 2012, Tim Kreider published a piece in The New York Times called “The Busy
Trap,” in which he examines the ways in which people self-impose commitments upon
themselves in order to stay “busy.” He implies that busyness becomes “a kind of existential
reassurance,” that serves to ameliorate the fear that our lives are “silly or trivial or meaningless”
(Kreider, 2012). The impetus to be busy, or to call oneself “busy,” and the ways in which people
allow the ubiquitous access to mobile communication technologies and constant connection to co-
opt our time also seems to communicate power or class. Individuals lucky enough to partake in
that which mobile communication technologies have to offer no longer simply wait at the airport
or train stop, or for a friend in a coffee shop, or for the doctor. They can also answer emails, read
books on an e-book device like the Kindle, play online games, do work, watch movies or other
media - being productive in some way, and thereby perpetuating the feeling of "busyness," of
12 There is something here about the social norms of shared economic capital and temporal capital within familial
relations, which will not be adequately explored in this dissertation, but would make for a very interesting future
project.
47
always needing to get things done. The ability, or freedom to do nothing has effectively been
eradicated, with mobile communication technologies playing a big role in enabling this mentality
of productivity during interstitial time. Ironically, Kreider implies that the less time one has, the
more important one seems, giving off an aura of elitism in which social relations, leisure,
pleasure, and nothingness become subjugated to a logic of productivity. When someone creates a
busy, hectic schedule, the aura of busy-ness is not one that is imposed upon by an external force
necessarily, but is self-created. In that way, the level of temporal capital for these “busy” people
may not be low, as their lack of quantifiable time may be due to exchanging their time for
meaningful activity. Indeed, the ability to create “busyness” with one's time can be read as an
indication of higher levels of temporal capital, where the act of self-imposed productivity is one
of privilege and power. Productivity is no longer relegated to the realm of work, but also pervades
throughout aspects of our lives that are considered non-work, including leisure (Rybczynski,
1991; Stebbins, 2012), as mentioned earlier. Indeed, mobile technology has enabled productivity
to happen outside of the spaces and times that have traditionally been productive. Stratifications
between work and non-work are breaking down, and lines between the different categorizations of
time (and the purpose that time is for) are blurring (Castells, 1996; Crang, 2007; Eriksen, 2001;
Hassan & Purser, 2007; Mitchell, 1996).
While mobile has been the latest development that has paralleled a change in the temporal
pace of social life, technology has historically had an impact on how people perceive temporality.
The advent of the railroad allowed for both faster transfer of knowledge, information, and content
(Beniger, 1986; Gergen, 2000), and the acceleration of trade and commerce, and the rise of mass
marketing and advertising (Sivulka, 2012). Since the popularization of the telegraph and the
telephone, communication has been able to happen instantaneously with relative ease (Adam,
48
2006; Marvin, 1988; Standage, 1998), severely truncating a sense of duration and succession. In
the mobile and digital age, societal acceleration arguably has reached a zenith (Eriksen, 2001;
Hassan & Purser, 2007), with instantaneous communication happening over great distances with
relative ease, not only with audio signals and texts, but with images, videos, multimedia, social
interactions, and capitalistic transactions woven together in complex and powerful networks
(Castells, 1996).
Mobile communication technologies have liberated communication from geographical
space. As Mitchell says, “more and more of the instruments of human interaction, and of
production and consumption, were being miniaturized, dematerialized, and cut loose from fixed
locations” (Mitchell, 1996). There are now advanced tools of communicating and connecting right
in people's pockets. Because mobile technology does not tether the ability to communicate,
produce, consume, and find information to specific locations, there are rarely moments and spaces
in which an individual who has a mobile device is not connected to people, issues, and events that
are not proximal. individuals living in the network society, as Castells (1996) conceptualizes, now
live both in spaces of place, which follow a traditional logic to the organization of space and
adheres to geographical locations, and spaces of flow, which are spaces that are organized with a
networked logic, which may be separated from a geographical location. Spaces of flow are
possible due to the proliferation of mobile technologies and the Internet, in which people can
interact in a virtual space, outside of a fixed time and location, outside of physical presence.
People and information are accessible anywhere and everywhere, anytime and everytime. It has
changed the ways social relations are organized, and enabled a sort of “timeless time” (Castells,
1996) where communication exists outside of time, and there is “systematic perturbation in the
sequential order of the social practices performed in this context" (Castells, 1996, sec. “V”, para.
49
3). Ben Agger has stated that this networked time has eroded boundaries in order to promote a
“social order bent on denying people private space and time” (Agger, 2004, p. 4). There is no
delay in responding, no delay in communicating at a distance. With the proliferation of mobile
technology, there is no longer the need to even take time to find a computer anymore. People have
the ability to respond to emails with the little electronic box in our pockets known as a
smartphone. Mobile technologies, in conjunction with the Internet, have effectively sped up
society (Agger, 2004, 2007; Eriksen, 2001, 2007; Gleick, 1999; Hassan, 2009). More so, though,
mobile technologies have normalized this acceleration.
Many scholars (Agger, 2004, 2007; Eriksen, 2001; Gleick, 1999; Twenge, 2006; Wajcman,
2015) wonder (and fret) how constant connectivity through mobility, and the subsequent
acceleration of society affects people’s sense of selves, ability to reflect, and connections with
others. Ben Agger (2004) and Robert Hassan (2009) both address the ways in which digital
culture has accelerated society to unprecedented levels, quickening the pace of life “in order to
meet certain economic imperatives and to achieve social control” (Agger, 2004, p. 4).
Additionally, there is the expectation of speed. The culture of speed has become so normalized
that one has to continually purchase new technologies in order keep up the speed at which one is
expected to function. Speed serves capitalism well. Capitalism seeks to minimize “turnover time”
(Harvey, 1989, p. 229) in the cycles of production and consumption in order to increase
efficiency, leading to accumulation of more capital. The faster society runs, the faster production
happens, the faster the accumulation of capital. Thus, technology has enabled this social and
capitalistic acceleration by overcoming the spatial barriers associated with production, and
increasing the efficiency by which space for production is organized and used (Harvey, 1989).
50
Expectations of communication have shifted. Following Kenneth Gergen’s (2000) idea of
social saturation, people and societies are more connected than ever before, yet with the expanded
networks - people to talk to, media to consume, news to read, videos to watch - information
overload becomes an issue, given the real limits of absolute time (Eriksen, 2001). Time feels
compressed - the time available to spend on any one friend, or video, or piece of news feels as
though it has been decreased because of the plethora of options out there. Time is necessarily
compressed because time is the ultimate limited resource. Furthermore, the more the means of
acceleration in both speed and access of information are available, the more there is a potential for
gridlock, and delays, a contradiction many scholars acknowledge (Adam, 2006; Castells, 1996; de
Grazia, 1962; J. P. Robinson & Godbey, 1997). Take transportation for example. The more cars
there are out there, the more instances of bad traffic or gridlock occur, which actually slows down
travel time, whereas bikes, whose maximum potential speed is much less than a car, will zoom
past hundreds of cars stuck in rush hour traffic.
13
Even air traffic nowadays is getting congested,
causing delays in flying times in and out of major cities (McCartney, 2009). Travel times aside,
new technologies help manage increasingly saturated social networks and the information
overload that has come with the digital age, and yet, it becomes a bit of a zero-sum game, as the
faster people are able to process information and communicate with people, the more they are
expected to do.
Interstitiality and Waiting
The norms about temporality and time as resource that has been encoded into society teach
people (of a certain position in the social strata) that their time is valuable, and should not be
13 During a 3.1 mile commute that took him 15 minutes, a bicyclist passed over 600 cars (Gallegos, 2013).
51
wasted. Given this assumption about the ways in which time is perceived, interstitial time, time
spent waiting, or otherwise “unoccupied” time (Stone, 2012) presents an interesting site to look at
the emotional dimension of temporal capital. During times of waiting, people have arguably very
low levels of control over their time, and the uncertainty that accompanies waiting, even for the
few minutes one waits in a grocery market line is often associated with higher levels of stress and
“torture” (Stone, 2012). These exemplify moments of decreased temporal capital. Waiting
individuals are often physically restricted to a place, unable to step away, in case the thing (or
person) that they are waiting for happens (or arrives). I would also argue that it is when during
waiting that time feels most tangibly like it is slipping away, and those who wait experience most
sharply the aggravations and frustrations of "wasted" time. Mobile devices potentially help
ameliorate this anxiety transit applications, allowing the individual some relief to the
“wastefulness” of waiting. Hence, it is a tool that can potentially recuperate temporal capital and
some sense of control when individuals are in a state where their time is utterly colonized by an
external force by allowing people to be productive in some form.
Interstitial time falls roughly under two categories: Stationary waiting times (temporal -
where one waits in one location) and transit times (spatial - where one's location is actively
shifting away from an origin and toward a destination). For both kinds of interstitial time, when it
comes to a sense of time and temporality, there can be expected/certain waiting time (scheduled),
unexpected/uncertain waiting time (delays, surgeries, things outside of one's temporal control),
and semi-expected/certain waiting times (queues and lines - when one can see where the end is,
but can also see all of the people who need to be processed before). Waiting is not a time of
empowerment. After all, the person who waits relies on an external factor, be it another person, a
process, or simply the passage of time, to put an end to the wait. Many psychological studies have
52
found a "strong link between uncertainty and anxiety" (Cavanaugh & Sweeny, 2012),
demonstrating that lower levels of temporal capital is associated with negative feelings and
emotional attributes.
In recent years, with the wide proliferation of mobile communication technologies in
developed societies, the act of waiting has been infused with the compulsion to pull out one’s
mobile device and immerse oneself in the plethora of activities enabled by ubiquitous
connection. James Katz & Mark Aakhus (2004) point to the impulse to be productive during times
of waiting, using mobile communication technologies to “harness spare time...to plan and
coordinate with others, get information or messages” (2), especially for “those who feel they are
not accomplishing enough” (2). The authors imply a compulsion for individuals (especially those
who can afford mobile communication technologies) to be productive while they can, and mobile
technologies maximize these moments of productivity. Hence, mobile devices have the potential
to ameliorate the frustration and uncertainty of waiting. It enables users to be "productive" during
interstitial times, either through doing work on-the-go (answering emails or making phone calls)
and maintaining economic and social capital, or filling the time with entertainment (like playing
games, watching videos, perusing social media sites) to obtain cultural and social capital.
Moreover, mobile applications geared toward easing transportation processes that help users
determine the amount of wait time or the amount of transit time manages expectations of waiting,
giving people a way to temporally map out their day. The ability to expect how long interstitial
time will last, and to better schedule one's day, potentially ameliorates the feeling of helplessness
and waste while waiting, giving us the illusion of control over time, even when time is co-opted in
ways that cannot be helped.
Time and temporality are major factors in both the rational organization and the affective
53
aspects of our lives. Much scholarship has been done to examine how time intersects with
sociocultural and economic structures and understandings. From here, I hone in on health care as
a site of inquiry and turn to a discussion of the issues plaguing the health care system where a
discussion of temporality is productive to understanding the underlying structures of power and
institutional impositions at play. These are issues that I address throughout the dissertation and
place in conversation with theories of temporality in order to demonstrate the usefulness of
temporal capital in thinking through and framing uneven instances of agency and differential
power within the practice of health care.
The State of the US Health Care System
The health care in the US, like most aspects of a capitalist society, is framed heavily
within temporal rhythms, both influenced by capitalistic purposes as well as the whims of
individuals on both institutional and individual levels. Indeed, how temporal constraints impact
the practice of medicine and the access to care cuts across all aspects of medicine, from the micro-
level of temporality of the day to day interactions between practitioners, and between practitioners
and patients, to the struggles of scheduling clinic, rotations, call, and surgeries, to the macro-level
of time spent in training that spans years, to a career that spans decades. Since the implementation
of the Affordable Care Act, the US Health care system has undergone tremendous overhauls that
affect everything from insurance reimbursements, to the delivery of patient care, to the workload
that health care systems and practitioners are experiencing on an everyday basis.
There are several issues currently affecting the health care system that either directly or
indirectly intertwined with the temporal rhythm and temporal capital in the lives of practitioners -
1) the shift to patient-centric care through policy and legislation changes, particularly with the
54
changes to Medicare and Medicaid reimbursements, and the implementation of the Affordable
Care Act, 2) a projected shortage of physicians, and the challenges in primary care due to the
shortage 3) the high cost of training on both temporal and monetary levels, and 4) high rates of
burnout and depression amongst health professionals, particularly physicians.
14
Let us take a
moment to look at each of these challenges.
The way health care has been delivered has changed drastically over the last few decades.
Going from a provider-centric model to an increasingly patient-centric method of care, providers
have had to adjust the ways in which they provide care to an aging population in a changing
health care system. With Medicare and Medicaid reimbursements under the new health care
reform resulting in decreased reimbursement rates for physicians in 2015 (Matthews, 2015),
maximizing reimbursements have become a priority, which often includes paying more attention
to patient experience. Hospitals in particular have had to take steps to protect their revenue stream
by improving their patient experience in order to boost patient satisfaction scores, officially
known as the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS)
survey (Letourneau, 2014), as greater percentages of Medicare reimbursements for hospitals are
now based on these patient satisfaction scores (Guadagnino, 2012). This is all despite the fact that
studies have shown higher patient satisfaction scores, while associated with lower emergency
room use, are correlated with higher incidents of complications and morbidity,
15
higher costs of
care, and greater prescription drug expenditures (Fenton et al., 2012). Fenton et al suggest that
this may be due to “patients bring[ing] expectations to medical encounters, often making specific
requests of physicians, and satisfaction correlates with the extent to which physicians fulfill their
14 Pamela Wible is particularly outspoken about this issue, with her articles regularly reaching the front page of
KevinMD, one of the most widely read blogs dedicated to the perspective of physicians.
15 The study followed respondents for two years – taking Year 1 of patient satisfaction scores and comparing them
to Year 2 of health care utilization.
55
patient expectations” (407), with patients taking cues from WebMD or Dr. Google. Alarmingly,
but perhaps not surprisingly, a study done in BMJ in 2015 found self-diagnosis through symptom
checkers found on the Internet to not be sound practice.
16
This does not, however, prevent patients
from taking what they find on the Internet, accurate of not, developing expectations for their visit
to the physician, and being dissatisfied with their care if their physician disagrees with their
Internet diagnosis. Hence, we then see a situation where good care and diagnosis is potentially
compromised through the priority of wanting to satisfy the patient, especially when physician
compensation is tied closely to those scores.
Such an emphasis on patient
satisfaction scores also dangerously leads to
over overprescribing medication and
overtreatment (Sibert, 2014), which drives up
the cost of health care without ensuring the
type of care that is best for the patient.
17
While
patient-focused care is should be a priority for
the health care industry, patient-centric care
places undue emphasis on patient care as
customer service. While it is important to acknowledge that the health care industry is a business,
do the economic necessities of the system compromise the quality of patient care?
16 The Harvard Gazette nicely summarizes the findings (Miller, 2015) of a study published in BMJ (Semigran,
Linder, Gidengil, & Mehrotra, 2015) that measured the diagnostic and triage accuracy (meaning, what condition
or disease symptoms point to, as well as how urgent they are) of symptom checkers that can be found online, and
found that the rates of accuracy were only around half, or less than half.
17 This is an ongoing concern in the health care field (Murphy, n.d.), as the previously mentioned Fenton et al
(2012) study on patient satisfaction scores being correlated with higher rates of complications, morbidity, and
prescription drug expenditure.
56
In addition to the pressures placed on the hospital system by the health care reform and
changes to reimbursements, we are seeing shortages of physicians and nurses that will only
exacerbate in the coming years. The Association of American Medical Colleges (AAMC) projects
a shortage of up to 90,000 physicians by the year 2025 (Physician Supply and Demand Through
2025: Key Findings, 2015), while the American Association of Colleges of Nursing (AACN) cites
a study (Buerhaus, Auerbach, & Staiger, 2009) that predicts a shortage of 260,000 registered
nurses by the year 2025 (Rosseter, 2014b). While there is a greater projected number of physician
specialists in the coming years, it is the shortage of primary care that will most greatly impact the
overall health of the public and cost of health care. Both the American College of Physicians

(Zerehi, 2008) the AACN describe a perfect storm of an aging population, practitioners retiring
from the profession, and a resulting decrease of resources to meet the demand for health care.
Primary care, at the front line of health care, is the first contact for patients entering the system,
and is key in providing continuity of care, as well as comprehensive and coordinate care. Access
to primary care will allow for detection of diseases and conditions and help the patient get
treatment before a condition or disease becomes acute and dire, at which point, costs of health
care increase drastically (Joynt, Gawande, Orav, & Jha, 2013). While I discuss the reasons for
overspecialization at the expense of primary care in depth in later chapters, the main reasons that
physicians choose to specialize rather than go into primary care practice have to do with the
disparity in the return on investment for the years put into training to become a physician,
regardless of specialty. Primary care physicians are paid an average annual salary of $195,000,
while medical or surgical specialists have an average annual income of $284,000 (Peckham,
2015a). As the temporal and monetary investments to becoming a physician are substantial (with
long years of training and hundreds of thousands of dollars in student loans), as we will see later,
57
the decision to enter primary care or a medical specialty is subsequently impacted.
Physicians, out of all clinical professions in the health care field, spend the most number
of years in formal training. After four years to earn an undergraduate degree and taking set
prerequisites that include general chemistry, organic chemistry, biological sciences, mathematics,
and humanities, aspiring doctors attend four years of medical school. Sometimes, medical
students take a year between their third and fourth years of medical school to earn another
graduate degree or conduct a research project in the specialty of their interest. After earning a
medical degree (MD or DO – allopathic or osteopathic doctors, respectively), fledgling doctors
undergo an additional 3-6 years of training, called “residency”, for their practice specialty, with
internal medicine residents doing 3 years of residency, and some surgical specialties requiring 5 or
6 years of post-graduate training, in order to be board certified. Following the residency, if a
physician wishes to subspecialize in their field, they often complete a fellowship of 1-3 years
before they are able to enter into private practice, or practice independently without supervision as
an attending physician as a part of a teaching hospital.
In contrast, professionals in the nursing field - registered nurses and nurse practitioners
require fewer years of training. A registered nurse (RN) is required to take nursing prerequisites,
which amount to about one year of school, before entering nursing school. The number of RNs
have completed an Associates Degree in Nursing as an initial degree is the highest amongst prac-
ticing nurses (45.4%), which encompasses the least amount of education necessary to become a
registered nurse. Other nurses have a Bachelor of Science in Nursing (BSN) as an initial degree
(34.2%), which requires an undergraduate degree in nursing (Ashford, 2011). There are acceler-
ated BSN programs in which an individual can earn a BSN in one year, given that they already
have a bachelor's degree. A Master of Science in Nursing, which one needs if one wishes to be a
58
Nurse Practitioner, requires a Bachelor's degree and a 2-3 year program.
18
Despite the fewer total
years spent directly in training, though, as we will see in Chapter 6, there is much more uncer-
tainty for nurses, as nursing schools are impacted, with many more aspiring nursing students than
there are spaces.
The years spent in training have a major impact on an individual's temporal capital in
terms of months and years, rather than minutes and seconds, demonstrating that temporal capital
is not only a Marxist notion of labor time translated into capital, but infiltrates all levels of one's
temporal considerations. Considerations of what sort of return on investment for time and money
spent in training, as well as future-facing factors like lifestyle, flexibility, and earning potential all
play into the decisions that an individual makes in choosing to go into a career and/or a specialty.
This will be explored to a greater extent in Chapter 6.
Finally, as alluded to earlier, physician and nursing burnout is an ongoing conversation
that has substantial research behind it, but not many viable solutions. Bodenheimer and Sinsky
(2014) take on the Triple Aim of medical practice - “enhancing patient experience, improving
population health, and reducing costs – [as the] widely accepted...compass to optimize health
system performance” (573) as not taking into account the challenges that physicians face,
proposing a “Quadruple Aim” that includes “improving the work life of health care providers”
(573). They cite physician burnout and dissatisfaction as factors associated with increased costs
and worse health outcomes.
There has been extensive research done on the effect of work hours and burnout of health
care professionals. In 2001, a survey was done on 4510 obstetric-gynocological medical residents
which showed that the majority of these residents were working long hours, which entailed over
18 Nursing professors are required to have both a BSN and an MSN, at least in California.
59
60 hours a week and “sleeping less than 3 hours per night while on night call” (Defoe et al., 2001,
p. 1015). Medscape found that working too many hours was the second most common cause of
burnout amongst physicians, whereas the “strongest predictor of work-life balance and burnout
was having control over their schedule and the hours they worked” (Peckham, 2015b). To
translate it into the framework that is used throughout this dissertation, the amount of temporal
capital one has seems to be a predictor of satisfaction and well-being, which has great
implications on how temporal capital is related to quality of life to an extent that may be greater
than the economic benefits and monetary compensation of time spent.
Economic factors, of course, directly related to temporal rhythms of medical practice still
have substantial impact on the well-being of health practitioners. Stingy Medicare
reimbursements and an over-reliance on revenue value units (RVUs) for physician compensation,
a form of measurement for procedures which allows physicians to bill patients and insurance
companies based on the complexity of the procedure provided, give way to an impetus to
accelerate the turnover of capital. Nowadays, more patients need to be seen in order to garner the
same economic capital than before. More patients equals more compensation, which allows a
private clinic to stay open, or to keep a practitioner in the good graces of the health care system by
which she is employed. Even when the practitioner does not directly reap the economic benefits
of seeing more patients, the culture is often that of an accelerated process. For example,
ophthalmology residents that I spoke to throughout the course of my research often see their
reputations measured by their ability to see a certain number of patients in a certain amount of
time. This results in the resident realizing they only have a few minutes per patient. One resident
in particular expressed frustration at the fact that she does not have enough time with patients to
talk to them about preventative care that will ensure healthy eyes and prevent these patients from
60
returning the hospital with eye problems. This acceleration of capital, as we will see in the
following chapters, compels practitioners to discipline their bodies temporally in a way that
interpellates them into this capitalist logic, often out of necessity rather than desire.
Breakdown of Physician Roles
Physicians represent a very diverse population of health care professionals in terms of the
number of specialties into which someone with a medical degree (MD) can enter after medical
school. Each specialty varies in time spent training, average income, and difficulty obtaining resi-
dency. Some specialties are more competitive than others. Some specialties offer a better lifestyle
– time for family and non-work activities,
19
while others pay very well but have long hours. Spe-
cialties also have varying lengths of training. For example, internal medicine and family practice
doctors complete residency in 3 years, whereas surgical residents complete four or more years of
training before practicing. As this dissertation is heavily comprised of the experiences of physi-
cians at various levels of training, it is helpful to give readers a rundown of the different roles that
they will encounter throughout.
19 Most famously the ROAD to Happiness – the specialties that have the best income and work/life balance –
Radiology, Ophthalmology, Anesthesiology, and Dermatology. More recently, Emergency Medicine was added to
the list, making it the “E-ROAD to Happiness” (surely also inspired by our electronic age)
61
Medical students comprise the very bottom of the physician food chain. These are students
who have completed college and are (usually) in their third or fourth year of medical school. They
cannot do much clinically, as they have not received their medical degrees, and are supervised by
the interns and residents. Their role is more one of observation and learning than of practice, yet
they must abide by the temporal rhythms set in place by the institution (in regards to when they
are required to be in the hospital, and the order of their rotations) and their supervisors.
Interns are physicians who have received their medical degree, and are in their first year of
residency. Internship generally only lasts one year after medical school, and is also known as
Post-Graduate Year 1 (PGY-1). In this dissertation, there is not much of a significant difference
between interns and medical residents. Many physicians who specialize will do an intern year that
is in either general medicine or general surgery, and may not be directly related to their specialty.
62
For example, an anesthesiologist is required to take a one-year internship in either general
medicine or general surgery (their choice), but the internship has little to do with anesthesiology.
For some of my informants, their PGY-1 was under the internal medicine department, and then
they would switch over to their specialty department after intern year.
Medical residents are physicians who have finished their intern year and are clinically
training in their medical specialty. Residency, which lasts anywhere from 3-7 years, depending on
the specialty, is often considered one of the most difficult times of a physician's training period,
save fellowship, which is not regulated by the duty hour restrictions that were put in place to ame-
liorate the grueling process of residency. Residents are supervised by their senior residents (resi-
dents who have completed more years of training), fellows, and attending physicians. These indi-
viduals' temporal rhythms are highly regimented. While their career path all but promises a high
salary at the end of their training, residents are not necessarily well compensated for their work.
Salaries for residents have not increased in the last 40 years (Peckham, 2014), and many medical
residents are saddled with debt from medical school, which almost forces them into a sort of in-
dentured servitude for a few years before they are able to liberate themselves with increased eco-
nomic health and social status, and their temporal investment in training paying off in the long
run. Still, residency is often thought of as the most challenging part of the journey toward becom-
ing a physician.
Fellowship, which is done after the completion of residency, is optional for most
specialties. Doing a fellowship allows a physician to subspecialize in their specialty. For example,
an anesthesiologist who has completed a comprehensive anesthesiology residency can opt to
complete a fellowship subspecializing in cardiothroacic anesthesiology, or an internal medicine
physician can subspecialize in hemotology/oncology or rheumotology, or any number of
63
subspecialties. Fellows in some programs potentially have even less temporal capital than
residents, though. Many fellowship programs (ophthalmology sub-specialties, for example) are
not accredited by the Accreditation Council for Graduate Medical Education (ACGME), which
would subject the fellowship to duty hours and billing regulations.
20
Such regulation, as Craig, an
opthalmology fellow, states in his interview (“Craig”, personal interview, February 9, 2015),
prevents fellows from being overworked, which is not an advantage to the department, as fellows
are legally attendings and can oversee the work of residents as well as attend surgical procedures,
which frees up the responsibilities of attendings, at least on paper. Hence, while not all
departments have fellows, those that do generally supervise residents along with the attendings.
At the same time, fellows work closely with attendings and are technically supervised by
attendings.
Attending physicians (also known as “attendings”) are at the top of the food chain, so to
speak. They are fully practicing physicians that function autonomously with little to no oversight
by any one individual. In teaching institutions, they are the practitioners ultimately responsible for
the care of each patient, even though the actual patient care work may be done by fellows,
residents, and intern. As will be discussed in further depth in Chapter 3, attendings also enjoy the
greatest flexibility of time and highest levels of temporal capital, thanks to the interchangeability
of their duties with residents and fellows under their supervision, as well as their ability to convert
their time spent at work into generous compensation.
Finally, nurses are in a different training hierarchy, and do not report directly to
physicians. In this dissertation, I do not make much of a functional distinction between different
20 There are hot debates over whether or not ophthalmology fellowships should be accredited and overseen by
ACGME. In 2004, the American Academy of Ophthalmology opposed the proposal that the subspecialty of
Ocularplastic and Reconstructive Surgery should be accredited (Frohman & Digre, 2004).
64
types of nurses such as nurse practitioners versus registered nurses versus nursing assistants in
terms of their relationship to physicians in discussions of the temporality of patient care. Temporal
capital as it relates to nursing will be discussed in Chapter 6 in terms of how their training
processes varies from the physician training process. As we will see, though, the cultural norms of
the hospital subliminally dictate that nurses cede control of their time to physicians' temporal
rhythms and schedules.
There is a fundamental difference between residents and attendings. Residency itself is
inherently temporary. The purpose of it is to transition medical students, and train them to
become, attendings and autonomously functioning physicians. Attendings, while necessarily
dealing with their own power struggles within their ranks, do not have roles that drastically
change from year to year. Once someone becomes an attending, there is no longer a “next step,”
so to speak. In a way, the temporality of residents is linear, going from first year of residency to
second year, to third year and beyond (depending on specialty), to graduating residency, to
subspecialty fellowship, then ultimately a position as an attending in an academic institution or
private practice. However, there is still a functional hierarchy at any given moment in the daily
routines of residents and attendings. Chapter 3 treats residents and attendings as being on the
same hierarchical line, examining instantiations of power dynamics along the health institution
hierarchy, making few distinction between the temporariness or permanence of their positions,
while Chapter 6 considers the differences in mentality, and how that impacts the temporality, of
residents and attendings framed within a broader time line.
65
Temporal Differentiations in Patient Interactions
From a patient's perspective, waiting to see a doctor is often one of the most frustrating as-
pects of health care. Not only are one's emotions heightened, as few people wait in waiting rooms
unless something out of the ordinary (and usually bad) is occurring, but waiting itself has often
been discussed as an unpleasant and unwanted stretch of time, as mentioned previously. Indeed,
some priorities for hospitals include increasing efficiency in terms of patient care and transfers,
decreasing length of hospital stay, and de-impacting the emergency room (ER).
21
The overcrowd-
ing of ER's is a particularly irksome problem that has a major temporal component as well as a
psychological one. The Center for Health Design conducted a study in 2011 to see if visual art re-
duces stress and anxiety for patients waiting in two Emergency Rooms of hospitals in Houston.
They found that adding visual art in these waiting rooms decreased restless and anxious behavior
at both sites (Nanda, 2011).
Waiting times are a symptom of scheduling techniques used that vary given the patient
population that is served. The differentiation in the socioeconomic class of patients not only have
a bearing on patients' temporal capital, but on the practitioners' as well. Studies have found that
that “[h]ospitals in areas with large minority populations are more likely to be overcrowded and to
divert ambulances, delaying timely emergency care” (Fernandez, 2012). There is even a web-
based application called the “ER Wait Watcher”
22
that will calculate the wait times in the ER for
nearby hospitals. Hence, decreasing waiting time in hospitals, or at the very least, making the ex-
perience of waiting as torture-less as possible, stems from the acknowledgment that the act wait-
ing is almost universally unpleasant. These wait times only serve to add pressure to practitioners
21 The first two priorities were communicated to me by an executive administrator at a private hospital (one that is
part of a larger health system) in Southern California. The de-impaction of the ER has been a goal for hospitals,
particularly county medical centers, for many years.
22 Found at this web address: http://projects.propublica.org/emergency/
66
as well, since, for the most part, practitioners will stay at work as long as there are patients to be
seen. The temporal rhythm of the day, the wait times for patients, and the perceived lack of tem-
poral autonomy are symptoms of the institutional imposition of how the schedule patients, which
vary between different types of hospitals. A private hospital with a clientele of higher socioeco-
nomic status puts more effort into valuing their patients' time than a county hospital which serves
a large minority and uninsured population. In the major teaching hospital system in Southern Cal-
ifornia that is the site of my research, informants tell me that ophthalmology clinics in County
Medical Center, which sees predominantly lower socioeconomic status and uninsure patients,
schedule multiple patients per time slot, with the assumption that a large percentage of scheduled
patients will not show up, while the main University Medical Center's Eye Clinic, a private facil-
ity with mostly insured patients, clinic schedules one patient per every 15 minute slot. Such a
move reifies the different valuing of time on an institutional level for individuals who occupy dif-
ferent rungs on a social hierarchy on an institutional level. Ironically, it is those whose time is val-
ued the least (ie: County Medical Center patients) who can least afford to spend precious temporal
capital waiting in the doctor's office, since that time waiting translates into lost income for the
day. The most vulnerable populations are the ones who are least able to protect their temporal cap-
ital in these situations due to institutionally imposed rules of scheduling, which reflect a devaluing
of their time.
Conclusion
Temporal tensions come to bear on health professionals in two ways – from other individ-
uals, and from the institution. For the most part, institutions win out in terms of commanding the
temporal rhythms of individuals through an impetus to generate capital, but individuals find ways
67
of resisting, subverting, and negotiating institutionally-imposed temporal patterns, or simply let-
ting them not work in practice. For example, a clinic may have a rule that schedules more patients
than a physician can realistically see given the allotted time. The schedule will simply have to run
late, but the physician may employ methods – using “dead” waiting time to complete other tasks,
or take more time documenting patient information after work hours, for example – to keep the
schedule on track. These are often done, however, at the expense of either the quality of patient
care, or the well-being of the physician. Hence, through the imposition of structures of temporali-
ties both from the institution and from one's position within the social and/or organizational hier-
archy, health care professionals are disciplined in a way so that their actions and behaviors are re-
duced to logics of productivity that determine and are determined by temporal capital both at and
away from work, ranging from micro-temporalities of the day to day, to macro-temporalities over
years and decades. And yet, there are spaces and instances of negotiation to recoup a sense of
agency by resisting or subverting the authority of institutional rules through cultural practices that
are not overtly sanctioned by the system.
68
Chapter 3: A Day in the Life
The alarm clock goes off at 6:00am, and Martha, a second year ophthalmology resident at the
University Medical Center Health System,
23
jumps out of bed. She takes 10-15 minutes walking
her dog, then gets dressed, microwaves some leftover pizza and eats it, sitting in the dim light of
her living room, while checking Facebook. At 6:30, she hops in her car and drives to the
University Medical Center-affiliated County Medical Center.
24
Once there, her entire day consists
of seeing patient after patient in the outpatient clinic, often up to 40 patients per day. Today,
because the clinic is too busy, she forgoes lunch, preferring to see as many patients as she can.
The new electronic medical record system slows her flow down considerably, since she and the
other physicians and staff members are still getting used to it. Her attending physician berates
her for not seeing patients quickly enough. Finally, the end of the day draws near. Although clinic
ends at 4:00pm every day, it is now 6:30pm, and she is seeing her last patients. These patients
have been waiting about 3 hours to be seen. After she finishes seeing patients, she stays behind to
finish up paperwork. Then, because she is on call that night, she makes a trip to the Emergency
Room (ER) to make sure that any patient who has an eye issue can be taken care of while she is
still on site, lest they call her back into the hospital in a couple hours. Finally, at 8:30pm, hungry,
dehydrated, and exhausted, she drives the 20 miles back home. Once she is home, walks her dog
again, then watches a video of the procedure that she will be doing in the morning while scarfing
down fast food that she picked up on the way. She falls into bed and immediately dozes off around
10pm, wanting to get as much sleep as possible before possibly being waken up by her pager,
which she keeps on her nightstand right next to her bed. She receives a call at 3:00am from an
Emergency Room resident who has a patient with a minor eye infection. She tells the ER resident
to ask the patient to come into the clinic the next day. She falls back asleep for another 3 hours
before her alarm goes off, kicking off another similar day.
23 All names and organizations have been changed to preserve anonymity.
24 University Medical Center has two affiliated County Medical Centers, which will be designated “County Medical
Center 1” and “County Medical Center 2” throughout. The two are interchangeable, and their differentiation is to
demonstrate the broad range of facilities that physicians in this health system must juggle.
69
The daily time constraints are arguably the most felt temporal tensions within a person's
day. From the moment we wake up to when we fall asleep, we cannot escape the steady march of
time from sunrise to sunset, from getting into work and counting down the minutes until we can
leave, go home, go to sleep, just to do it all over again the next day. Many scholars have noted
that, in the developed, Western world, time is perceived as a linear progression, with a definitive
past, present, and future, while many non-Western cultures see time as cyclical (Levine, 1997;
Zerubavel, 1985). The time framed within a day, within the limited 24 hours, is a fundamental
measure of this cyclity. It is only when we frame our thoughts within one day that we start to take
note of the hours and minutes that make up the time between wake and sleep. It is in the hours
and minutes that time as an exchangeable resource is concretized, standardized, and measured.
Marx famously conceptualized “labour-time” in which the modes of production in a capitalized
system are measured by how much time an individual works. The individual is then paid
according to how long he labors for a supervisor or institution – an entity that occupies a position
of higher power. At the same time, the value of said time is correlated with one's position in the
social or organizational hierarchy, thus implying a relationship between the power structures
within society and the usage and value of time.
In this chapter, I explore how the colonization, or control, of time on a micro-temporal
level (minutes, hours, and days) works on two levels. On the individual level, the time of people
lower on the hierarchy in health care is colonized by either those in a higher position of power. On
the institutional level, time is co-opted by the institution of health care itself, and its schedules,
processes, laws, policies, and rituals. The institutional co-option of time is framed within a
capitalist context where a practitioner's time is exchanged in the labor of seeing patients and
ostensibly increasing economic capital for both the institution itself and the individual
70
practitioner. In this way, the bodies of the practitioners are disciplined
25
to function to serve a
capitalist mindset and purpose, and interpellated into a temporal rhythm governed by the
institution.
In today's corporatized world, time is a ubiquitous and relatively invisible notion.
Employees are full-time or part-time, with the norm that a full-time job is approximately 40 hours
per week, regardless of if the employee is salaried or hourly. Full-time equivalents (FTE), then, is
a measurement of the number of service hours (1 FTE = 40 service hours) that a corporation or
organization provides for which there is no monetary compensation. For example, I used to run an
unpaid hospital volunteer/internship program for a health care organization. To the hospital
executives of hospitals in which we ran the program, we would report the total number of hours
our interns volunteered to demonstrate the monetary value of their timed labor. For instance, let us
say that we had a hospital with 200 interns that volunteered a total of 1300 hours in the first week
of April. We would then divide 1300 hours by 40 (hours per week for a full-time employee) to
yield 32.5, and the unit “FTE” would be assigned to that number. So we would say to the hospital,
“For the first month of April, we provided 32.5 FTEs, or the equivalent of over 32 full-time
employees, in our services to your hospital. These 32 full-time employees would normally cost
you around $33 an hour,
26
or $1,320 per week”, thus assigning a monetary value to the service
time that our volunteers completed. FTEs are also used to calculate the number of hours for
activities or temporal commitment against the arbitrary number of hours an employee is
25 Foucault is known for his pontifications on how individuals discipline their bodies to fit certain institutional
expectations. He uses the army as an example of an obvious disciplining of bodies. However, his concept of the
Panopticon, which functions as an invisible force that compels self-surveillance due to the uncertainly of whether
or not the Powers That Be are watching at any given moment, thereby disciplining bodies to the logic of
institutional power that is oftentimes invisible yet omnipresent (Foucault, 1975). In the case of this dissertation,
practitioners are not only being disciplined to the expectations of the health system, but to the temporal logics
that govern the patterns and cycles of capitalism.
26 The average nursing salary per year in 2013 was $68,910, according to the Bureau of Labor Statistics
(“Registered Nurse Salary and Wages by State,” 2013).
71
considered full time (40 hours per week). Even in graduate school, teaching or research assistant
assignments are calculated as 25% or 50% assignments, signifying what percentage of a full-time
job that particular assignment should take. For example, a 25% teaching assistant assignment
should take on average 10 hours of work per week, even though the actual pay itself is rarely
measured by how many hours actually worked. Lawyers similarly concern themselves with
billable hours, broken down by the quarter-hour, and inflating these billable hours in order to
increase their income has become a widespread issue (Rotunda, 2014). The inflation of billable
hours points to an interesting trend wherein the value of time in terms of money oftentimes does
not collude with the actual clocktime hours spent on a certain activity,
27
yet the fact that time is
used as a monetary measure indicates an underlying assumption of time as capitalistically
valuable.
Needless to say, not all salaries are based strictly on number of hours worked. Exempt
employees are salaried annually, rather than hourly. This difference is important, and betrays an
underlying notion of how time for different people in different positions of a hierarchy are valued.
It also subliminally signals that some work (salaried) is more meaningful than others (hourly), as
salaried work is not bound by the clock, and tends not to be scrutinized by one's boss, but rather
seeps into other aspects of that employee's life. A CEO is arguably always working and never
officially “off the clock.” This is a similar dynamic as with graduate students, who work on their
own time and have great flexibilities in their schedule, yet are constantly thinking about their
work or their research. In the health care system, the use and control over time – both one's own
27 While such a statement may open a can of worms by questioning what exactly would constitute a moral standard
of billable hours, or work hours – after all, most people likely take a few minutes out of their workday to
daydream, check their phone, return a text, this particular line of questioning is outside the scope of this
dissertation. I merely mean to point out that time as a monetary measure does not always correlate with the actual
passage of time.
72
time, and others' time, imply, reinforce, inform and are informed by the power dynamics that
occur between individuals, and between individual and institution. Distinctions of temporal
capital between professional groups and members in different positions on the hierarchy are
subtle, but present, and the control of time is often subliminally used to communicate and
reinforce structural power hierarchies.
The general consensus for health practitioners is that their work days are long and often
hectic. Once at home, there is precious little time to do leisurely activities. Physicians,
particularly, are often on-call on nights and weekends, which limits what they can do. This takes a
drastic toll on their well-being.
28
In 2011, the Accreditation Council for Graduate Medical
Education (ACGME) issued a new policy limiting residents' duty hours to an average of 80 hours
per week over a 4 week period. While there was little effect of the limiting of duty hours on the
quality of patient care or the outcome of board exams,
29
such a move on the part of a governing
body in medical education is a start to recognizing time as a factor in the processes of health care,
especially as one of its main purposes for implementation is to inoculate against chronic sleep
loss.
This chapter, consisting heavily of interviews conducted of physicians and nursing staff in
a hospital or clinic setting, explores the daily dynamics of temporality within the lives of health
practitioners, from the point of view of health practitioners. In particular, I look at the dynamics of
communication and power through the lens of time and temporality on a micro-temporal scale
28 Pamela Wible is a leading voice on bringing high rates of physician suicide and depression into the spotlight
(Wible, 2014). Her more colloquial work reflects the patterns of depression and burnout physicians and nurses
encounter in more scholarly work that has been previously mentioned (Anderson, 2015; Defoe, Power, Holzman,
Carpentieri, & Schulkin, 2001; Keeton, Fenner, Johnson, & Hayward, 2007; McHugh et al., 2011; Peckham,
2015b; Shanafelt et al., 2012).
29 There have been a number of studies done that show the insignificant effects of restricting duty hours on rates of
complications and morbidity, as well as board exam scores for residents (Ahmed et al., 2014; Bilimoria et al.,
2016; Patel et al., 2014; Rajaram et al., 2014; Rau, 2016).
73
and examine the minutae of the temporal power tensions that exist throughout the day between
different groups of practitioners. In particular, I will look at the differences between attendings
and residents, between physicians and nurses, and between different services in the consulting
aspect. I will also consider the temporal rhythms that dictate the relationship between practitioners
and patients, and the difference of temporal value and perspective between different health
systems, such as county medical centers versus private institutions. Through these investigations,
it becomes clear where breakdowns in processes happen in the name of trying to be more
efficient. The work in this chapter concerns itself with the give and take of the minutes and hours
of the day, how minutes and hours are used, who controls whose minutes and hours, where
flexibilities with in the day lie, if at all, and negotiations of temporal rhythms within the
framework institutional procedures in which health practitioners function.
Often, the position of the practitioner, and their placement in the hierarchy of training or
institutional structure is interrelated with their temporal capital, as in, how much power and
control over their time they have, and how much control over others' time they have. At the same
time, certain institutionalized or ritualized activities that follow a certain schedule also dictate
temporal power dynamics. The two factors – position of the practitioner and the implications of
ritualize activities that are temporally located – interplay with each other throughout the day.
Zerubavel (1979) suggests that there are daily routines that physicians and nurses must complete
during the day, some of which may be temporally located, and some which may not be. Those that
exist within a rigid temporal schedule, like rounding, are often prioritized and imposed upon by
some higher authority. For example, nurses must administer medication in a temporal rhythm,
either tied to clock time, or tied to a temporal schedule (ie: to administer medication every 6
hours), and this temporal rigidity, and therefore decreased temporal autonomy, is imposed upon
74
by the physician who ordered the medications. Similarly, “rounding” schedules, during which
members of the physician team walk around and review all of the patients for the day, are often
set by the attending, who dictates what time rounding will start each morning.
Hence, the practitioner's timeline also interacts other practitioners' timelines. The best
example of this is looking at the relationship between attendings and residents, in which residents
must interact and wait for attendings during some parts of their day, especially when it comes to
staffing patients, which I will elaborate on. The attendings' times, though, are also tugged by yet
other factors – by other practitioners or other patient encounters. These interweaving, overlapping
timelines make for a complex system of temporal dynamics that play a role in the temporal capital
of the practitioner at any given moment of the day.
Attendings vs. Fellows vs. Residents
Residents, fellows, and attending physicians work closely together on a daily basis in
teaching hospitals. Residents are physicians who are still in training. They have graduated from
medical school, and are now practicing and furthering their training in teaching hospitals. Fellows
are physicians who have complete residency and have chosen to subspecialize in their field,
requiring a further one to two years of training.
30
Residents and fellows work under the direct
supervision of attending physicians, who are practicing doctors who have completed residency,
and oftentimes, a fellowship. These relationships between residents, fellows, and attendings
strictly adhere to the institutional and educational hierarchy of the medical field. Individuals tend
30 Ophthalmology is an exception to this rule (“Martha”, personal communication, 2/7/2015). Ophthalmology does
not have any fellowships that are defined by the Accreditation Council for Graduate Medical Education
(ACGME) or the American Board of Ophthalmology (Frohman & Digre, 2004; “Ophthalmology Fellowship,”
n.d.) and therefore the fellows are not officially certified. According to both Martha and Craig, there are two
reasons for this. On one hand, this technically makes ophthalmology fellows attendings, and can staff cases,
which increases patient encounter flow. On the other, more cynical, hand, this means that fellows' duty hours are
not regulated, leading to fellows being overworked and underpaid.
75
to know their position and play their roles accordingly. The differences in responsibility and
investment of time is not only cultural, but institutionalized, as I will demonstrate. Furthermore,
there are many hierarchical nuances within these three groups as well. Residents are split up by
cohort, with the “younger” residents taking on the bulk of the time-consuming work, while junior
attendings' schedules and call days are often at the whim of senior attendings.
Staffing
When it comes to responsibility, residents and fellows bow to the authority of attendings.
Attendings must oversee, either directly or on paper, the treatment of all patients at a site. As such,
while residents are often the ones that directly interact with patients,
31
they must go over each
patient encounter with an attending, ensuring that an attending reviews the proposed management
of care for the patient. This process is called “staffing” the patient, where the resident “staffs” the
patient with an attending. This seems straightforward enough, but there are many times,
particularly in clinic settings, in which a resident examines a patient, then needs to talk to an
attending about the patient, and the attending is not available for staffing, is busy, or is staffing
another patient with another resident, causing the resident who needs to staff the patient to either
wait, or occupy his or her time with something else while waiting for the attending to become
available.
The procedure for a typical patient encounter for non-surgical both inpatient and
outpatient services is as follows:
31 There are exceptions to this. At the main University Medical Center Eye Clinic, residents do not interact directly
with patients. Attendings themselves see patients, while residents shadow the attendings. Conversely, for the
county clinics, attendings are not supposed to be seeing clinic patients. They need to be free either to staff
patients, or to oversee surgical procedures.
76
1. Exam patient
2. Come up with management plan
3. Staff patient with attending
a. Present proposed management plan
b. Agree on plan
4. Wrap up with patient
a. Prescribing medications
b. Answering questions
c. Schedule next patient visit or followup (for an outpatient clinic)
5. Post-encounter tasks
a. Write note, document
b. Enter orders
c. Communicate management plan to nursing staff and other providers
Mickey, a third year internal medicine resident, describes his experience in an outpatient
clinic, in which patients are scheduled an appointed time for an exam. In the internal medicine
clinic, residents are allotted 30 minutes for each patient encounter, while attendings are allotted
for only 20 minutes. The additional 10 minutes accounts for the time it takes for a resident to staff
a patient with an attending. Therefore, Mickey says that he is “expected to see a patient, then go
back and staff it with an attending, and go back and see the patient, and give them any updates
and get them out and ready for the next visit in [30 minutes]” (“Mickey”, personal interview,
September 18, 2014). But he also acknowledges that, even with the additional 10 minutes, 30
minutes is not enough time to get everything done, that “it's really tough and it's really easy to get
behind, and I feel very, it's just frustrating” (“Mickey”, personal interview, September 18, 2014).
Part of the reason why pre-determined additional minutes is insufficient for each patient
encounter is due to the delays and tensions involved in staffing cases with attendings. Attendings,
understandably, are not just waiting around for residents to talk to them about patients. Therefore,
77
when a resident needs to staff a patient, he or she ends up waiting for an attending to become
available for staffing. Mickey does whatever work he can while waiting for an attending, but as
soon as an attending becomes available, he will drop whatever he is doing in order to talk to the
attending:
So you try to get some of your work done, cuz you're still going to have to
write the note, you have to get the orders in, you have to communicate with
the other providers, you have to talk to the nursing staff so there's like
multiple other things that you [do]. Usually I'll go back and look for the
attending and [see that] the attending is not ready, or usually I'll say, 'Hey,
when you're ready, I need to staff somebody,' and I sit down at the
computer, and I start doing the most urgent things on my tasklist. When the
attending is ready, then I drop that, and I staff with the attending, and I go
back and take care of the patient or do whatever needs to be done after I've
talked to the attending (“Mickey”, personal interview, September 18,
2014).
There are a few interesting things happening here in Mickey's testimony. First, he writes his
orders and starts on his note about the patient (Step 5) while waiting for the attending to become
available. The orders and the notes are written as part of a daily routine that must be done that
day, but is not temporally located within the day (ie: he does not have to write the note at 3:20pm,
he just needs to write the note before he leaves the hospital in the evening). Hence, he exhibits a
modicum of temporal autonomy in the writing of the note during this waiting period, so that the
waiting time becomes productive time for non-temporally located activities that have to be done
anyway. Second, he also writes the note before he has confirmed the treatment plan with the
attending. This is a breakdown in the rigid procedure outlined above, yet he, being in his third
year of residency, he feels confident enough to start the later process while waiting for the
attending. In this case, he ruptures the rigid process of a patient encounter, thereby saving him
78
time in an attempt to follow the pre-ordained time restrictions of a patient encounter (30 minutes).
Finally, his temporal autonomy extends only to doing what needs to be done for the patient. It is
encompassed and framed by the patient encounter timeline, and that temporal autonomy is
completely eradicated as soon as the attending becomes available. Therefore, during the waiting
time, the resident has increased temporal capital to control the duties done, which are conscripted
to the confines of one day. Temporal capital then gets decreased as soon as the attending imposes
his or her presence on the temporal sphere of the resident.
Donna, a 2
nd
year emergency department resident, also points at the rupturing of the
“rules” of staffing:
There's a patient I see, like, this kid's getting admitted, a [kid with a
pediatric congenital condition], it's like, the pediatric hospital has already
seen the patient before, I'll staff it often. I'll put in the [order for admission
to an inpatient unit] before I staff it. I'll be like, “Hey, FYI, I have a kid
with XYZ who's getting admitted to the [pediatric intensive care unit],”
and the attending's like, “Ok.” And with sicker patients because you know
they're gonna be admitted [it's easier sometimes to just admit them], so
you're not in as much of a rush to get the approval. [You can] get them
moving, get them out. Usually [with] sicker patients... you can be more
liberal with ordering tests and... at least by this point in the year, you're
like, “Ok, I feel comfortable initiating the workup and treatment by myself
for a pretty significant period” (“Donna”, personal interview, October 1,
2014).
Like Mickey, Donna feels comfortable enough to step outside of the rigid rules and procedures of
staffing and authority in order to keep things moving in the ER, and also points to her own
learning curve, familiarity with different cases, and comfort level in being more autonomous
during patient encounters. The autonomy as one gains more time training under one's belt allows
79
for the flexibility to not do things in exactly the order they should, in order to save time. In this
way, the autonomy allows both Mickey and Donna to ostensibly increase their own temporal
autonomy as it is framed within the patient encounter.
Amy, a second year psychiatry resident, tells a slightly different story, in which even her
waiting time – the time that Mickey uses to do other tasks in the hopes of saving time down the
road - is co-opted by the staffing process:
I knock on the door gently, and because there's usually a tad open when
[the attending is] staffing, you kind of peek in. And I smile, and give a look
like, 'Ok, I need to staff a case too.' And they nod, and they wave you in,
and you come and you sit down and then if somebody else is staffing, you
then, unfortunately, become a victim of a pimp session about a case that
you don't even know. But it's worth it because you learn (“Amy”, personal
interview, September 22, 2014).
In Amy's case, her use of the words “you” and “I” interchangeably signals that this type of
experience is typical to residents in her program. She implies that it is often the case where the
resident is roped into a “pimp session,” in which the attending, using a potentially stressful brand
of the Socratic method (depending on the individual attending), asks pop-quiz-like questions in
relation to the patient's condition to test the resident's understanding of a specific disease,
condition, treatment, medication, etc. Amy finds the silver lining by saying that the resident learns
from the experience, even though the information presented lies outside the realm of the resident's
patient encounter. Yet nonetheless, unlike Mickey and Donna, Amy's waiting time also becomes
property of her superior, in the name of future self-investment, self-improvement, and a process of
professionalization.
Variations in the need to staff, and the temporal limitations put on the process of staffing
80
also differ according to how advanced in the training a resident is, and the type of patient is being
seen. In psychiatry residency, the hierarchy of residency is built into rules on staffing. For
example, as Amy elaborates,
As a second year, medication cases or medication management cases need
to be staffed before the patient leaves...before they leave the building.
Except for therapy patients. We have therapy patients who just need to be
staffed within a week or so. As a third year, which is our second year
during outpatient, you know, psychiatry in the afternoons, so as a third year
resident, the patient needs to be staffed by the end of the day (“Amy”,
personal interview, September 22, 2014).
As can be seen here, the flexibility of time for the resident to staff a patient (either before the
patient leaves, or by the end of the day) depends on both the type of patient, and what year the
resident is. The third year just has to staff the patient by the end of the day, compared with the
second year, who has to staff the patient before the patient leaves. This means two things – one,
the patient's time is controlled by the resident, but the resident also feels pressure to find an
attending and staff the patient quickly, as to respect the patient's time. The availability of the
attending, in this particular case, then, dictates the temporal flow and flexibility of both the
resident and the patient. Moreover, even among the residents themselves, control of time runs up
the hierarchy:
I spend time not only waiting for the attendings, but I have to go find an
attending to staff with, which sometimes they can be very difficult to track
down. I then wait for them to either be between patients, finishing with
other patients, I have other residents who are seniors who are above me
that I have to wait for, because they get priority to staff if they happen to be
around. It's a hierarchical system (“Amy”, personal interview, September
22, 2014).
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While staffing a patient is required by law, as the resident must document with which attending
they discussed the case, which effectively transfers full legal responsibility of the patient to the
attending, the reality of staffing is often rife with frustrations. As I have shown, just in the process
of staffing, the residents' time is under the control of the attending, whether the attending is
consciously aware of this fact or not. In fact, the attending's time may be further controlled by
another resident who got to that attending first, and is commanding the attending's time staffing
another patient.
The landscape of health care, especially from an institutional level, is changing, and
greatly affects the temporal organization of attending physicians. Physicians are now required to
see more and more patients as compared with two or three decades ago.
32
The number of patients
seen in the clinic and the number of operations performed determines the compensation of the
physician, even in a teaching institution.
33
Moreover, the attending's time may be tied up doing
tasks related to maintaining a good standing within the health system and addressing invisible,
institutional pressures – seeing more patients, respecting a patient's time, teaching, researching,
managing and teaching residents, etc.
34
These obligations are both legal and cultural, and but into
the limited time physicians have during the day. Hence, the temporal dynamics of control are not
linear. Attendings do not necessarily have control over when they are available to staff patients
with their residents. It often depends on a multitude of factors.
32 This has been a trend that many of my informants mentioned. Danny, an administrator in the department of
Radiology at University Medical Center, in particular, outright states that this is the case that faces many
physicians now (“Danny”, personal interview, November 17, 2014).
33 Many informants either outright state this fact, or imply it in their conversations with me. Mickey (personal
interview, September 18, 2014) and Sarah Jane (personal interview, February 17, 2015) in particular speak about
Revenue Value Units (RVUs), where certain procedures are assigned certain numbers of RVUs (for example,
surgeries are worth more RVUs than a simple clinic checkup), and RVUs ultimately determine their
compensation both from the hospital and from insurance companies.
34 Another piece of information that is repeated by many informants, notably Sarah Jane (personal interview,
February 17, 2015) and Rose (personal conversation).
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Rounding
“Rounding”, which happens every morning on inpatient units, is the process by which key
physician members of a patient health care team meet to discuss management of patient care for
the day. This practice usually involves residents and attendings, who meet at the beginning of
each shift to discuss patients on the unit under their care. While nurses sometimes participate, it is
generally not mandatory for nursing staff to be present (“Sarah Jane”, personal interview,
February 17, 2015).
The schedule of rounding is usually up to the individual in power. Zerubavel, in his
analysis of time patterns in the hospital, examines the relationship between interns (who are just
one year out of medical school) and residents (who have completed internship and supervise
interns) and notes that during rounding, the “[intern's] precise temporal location...was dictated by
the resident, which suggests how one can exercise social control by dictating the timing of others'
activities” (Zerubavel, 1979, p. 51). Indeed, this pattern is repeated, for our purposes, between
attendings and residents, wherein the attendings dictate when rounding starts, around which
residents then organize their daily schedule, especially when they need to arrive at work.
Attendings, though, will sometimes, necessarily, take the residents' schedules into account.
As Rory, a junior internal medicine attending at County Medical Center 1,
35
states,
In general, I work around the residents' schedules. Because the residents
have a lot of teaching activities they're required to go to, and I, as an
attending, you never want to deprive residents from their teaching
activities, so because of that, I work around their schedule...one of the
things that County Medical Center 1 pride's itself on is that they're
primarily a teaching institution (“Rory”, personal interview, May 29,
35 As I mentioned before, University Medical Center has two affiliate County Medical Centers. This is one of them.
83
2015).
What is interesting here is that, while he, as an attending, still dictates the time that rounding will
happen, his control over when rounding happens is subordinate to the institutional requirements
of the educational and training process for residents. Interestingly, the schedule for the teaching
activities for the residents at County Medical Center 1 is set by the chief residents in conversation
with the program director, who is an attending and has ultimate final say as to the teaching
schedule (“Rory”, personal interview, May 29, 2015). So on one level, the temporal capital of
residents is co-opted by the attending, but in reality, the attending's options are limited by the
institutional demands on the residents themselves. So, the residents, in essence, are on the lowest
rung of the ladder in terms of their control of time, where their time is co-opted both by the
institution as well as the attending. Yet, regardless of the individual co-option and control of time,
the institutional expectations – in this case, the mission to educate residents – trumps any
temporal dynamics between individuals, and individuals must conform temporally to the demands
of the institution.
Outsourcing/Delegating Work
The delegation of tasks down the relevant hierarchy in order to expand the temporal
capital of those sitting higher up is very obviously seen in teaching hospitals. Rory, the junior
attending in internal medicine, mentions that it is in large part due to the fact that his department
at County Medical Center 1 is a 100% teaching department that he is able to delegate tasks to
residents and interns (“Rory”, personal interview, May 29, 2015). Perhaps the most helpful part of
being higher up on the medical hierarchy is due to the hierarchy itself. The higher up one is on the
84
chain, the more they are able to delegate tasks to subordinates. This is due in large part to the
interchangeability between practitioners, and the process of training, wherein at the end of
training, all those within the same relevant group (ie: all ophthalmologists or all internal medicine
physicians) are expected to have the same scope of duty.
As we saw before, the temporal requirements for staffing change as one moves up the
ladder, with those higher up on the hierarchy with more temporal flexibility than those lower.
Residents who have more years of experience are able to staff patients within a wider temporal
range than new residents. Attendings, on many levels, command the time of their residents and
fellows, but are also able to displace their temporally-bound duties onto their subordinates,
freeing them up to do other tasks, and ultimately allowing them a greater degree of temporal
flexibility. Sally, a junior ophthalmology attending, expresses the fact that residents talk with her
only if they have a question about a patient. Otherwise, she spends the day reading and
researching on the computer, conducting phone meetings, and completing other administrative or
research tasks (“Sally”, personal interview, June 17, 2015).
Particularly in a 100% teaching institution, where attendings' tasks are completed with
medical students, interns, residents, and fellows, they “hardly do any paperwork, [they] don't
write any orders, and yes there's the expectation to see patients, but at the same time though, most
of the patient/doctor interaction happens at the intern/resident level” (“Rory”, personal interview,
May 29, 2015). Ironically, while Rory says that he is able to expand his or her time through
residents, and that it is a “luxury”, he also thinks that “attendings really value the ability to teach.
Because of that we always work around the residents schedules. Part of it, I may be biased
because I'm a former chief resident, but my commitment is always to the residents” (“Rory”,
personal interview, May 29, 2015). In this way, it is not only the institutional expectations and
85
privileging of teaching that is mentioned above, but Rory's own commitment, as an exchange for
the expansion of temporal capital thanks to the residents, to give a bit of that temporal autonomy
back in the form of prioritizing teaching for his residents.
This pattern of temporal flexibility as correlated with position in hierarchy is evident in
how call schedules and call etiquettes to which ophthalmology residents adhere. Ophthalmology
residency lasts for a total of three years. At University Eye Clinic, first-year ophthalmology
residents always take primary call, meaning if another department at University Health System
needs an ophthalmology consult outside of clinic hours, the first year on call is paged, and may
have to go in to the hospital to take care of the issue. Second year residents, on the other hand, are
back-up call. If the first year, for whatever reason, needs assistance, advice, or support, they call
the second year back-up, either by phone or by pager. Depending on whether or not the issue can
be resolved over the phone, the second year backup may have to go into the hospital to assist in
person. As we can see here, then, the chance that an individual will be moved from the non-work
sphere into the work sphere decreases as one's position on the organizational hierarchy increases.
Moreover, the amount of time necessarily spent in the work sphere also varies depending on
position, with second year backups spending considerably less time in the hospital during call
than the first years who are on primary call. This is due to the fact that the first years are called in
first and conduct an initial exam of the patient. Then, if a second year is needed, the second year
can tell the first year over the phone to prep the patient while he or she drives over to the hospital.
After examining the patient, the first year is the one obligated to stay and complete notes on the
patient, freeing the second year up to go home. In this way, the second year spends less time
overall in the work sphere during non-work hours by outsourcing the patient care duties that
either first or second year can perform onto the first year.
86
We have to recognize that there are task delineations given the job scope of certain health
professionals. For example, a clerk in the ophthalmology outpatient clinic at Harbor checks
patients, while the nurses ask in-take questions. Physicians then perform the exam. Zerubavel
(1979) points to an interchangeability between individuals of the same occupation in order to
maintain continuous coverage. In this case, Zerubavel talks about inpatient units. This same idea
can be applied to outpatient clinics for continuous flow. For example, in the County Medical
Center 2 outpatient clinic, any physician, from a first year resident to a fellow to an attending can
perform the tasks within the physician's scope of duty in the clinic for any patient. In fact, in the
clinic, patients are not pre-assigned to physicians and nurses. The clinic staff will look in the
EMR system and see which patient has been waiting the longest. They will then take that patient
next (“Vera”, personal interview, February 18, 2015). The specific patient, nurse, or doctor do not
matter.
It is within this capacity for interchangeability that individuals higher on the hierarchy are
able to displace temporally-bound duties and increase their own temporal autonomy at the
expense of their subordinates' temporal autonomy. Going back to the on-call ophthalmology
residents, either first or second year are capable of examining, for example, a patient who came
into the ER with a blunt force trauma to the face, determining the amount of injury to the eye,
proposing a plan of care, then documenting the patient encounter in the electronic medical records
(EMR) system. However, the onus of spending the full time of the patient encounter at the
hospital – from initial examination to the completion of documentation – falls to the first year, the
individual lower on the medical training ladder. It is important to remember, moreover, that the
expansion of temporal capital for an individual can only happen if that individual shares the same
scope of duty as their subordinate. In the case of health practitioners, individuals must be in the
87
same professional group, or on the same ladder of the hierarchy in training. For example, a
resident can relieve an attending or their senior resident of certain menial tasks and duties because
they share the same role and duties in relation to the care of the patient. However, a physician's
time will not be expanded through the work that a nurse or a technician does, because a nurse has
a different set of tasks and responsibilities.
We see a similar dynamic happening between attendings and residents. Attendings are able
to step away from a time-consuming and temporally-bound procedure if there is a resident on
hand to take care of the patient. Rose, an anesthesiology attending, is often able to leave an OR
with an ongoing case and step into her office to work on research and other tasks because an
anesthesiology resident is physically in the OR attending to the patient (“Rose”, personal
interview, October 12, 2014). This, however, does not absolve Rose of her responsibilities as the
attending physician, and as such, she will monitor the patient's vital signs in real time from the
EMR system she accesses through the computer in her office. There are two things happening
here that make Rose's life easier. On one hand, having a subordinate with the same scope of duties
as herself allows her to free up her time to do other tasks, to not be spatially or temporally bound
to the case. On the other hand, the presence of a working EMR system allows her to monitor the
patient in real time, fulfilling her responsibilities as the attending physician on the case, extending
her ability to complete her duties outside of a spatially-bound situation. At the same time, the
resident necessarily has to put in the hours in the OR to gain experience and learn how to take
care of the patient and take care of irregularities or emergencies. As Rose states, as an attending,
“you can't be IN there with the resident the entire time, otherwise they're never gonna learn how
to fix problems on their own, you know, if you're kind of holding their hand the whole time”
(“Rose”, personal interview, October 12, 2014). In case of an emergency, however, Rose can
88
easily step back into the OR and take over as needed, thanks to the off-site monitoring capabilities
of the EMR system.
Similarly, Sally finds flexibility in her time by allowing her residents to function
autonomously, then checking their notes at the end of the day,
They can function fairly autonomously. They have to technically, run a
patient by me, but the way they can do it is by sending me the note. So if
they don't have a verbal question, or if they don't have a management while
the patient is there, they can let the patient go, and then I'll read the note
later (“Sally”, personal interview, June 17, 2015).
This interchangeability of staff and patients in order to maintain continuous coverage and
continuous flow, both in the inpatient and outpatient sections of a hospital reveals an interesting
tension between humanness and machination of clinicians. In fact, as we can see in both Rose and
Sally's cases, the EMR system mediates the ability not only for the attending to have greater
flexibility and temporal autonomy throughout the day, but it directly mediates their ability to
fulfill their responsibilities as the primary physician for particular patients as they offload their
minute by minute tasks to residents. Signing off – the process of passing on the information to
another health practitioner – is necessary because clinicians are human, yet because of the signing
on and off, the stepping into a role, mediated by communication technologies and the EMR
system to transfer information into the brain of the doctor is a way of making those humans into
machines, to strip them of individual thoughts and feelings, to deny the tacit knowledge of the
individual physicians and nurses, and their personal connection with the patient. This
interchangeability undoubtedly also contributes to the perception that physicians are stoic, coldly
rational individuals rather than having a full range of human emotions.
Another example of how the interchangeability of physicians reifies a hierarchy of
89
temporality in the hospital is through charting, or patient documentation. While I will talk a bit
more about how EMR systems and technological literacy has impacted the differential temporal
capitals between individual practitioners, it bears mentioning here that the amount of time spent
charting is negatively correlated with one's position in the hierarchy in general. Rory, the junior
attending at County Medical Center 1, mentions that, while he is on call 4 months out of the year,
he rarely needs to chart, because the Internal Medicine department at County Medical Center 1 is
a 100% teaching hospital, and “[y]ou do hardly any paperwork, you don't write any orders, and
yes there's the expectation to see patients, but at the same time though, most of the patient/doctor
interaction happens at the intern/resident level” (“Rory”, personal interview, May 29, 2015). At
County Medical Center 1, attendings and residents constitute a medical team, and each patient is
the responsibility of the entire team. Therefore, Rory never works alone – he always has residents,
interns, and fellows taking care of the same patients. Therefore, he is able to outsource that task to
these underlings, saving many hours of time he would otherwise be spending with the chart.
Other aspects of charting delegation includes physicians who independently have the
option to hire scribes - people who follow a physician around and do patient documentation for
them. While there is a concern that scribes are unevenly trained to document, and there are moves
to push for the universal certification of medical scribes under the American College of Medical
Scribe Specialists (ACMSS) to ensure that all scribes are familiar with medical terminology and
procedures (Murphy, 2013), scribes are fairly commonly used to offset the temporal commitment
that comes with charting. Indeed, University Medical Center's emergency department (ED), a
very fast-paced specialty, provides scribes even for its senior residents, to save them time charting
as they see patients, according to Donna, second year ED resident (“Donna”, personal interview,
October 1, 2014). Starting with the 3rd year resident and higher, every physician working in the
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Emergency Department is assigned a scribe
36
– an additional person who follows the physician
around and documents for the physician in the EMR system. In this way, the ED has essentially
outsourced a function that other physicians must do themselves. But only those high enough up
on the ladder are able to outsource that time, allowing for more temporal flexibility and the
potential to see one patient after another. The pattern that the more power one has within a
relevant hierarchy, the higher the levels of temporal capital holds true even between residents in
this department, as the junior residents (those in their first or second years) still need to do their
own charting. The need for scribes is also likely due to the high pace of the ED. Donna implies
that a “good” day is one that has exciting case after exciting case. The pace of the ED also tends
to be faster than other departments, as the ED is a gateway department through which the patient
must first be seen before being admitted to the hospital. In fact, the vast majority of inpatients on
medical units are ED admits – admitted into the hospital through the emergency department
(Morganti et al., 2013). While a scribe in the particular case of the ED seems necessary, who gets
a scribe and who does not implies differing values of time for those positioned differently on this
hierarchy. The times of those who are more advanced in training are clearly valued more than
those just starting out, who need to chart everything by themselves.
Relationship between Doctors and Nurses
On inpatient units, physicians and nurses function with very different timelines. Often, the
timeline of the physician will determine, in micro-moments, the timeline of the nurse. In other
words, the fickle timeline of the physician impacts the timeline of the nurse. According to Alaya,
a unit director for a medical/surgical unit at University Affiliate Hospital, a private community
36 As Donna, who was a second year resident at the time of this interview, was telling me this, she sounds rather
jealous even, saying that having a scribe is “phenomenal” (“Donna”, personal interview, October 1, 2014).
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hospital affiliated with University Medical Center, the hospital has been working on their
physician/nurse rounding. Alaya remembers that when she first started nursing a couple decades
ago, it was mandatory for the physician to round with the nurse. They would be able to talk face
to face about the management of care for each patient, and the nurse would make sure he or she
could read the doctor's writing. Alaya implies that technology has something to do with the
dissolution of the practice of rounding with both physicians and nurses. With technology, there is
no longer the impetus to make sure the nurse can read the doctor's handwriting, since everything
is typed now. But the collaborative aspect of patient care has also diminished. Rather, the “doctor
will say one thing, the nurse will say one thing, they go [into the patient's room] separately, and I
think it's missing that piece, you know, that inner relationship between the patient, the doctor, and
the nurse, and working collaboratively together” (“Alaya”, personal interview, October 27, 2014).
Doctors give orders through the use of communication technology, thus working in a different
temporal sphere as the nurse, using the electronic medical record system as the mediator to bridge
the two spheres.
The power relationship between doctors and nurses are apparent in the temporal dynamics
between the two, as Clara, another nurse at University Affiliate Hospital illustrates:
And that is true, too, with the time constraints, because with the technology
and time, we'll get told, “The doctor's here for this patient, can you come?”
“Uhh not right now,” you know? So then I try to finish up quick and get
there. They did actually reach out to me, so I need to make it some more of
a point. (Interviewer: So if a doctor reaches out to you, you will try to
prioritize talking to that physician?) Yes. Absolutely. Because otherwise,
catch 'em now! Or they're gone (laughs) (“Clara”, personal interview,
October 20, 2014).
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Clara implies that if the doctor is on the unit, she will compress her time and hop into the room
with the doctor to see the patient together. In this particular relationship, the physician holds the
temporal power, even though the physician him/herself may not actually have that much temporal
flexibility, as I had mentioned before. Physicians rarely see patients at their leisure - they see them
under pressure, because of the increasing number of patients physicians are now required to see in
order to maintain a good standing at University Health System.
The relationship between doctors and nurses in an outpatient setting, where patients show
up for a couple hours for an appointment, can be different. In this section, I use an ophthalmology
outpatient clinic as my example to examine the temporal dynamics of nurses and doctors in an
outpatient clinic. Outpatient clinics generally have a set daytime schedule. In this case, the
ophthalmology clinic at Harbor is set to open at 8am every day and close at 4:30pm. Vera is a
Licensed Vocational Nurse (LVN)
37
in the clinic – one of four LVNs, in addition to two registered
nurses (RNs), one of whom is a charge nurse and is in charge of scheduling and assigning the
other RN and the four LVNs to duties throughout the day. Vera arrives at the clinic before it
opens. There is usually already a handful of patients waiting. There, according to Vera, nurses'
duties are to “intake” the patient, asking them a series of simple questions, and conduct a visual
acuity test before the physician examines the patient. Because the nurses are the first line of
contact for the patients, the doctors must wait on the nurses to be done with their duties before
engaging in that particular patient encounter. Hence, it would seem as though the nurses in this
clinic are the ones determining the pace of work. However, this is far from the truth.
This particular eye clinic, which is based at County Medical Center 2, according to Vera,
37 LVNs are not Registered Nurses (RN) – they are a step below, if you will. the can perform some, but not all
duties of an RN. It takes much less time to become an LVN. Many aspiring RNs become LVNs first while
waiting to get into nursing school so they can get the clinical experience.
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had done an informal time study to see how long intake and discharge processes realistically take.
While intake and discharge usually take 10-15 minutes, Vera explains that to discharge a single
patient often takes longer because of unexpected duties that come up. Walk-in patients will come
in for medical refills. The phone will ring. The charge nurse or the physician will ask them to
fetch a certain type of medication or chart. Not to mention, the scheduling system upon which the
clinic runs is rife with errors and inconsistencies, so many patient appointments need to be
rescheduled or canceled. Therefore, nurses' patient encounter time (the whole time it would take
to intake and discharge a patient) becomes fragmented through these unexpected interruptions,
with them potentially having very little control over their time throughout the day.
Relationship between Physicians and Patients
The question of who has the temporal power between physicians and patients is one that is
complex and complicated. It is also heavily influenced by the shift to patient-centric care, and an
emphasis on patient satisfaction. Danny, an administrator for University Medical Center's
Radiology Department,
38
contrasts today's patient care situation from those from the 80's by
saying, “Now, today's health system, patient says I need to seen now, you say, sir, yes sir, let me
see what I can do, to be more accommodating, and that puts a lot of strain on the physician”
(“Danny”, personal interview, November 17, 2014).
Indeed, the struggle that many providers face in today's health care environment is the fact
that Medicare reimbursements are oftentimes based on patient satisfaction scores. The conundrum
for providers lies in the fact that they often disagree with patients' self-diagnosis or what the
patient perceives is the problem. A patient may come to the doctor's office having done research
38 His job is to mediate the supply (imaging study machines, attendings, residents) and the demand (patients who
need imaging studies) for the department of radiology.
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on WebMD or Google, which may have suggested diagnoses or tests which may not be at all
relevant to the patient. Yet, if the physician does not run superfluous tests or suggest treatments in
line with the information on the Internet (but are not the best fit for the individual patient), the
patient may end up upset at the physician and giving the physician lower patient satisfaction
scores, thereby impacting the physician's financial situation. In this way, there is a tension
between the capitalist logic that governs health care, and the ideologies of medicine and patient
care. The more the patient care experience is framed in terms of the logics of customer service,
the more power the patient has the power to colonize the practitioner's time and impact the
practitioner's financial situation. And yet, this works on both an individual and an institutional
level. A patient's power will depend upon his or her individual position within society (a hospital's
board of trustee member will never have to wait to be seen, regardless of how severe his or her
condition is), which is then framed by the physical constraints of time and mediated by the
aforementioned capitalist logic. In other words, let us say a patient wants to be seen. Framed
within a customer service logic, which much of health care is now, the patient will not have to
wait too long. However, they will have to wait as long as the doctor is still seeing other patients, if
all of the other patients are on the same or similar power level (ie: none of them are a member of
the board of trustees). In this section, I will explore the difference in this relationship between
clinics and inpatient services, which are two common situations during which patient and
physician paths cross.
During the day of the practitioner, there are multiple timelines to differentiate. First is the
timeline of the practitioner. This timeline indicates the duties that the practitioner performs
sequentially throughout the day. Another timeline is the patient-encounter timeline, in which
contact with the patient, and duties performed for a certain patient, such as ordering medications,
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nurse intake of patient, and such are sequentially mapped onto the timeline of the practitioner. The
patient-encounter timeline is often both fractured, with the different pieces placed upon the
practitioner's timeline, yet the patient encounters are often not taken as one whole chunk. The
chunk is fragmented throughout the total time the patient is officially in the care of the
practitioners, which starts when the patient checks in, to the time when the patient is discharged.
For an outpatient patient, the patient encounter temporally fragments throughout the day. For in-
patients, this fragmentation of the patient-encounter timeline can take place over the course of
multiple days.
Clinics
When a patient goes to a medical clinic to see a doctor, he often finds himself waiting past
his appointment time before he actually interacts with any practitioner. The first point of contact
for the patient in a clinic setting is often nurse who does intake – taking the vital signs of the
patient and performing preliminary exams, such as a visual acuity test for an ophthalmology
clinic
39
to determine the extent to which a patient can see. The patient then waits for the doctor's
examination. At a popular OBGYN's office, her patients often jokingly complained that they
would wait with their pants (in the office waiting room) on for an hour, then wait with their pants
off (in the examination room, after the nursing intake process) for another hour to interact with
the OBGYN. From the patient's perspective, the doctor controls both the patient's time, and the
overall pace of the clinic.
From the doctor's perspective, however, the situation is much more complex, and
frustrating. Especially at the County Medical Centers, patients are overbooked in the system, and
39 The following clinical procedures are pieced together by interviews and observations.
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unexpected walk-ins occur which further delays the seeing of patients. Physicians themselves feel
they have very little control over their time, and little control over when to see patients. While
Danny, the Director of Radiology, describes the medical system as a system of supply and
demand, with the insertion of physicians, residents, techs, and patients into predetermined slots in
the process (“Danny”, personal interview, November 17, 2014), the reality of it defies systemic,
structural rationalization. As the patient-centric culture of health care increasingly overwhelms the
system, driven by changes in Medicare reimbursement policies, doctors are forced to see
increasing numbers of patients compared with two or three decades ago. As such, the time slot
allotted to each patient shrinks, and doctors feel more harried than ever before, with the goal of
the day to get through the patients, often at the expense of the quality of patient care.
Martha, second year ophthalmology resident, expresses that if she had just 5 more minutes
with each patient, she would be able to do a better job in educating her patients in preventative
measures to decrease the need to go to the hospital, or at least decrease the severity of their
condition (“Martha”, personal communication). Yet the system in which she works demands that
she runs through as many patients as is scheduled for the day, and if she wants to go home by a
decent hour, she must truncate as much as possible each patient encounter. The temporal power, in
this case, lies with the system, and the schedule by which the clinic runs, rather than any
individual agent, and this is the overarching institutional driver of the pace of hospital life.
Similarly, Harriet, a 3rd year internal medicine resident, illustrates the tensions between
patient expectation and physician obligations to tasks not immediately related to that particular
patient encounter in a clinic setting, while highlighting the desire to respect a patient's time, and to
understand that patients, likewise, have other obligations:
[Attendings will] cut you off when you're presenting to them, and say, [this
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patient has] too many problems. We have to address these today, and just
tell them, “I'm sorry, but [we will address your other issues] next time.”
And then of course, you tell [the patients] that, they're not happy. [They
think,] “You're not listening to me, you don't care about me, it's a county
hospital blah blah,” well, no, but you're right, it's county hospital, and you
don't understand the system of that. Doctors have little time in general, but
really really in the county system, time is really spread thin, and you do
what you can do, but you also have a life too. You don't want to live in the
hospital, and you want to respect their time. If you spend forever on them,
you're late seeing your next patient. They're waiting, and they have to go
pick up their kids or whatever (“Harriet”, personal interview, October 6,
2014).
In this statement, Harriet also draws out the particularities of County Medical Center 1 (where she
primarily works) in which the patients tend to think the doctors do not care about them, and where
time in the county system is spread incredibly thin because many of the patients are
undocumented and/or uninsured, and of a lower socioeconomic class. More patients are scheduled
per slot, and the residents are the ones running the show. Recall what Mickey said earlier, that
physicians-in-training tend to be allocated more time in the clinic to see each patient, indicating
that residents tend to be slower than attendings in general. In the case of County Medical Center
1, this discrepancy in speed can contribute to longer wait times for the patient. We can see how
Harriet struggles to articulate and makes sense of the different forces that tug on the temporal
rhythms involved, from her own desire to go home at some point, to the patients' anxiety about
not being able to pick up their children, to the fundamental perceived emotional gap between the
physician and the patient that is often due to temporal constraints.
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Inpatients
My brother had a case of spontaneous pneumothorax (unprovoked collapsed lung) in the
middle of my field work for this dissertation, which necessitated me flying to New York for two
weeks to take care of him.
40
Because we spent most of our time in the hospital, I was able to make
some interesting observations from an inpatient perspective. At this particular hospital in New
York, my brother's cardiothoracic surgeon would run up to the inpatient unit to see pre-operative
or post-operative patients between surgery cases. Because the timing of surgical cases was
difficult to predict, family members and patients would wait for uncertain periods of time to talk
to the doctor without really having control of their own time. There is the sense of not wanting to
leave the bedside, since the doctor might finish surgery and arrive on the inpatient unit any
minute. Moreover, doctors usually do not stay long by the bedside – usually a minute or two, 5
minute at the very most. The doctor's lack of temporal autonomy, and the lack of a temporally
located visit creates tensions for patients and family members. In an effort to not miss the doctor's
lightning visit, the family is compelled to stay at the patient's bedside, drastically decreasing their
temporal autonomy until the doctor's arrival. The doctor, then, implicitly controls the time of not
only the patient during this encounter, and the nurses who may be expecting him and who want to
participate in that conversation, but also that of the family members. Family members, then, in
this situation, which may be limited to a day at the hospital, exist and function within the confines
of the physician's temporal patterns, flexibilities, and limitations of the day.
In my brother's case, he had a complication for which a cardiothoracic surgery fellow was
called in to perform a simple bedside procedure. We were told the fellow would be arriving in a
40 Fun sidebar: Incidents of spontaneous pneumothorax is apparently higher in siblings, even if the parents do not
have it. I have a history of spontaneous pneumothorax, which made me, moreso than my parents, an ideal
candidate to take care of my brother due to my not freaking out.
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one half-hour time slot. The fellow did not actually show up for over an hour after the estimated
time of arrival. Similarly, at one point during his hospital stay, the nurse practitioner informed us
that the cardiothoracic surgeon was currently in the operating room, and would drop by to check
in on my brother after his surgery case. The problem was, no one knew when the surgery case
would finish. Because of this, I was wary of leaving his bedside to even go down to the basement
to get a snack, and waited for a few hours until the doctor was finished. My time, then, as a family
member, was controlled completely by the fact that the surgeon himself had no control over how
long the previous surgery was going to take. So in essence, it is not the surgeon commanding my
time, but the surgical procedure itself, and any medical complications as a process that
commanded both our temporal rhythms. These institutional processes, as we see over and over,
dictate much of the actions and activities practitioners perform, that have wide-reaching impact
over the temporal capital of individuals. And even though seemingly controlling many people's
time by making them wait, the physician is often tugged in multiple directions by other forces
beyond their control that demand time.
Many physicians do their best to respect patients' time, which becomes tied to the
temporal patterns of staffing, as I talked about earlier. As Donna, the second year emergency
resident states, “If there's a patient who I see right away, and I'm like, I see him, this patient can
be discharged, we don't need any more tests or any further workup, I'll try to staff that patient
relatively quickly so I'm not making them wait for no reason. Keeping things moving” (“Donna”,
personal interview, October 1, 2014). It is evident here that the urgency to staff indicates the
attempts to respect the patient's time. Moreover, discharging the patient will “keep things
moving,” relenting to the pressures of the institution, and pressure of the normative hectic rhythm
of the emergency department to keep beds free to be able to see more patients.
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There is a misunderstanding of perspectives both from the patient and the doctor's side,
mostly with patients not understanding doctors than the other way around. Mickey expresses this
point while illustrating his experience with a particularly demanding patient:
[The patient] kept saying, “I will only take 15 minutes of their time, I don't
know why they can't just come in and talk to me.” And I'm like, “Well,
there are a couple hundred patients in this hospital, so everyone can't have
a 15 minutes of their time, so we have to prioritize, and you think it's just
gonna 15 minutes, but I can't even spend less than 40 minutes in the room
here in the morning, so I know you're going to take more than that of [my]
time.” So, I felt, so there's a perception on our part that the patients really
have no idea how much time it's all taking. And like, what an investment of
energy and time it is. And on the converse, I think the patients are like, I
only saw you for 5 minutes today, I don't understand what's going on,
which is I mean, in some sense that's true, they only seen the intern for 5
minutes in the morning, then they see the team for 5 minutes later, then
someone at night. Like, they don't see the doctors that often, I think they
don't realize there's like, what I encounter most often is when the patients
do not appreciate that there are like, 9 other people, but that like,
everything that I say that I'm gonna do for them in the morning requires
extra work outside that's not fast always. And there's just a lot to prioritize
(“Mickey”, personal interview, September 18, 2014).
Here, Mickey is trying to see the patient's perspective, and understands it, while trying to
negotiate his own stressors from the day, which is a balancing act that many of the physicians I
spoke with mention.
The emergency department often has different perceptions about time. The ED works
under a triage model. There is a triage nurse who determines the severity of the condition of the
patient and assigns them an Emergency Severity Index (ESI) level from 1 to 5.
41
The most severe
41 The standards of how to use this form of triaging, as well as training and more information, can be found here:
http://www.esitriage.org/
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patients are marked with a 1, with 5 being the least emergent. Physicians in the ER use an
electronic tracking system to determine which patient should be seen next, and the priority given
to patients are based on a balance of how long they have been waiting, and their ESI level.
Generally, if a patient has an ESI level of 1, they do not wait. If there are a few level 3's that have
been waiting for 3 hours, but then a couple level 2's that have been waiting for close to an hour,
Donna says that she will see the level 2's first, but check in with the level 3's briefly. Therefore, in
the ED, while the residents do try to respect the fact that many people are waiting very long
periods of time, the order in which patients are seen is dictated more by the severity of the
patient's condition rather than by that respect or value of their time.
Flexibility of Time at Work
Flexibility of time on the unit often depends on the position of the practitioner, and
sometimes also on the specialty. Residents often find themselves very much lacking in temporal
flexibility:
So sometimes I'll get lunch, there are times I haven't been able to get lunch
until like, 6pm (laughs) or so, and by then, I always carry a bar with me, or
a couple of bars just in case. There's one shift last year, I like, barely got to
eat a bar, and I like, stepped into the nursing area where they have like
water and filled up a cup of water and like, swallowed a bar practically
whole, like, chugged water down and went back out just because it was
such an insane day (“Donna”, personal interview, October 1, 2014).
The lack of temporal capital often manifests as an inability to take care of oneself, and one's
bodily needs calls to mind Foucault's work on biopower and the institutional imposition in
disciplining bodies, which is evident at times in the daily routines of physicians, especially when
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it comes to intaking and excreting, or to put it more crassly, eating/drinking and
urinating/defecating. Similarly, as mentioned previously, Linder and Nygaard discuss in detail the
Taylor-esque ways in which factory workers' bodily functions are tightly controlled by the clock
in the service of capitalistic profit for the institutional for which they labor. The time they have to
void is both temporally located (ie: they may use the restroom at a certain time during their shift)
and temporally restricted (ie: they are only allowed a certain number of minutes to use the
restroom). While nurses have set breaks, physicians do not, which often leads to residents not
eating, drinking, or voiding for hours at a time. One second year ophthalmology resident,
Toshiko, jokingly says of her and her colleagues, “I think we're all in renal failure. (laughs) I
really think so” (“Toshiko”, personal interview, September 20, 2014). There were two reasons
given why this happens, both of which contribute to the lack of body awareness. One is simply
the imposition of the institutional expectations to see greater volumes of patients, and an
awareness that patients are waiting for long periods of time. This is what Donna points to when
she talks about the “insane day” that causes her to quickly chug water and swallow food as fast as
she can. The other is that residents enter into a state of flow, a phenomenon that Mihaly
Csikszentmihalyi discusses at great length which describes a state of mind where an individual is
so wrapped up in what he or she is doing, that he or she becomes unaware of the passage of time
(Csikszentmihalyi, 2008). As Toshiko states,
You just don't remember. It's like you forget to drink water. I think
everyone is permanently dehydrated...I used to bring in water bottles, but it
just sits there. You just forget to drink it. After a while you don't feel
thirsty. I never go to the bathroom during clinic. It's not because I don't
think I can take out time to do that, but it's because I don't drink water, so I
don't go to [the bathroom] (“Toshiko”, personal interview, September 20,
2014).
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In both cases – either because of a large number of patients or entering a state of flow (or both!),
there is an impetus and an obligation to continue working at the expense and to the neglect of
their own biological needs. The act of continually working, as if a machine, works to dehumanize
the physician, alienating the physician's labor from his or her own bodily functions.
While the temporal inflexibilities of residents may sound dire, this does not mean that the
labor they perform is necessarily alienating, as many practitioners, both nurse and doctors, gesture
at greater meaning behind their time expenditure. Each in these three categories of attendings,
residents, and nurses use different methods to control their time, as we have seen. Attendings are
able to outsource their time to residents. Residents may perform tasks out of order when they are
waiting for an attending but may find flexibilities and other ways to control their time, while
nurses' time is flexible as long as they hit the temporally located activities of administering
medication when needed. Moreover, as alluded to, the fact that many residents enter into a state of
flow indicates that the work they do transcends the simple imposition of time from a higher
power. It indicates that the work is meaningful to them. I will explore the difference between
physicians and nurses and the meaning they draw from it in the larger scope of this project.
42
Some specialties allow for greater flexibility during the day, and throughout the longer
temporal landscape of their career than others. Radiology, in particular, because of its relatively
lower frequency and intensity of patient contact, is a specialty that is quite flexible thoughout the
day. As Simon, a first year radiology attending states, “For radiologists, our schedules are a little
more relaxed, which is probably why we go into it, actually is to be able to have a more flexible
schedule...because of our specialty, we can just save the work for tomorrow, for example. It
42 It is interesting to note here that nurses tend to find meaning in helping patients. Physicians often talk about the
temporal investment as an investment in themselves, indicating a greater association of identity with occupation.
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doesn't have to be done by the end of the day, or by lunch. Basically however fast you work, and
that flexibility is really really nice” (“Simon”, personal interview, March 11, 2015). Simon
implies that the temporal flexibility – the increased amount of temporal capital throughout the day
factors into the decision-making process for people who decide to enter the radiology specialty
(among other specialties). The ways in which physicians-in-training make decisions about which
specialty they will pursue and the factors that play into that decision have long-term effects on
their temporal patterns, which will be elaborated upon in Chapter 6. In Simon's case, he chose
radiology because the specialty itself allowed for temporal flexibility throughout the day. Most of
their work is looking at and interpreting image studies (eg: ultrasounds, X-rays, and
mammograms), which is not temporally locked – meaning, there is no rule as to how long they
should spend on working on one image, as long as they get through all of the images that day.
Therefore, the radiology specialty is one that has a very high degree of temporal capital on an
hour by hour level, and is thus considered highly desirable by many graduating medical students –
something that will be expanded upon in Chapter 6.
Shift vs. Non-shift Work
Because health care is an industry that runs 24 hours a day 7 days a week, the times that
practitioners work reject a typical 9am to 5pm pattern. Rather, the health system or hospital, and
each service department, must make sure that “coverage”, the process of ensuring that someone is
present in case of an emergency, is provided at all times, generating two general patterns of
schedules – shifts and non-shifts. Shift schedules are framed by time, whereas non-shift
schedules, while also roughly framed by time, are more framed by need and completion of task.
There are subtle differences between the two in terms of how we can think about temporal capital.
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Essentially, shifts are bracketed between specific hours. For example, a daytime nursing shift runs
from 7am to 7pm. At 7pm, the daytime nurse is relieved by the night shift nurse. Whereas the
transfer of information may take anywhere from 20 minutes to 45 minutes, according to Kaylee, a
nurse who specializes in oncology (“Kaylee”, personal interview, July 3, 2015), once the
information is transferred to the next shift, the daytime nurse is officially off work. Hence, the
lines between being at work and being not at work are more clearly delineated than for need-
based schedules, which creates a culture of expectation and certainty that correlates with lower
levels of stress.
43
Practitioners who work in shifts, therefore, have greater control over their time
over longer periods of time (even if their time is completely co-opted by work activities during
their 12-hour shift), as they can predict when they will be able to leave, and therefore plan non-
work activities around a predictable and set work schedule.
In contrast, practitioners on need-based schedules have more flexibility in terms of when
they arrive and leave work, which would, at first glance, make it seem like need-based schedules
allow for greater temporal autonomy for practitioners, but this is often not the case. The county
medical clinics are infamous for running way behind schedule, to the point where the shift-based
personnel leave, and the all clinic tasks are left to physicians, as Nasreen, an ophthalmology
fellow, laments. Because the physicians are then left with fewer resources, they end up staying in
the clinic long after it has closed. Moreover, there is a lot of uncertainty in terms of when one
might be able to leave the hospital, which not only affects the physician, but also family members.
Nasreen attempts to sympathizes with the people in physicians' lives who are not in the medical
field:
I really think for you guys who are non-medical too, it takes a lot of
43 Uncertainty and stress tend to be correlated, as studies have shown (Cavanaugh & Sweeny, 2012)
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patience because ... There's so many times, I'm like, I'll be done in 10
minutes and it literally is 45 minutes later. I try to consciously be like,
okay, I should not say I'll be done in 10 minutes. I see the finish line in
sight so I'm like, okay, I'm almost done. It'll be real quick but then you
realize 4 patients have called you and you have to fill these prescriptions
and all this stuff that you have to do before you leave. Then you just don't
realize that all that stuff takes a long time (“Nasreen”, personal interview,
June 24, 2014).
In most cases, physicians themselves have little control over their timing given the number of
tasks that must be completed before day's end. Because they are not shift work employees, they
must stay until everything is finished, adding an element of uncertainty to their temporal rhythms,
often creating stressful situations for both physician and non-medical family/friend, leaving all
parties disempowered and at the whim of systemic procedures and the normative cultural
practices of medicine. In cases like this, it is more difficult to trace who or what has temporal
capital, or specifically how their time is co-opted. Because for the most part, physicians do find
their work meaningful, especially during training as it relates to their future career, the time they
put in, uncertainty and all, is an investment in themselves, and therefore not completely devoid of
agency, despite the frustrations of not being able to plan activities outside of work or be a reliable
person in their non-work/social life.
This trend is so common that the 2005 movie, Saving Face, featuring a young surgical
resident (Michelle Krusiec), contains a scene in which the surgeon is trying to get off work in
time to make it to her girlfriend's (Lynn Chen) birthday. Throughout the scene, she calls her
girlfriend, promising she would be home at a certain time, with each subsequent call pushing the
time back another hour, and another hour. At the end of the night, her attending (Louyong Wong),
on his way home, asks her to take a last minute emergency case. When she finally makes it to her
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girlfriend's apartment, the party is over, and her girlfriend is none too happy. Trying to
communicate when one will be home for dinner, for example, can be an exercise in negotiations
of epic proportions. I remember once, early on in our relationship, my partner, who was in her
first year of residency, called me a little after 8pm to let me know she is on her way home, and to
please wait for her to eat dinner. Three hours (of complete non-communique) later, I get a mea
culpa call from her. She had, of course, a last minute emergency.
Conclusion
The daily temporal dynamics of health practitioners are varied and complex, with
pressures placed on both the individual and institutional levels of interaction. The data and
analysis presented here illustrated only a segment of the various complexities and factors that
affect the daily organization of a health practitioner's time. What is clear is that there are two
levels at which temporal power is negotiated – at the institutional level, and at the individual
level. For the most part, institutional processes and co-option of temporality of individual
practitioners is almost absolute, while temporal negotiations between individuals are enacted
within this larger institutional framework. Temporal capital and autonomy also correlates with
power up and down the training hierarchy, wherein the interchangeability of tasks between
residents and attendings, for example, allows attendings to have higher levels of temporal capital
as they delegate time-consuming tasks to their subordinates, the residents.
Individual temporal power is not absolute. It is heavily constrained by the requirements of
the institution. Temporal flexibility is not necessarily built into the system deliberately, but is
rather negotiated for at the individual level, or is a result of practical functionality of tasks. For
example, while Rory, internal medicine junior attending, is ultimately responsible for patient
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documentation, with the institution expecting him to shoulder that responsibility (and putting in
the requisite time to do so), he relies on his residents to do most of the heavy lifting in terms of
charting, increasing his individual temporal capital. As we will see in the following chapters, the
institution can dictate temporal rhythms, but individuals, in the quest to find more temporal
capital, autonomy, and flexibility, can resist or subvert this institutional imposition of temporality.
While temporal constraints often eradicate any hint of control that practitioners have over their
day, these moments of resistance and negotiation allow for a modicum of individual agency and
temporal capital.
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Chapter 4: Negotiating Weekly and Monthly Schedules
The last chapter took an in-depth look at the daily interactions of practitioners, showing
that, while the institution imposes its temporal logic on the daily rhythms of practitioners, it does
so unevenly, and an individual's temporal capital often correlated with their position within the
organizational hierarchy. Following a similar theme, this chapter will examine how the
institutionalized system of scheduling impacts the lives of health practitioners, and the different
types of power dynamics that are embedded within both the process of scheduling, and the
presence of the schedule itself as a concretized thing into which people's lives are temporally
locked. In health care, daily work schedules and call schedules dictate the actions of a
practitioner, the locations in which they must physically be, or a state of being that may be
disrupted at any moment with a page or a call. A schedule is often not dictated by an individual,
but is an example of how institutional culture works to discipline the bodies of health practitioners
(where they are physically, how they behave, what actions are taken given the authority of the
schedule) and dictate the temporality and temporal rhythms of individuals.
Schedules indicate differing positions within society and are ways in which temporal
capital, and other temporal patterns are enacted. Amy Jordan (1992) found that the adherence to
schedules and to clock time is correlated with the socioeconomic class of families. Families of
higher socioeconomic statuses (SESs) tend to adhere more to a schedule, regardless of whether or
not the task or activity scheduled for that time is completed within the scheduled timeframe.
Jordan uses television watching as an example. While children of higher SES families could
watch TV until a specific time at night, say, 9pm, children of lower SES families would watch TV
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until the program or the movie was finished. Jordan calls this monochronic versus polychronic,
respectively. This study implies that it is not only schedules, but the increased framing of lives
and actions within a temporal framework, that people of higher socioeconomic class statuses take
more at face value as a way of dictating actions, that they are willingly but subconsciously
disciplined to an imagined or self-constructed institution of temporal rigidity mechanized by the
use of and adherence to schedules.
David Harvey (1989) famously discusses the imposition of social power through the
organizing of temporality as it relates to a neoliberal capitalist mentality. Schedules are a physical
manifestation of this temporal control over people's lives through the way it dictates where we are
and what we do at any given day or time. Even self-created, they concretize and map out one's
actions, the course of one's life, throughout a day, a week, a month, a year, or over the course of a
few years. In the case of health practitioners, schedules are yet another institutionally imposed
function that dictates one's day. Schedules, then, are both externally imposed and self-imposed,
adding another layer of regulation to one's life temporal structure. Moreover, how struggles of
power happen, and how individual agency are negotiated during the process of creating a
schedule reveal power differentials between individuals, and between individuals and institutional
expectations, along the hierarchical lines that we have seen throughout this project. Often,
schedules are not imposed in any official way, as Nasreen, ophthalmology fellow, mentions:
we schedule our own patients so that we have control over when they
come, so that we can play the system a little bit. That's something you learn
as you are here longer. When is it safe to see patients? When is it not a
good time? When is it really busy in clinic? When is it not as busy?
(“Nasreen”, personal interview, June 24, 2015)
Health practitioners' work functions and activities are framed by schedules. These
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schedules range from minute to minute bookings of patient appointments throughout the day for
clinics, to hour by hour schedules for surgical procedures, to days and weeks and months of
scheduling different rotations, coverage, call schedules, and holidays. There are two types of
schedules that govern these temporal rhythms – work schedules, which dictate when health
practitioners must be physically present at a health care facility or site with specific duties and
functions for a set amount of time, and call schedules, where the practitioner does not have
specific work activities, but must be available to attend to any emergencies that may occur.
Schedules, both regular work schedules and call schedules, represent the physical manifestation of
patterns of power through its organization of individual bodies and behaviors. The way that
schedules are made, and the way work and call schedules interact with practitioners' non-work
schedules and obligations longitudinally reveal interesting processes of negotiation within the
requirements of the institution, ritualistic and cultural practices, and challenges. After all, making
a schedule, while supposedly a rational and objective process, may not always be perceived as
fair. Emotions can potentially run very high during these negotiations at times, and the power that
individuals have other others' schedules also also have institutional and cultural implications that
weigh on the lives of individual practitioners.
Throughout this chapter, we will see broadly two things. First, while institutional
processes often trump individual agency, the more power one has, the more authority one has to
schedule one's own time and negotiate agency within the rigidity of institutional imposition, thus
creating a modicum of predictability in one's schedule, leading to a state of higher temporal
capital and more control over one's time. With more ability to schedule, one is less bound by
unexpected co-optations of one's temporal capital, thereby decreasing levels of uncertainty and
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stress.
44
Indeed, a 2001 study by Fenwick and Tausig found a “lack of scheduling control had
strong negative effects on...family and health outcomes” (Fenwick & Tausig, 2001, p. 1179)
independent of whether the work is standard or non-standard hours. Secondly, and more subtly,
the act of scheduling call and work schedules in a seemingly more democratic process without an
authoritative figure or a structure of power can sometimes be more challenging than if an
authoritative figure were present. The presence of an authoritative figure, in a way, allows for less
time and less anxiety that is spent negotiating schedules within a group. When there is someone
controlling the schedule, the individual, in a way, realizes that time is out of their hands, and
needs to just live with the schedule. As we will see later, a more democratic approach to
scheduling may end up taking more time overall, and induce feelings of stress and anxiety. What
is interesting to note here, is that residents, who have lower temporal autonomy, are more
protective of their time than attendings, and, in the data that was collected for this project, tended
to indicate that the scheduling process was more stressful than the scheduling process for
attendings.
While Chapter 3 discussed the micro-temporality of hour to hour schedules, this chapter
expands the temporal spectrum and explores schedules by days and weeks, sometimes even
months. Because the health care industry never rests, the individuals that run it also never rest,
and the institutional purview of the industry must ensure that proper coverage is maintained at all
times. The mechanism by which said coverage is maintained is most often done through the
process of scheduling both regular work and call schedules so that even if a practitioner is not
physically present within the vicinity of a hospital or clinical facility, they are easily accessible
and can address emergency situations as needed. The autonomy one has in both the process of
44 As was referenced in the last chapter, there is a correlation between uncertainty (while waiting to hear back about
feedback) and stress (Cavanaugh & Sweeny, 2012).
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scheduling, and the actual nature of adhering to the set schedule has interesting implications for
one's temporal capital as well as one's ability to balance one's life outside of work. Following the
general hierarchy of an organization or training process, those higher up on the food chain tend to
be able to not only control others' time and dictate when their underlings are on call, but also have
more control over their own schedule through institutional rules and ritualistic practices.
Much work has been done the social, cultural, and organizational implications of
schedules and structure in relation to time management. Personal control over one's schedule
tends to have positive behavioral outcomes (Krausz, Sagie, & Bidermann, 2000), which falls in
line with the notion that increased amounts of temporal capital – having more time under one's
control, including one's schedule – leads to greater life satisfaction and happiness. Krausz, Sagie,
& Bidermann (2000), in an effort to interrogate the long-held notion that part-time work was less
desirable than full time work, did a study on the schedules of nurses in Israel, which found that
actual work schedules (ie: part time vs. full time, or hours worked) had little impact on variables
like job satisfaction, organizational commitment, and burnout rates. Rather, the preference of the
individual for their work hours correlated more strongly with job satisfaction and organizational
commitment. For example, if an individual wanted to work more and had a heavier schedule, they
were found to be satisfied with their schedule. On the other hand, if an individual wanted to work
less than their actual schedule, they had higher burnout rates. The ability for one's schedule to
intersect with a normal temporal pattern also has not only an impact on life satisfaction and
relationship maintenance (Sagie & Krausz, 2003), but also, for nurses working either rotating
shifts or night shift, one's health. Similarly, scholars found that nurses who worked a rotation shift
rather than a fixed shift had more predilection to leave the profession, which falls in line with the
idea that predictability and stability in schedule correlates with higher levels of satisfaction
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(Krausz, Koslowsky, Shalom, & Elyakim, 1995). Moreover, low control over one's schedule, as
Sagie & Krausz (2003) found, was correlated with higher levels of burnout and decreased
organizational commitment as work demands increased.
How schedules are scheduled often depends on the occupation and position of the
individual (Beers, 2000). Often, individuals in managerial or executive positions tend to be able to
have more flexible schedules (Sabelis, 2007), whereas occupations like nurses, teachers,
firefighters, and factory workers who have jobs with set times, or shifts, tend to have lower
amounts of flexibility in their schedule (Sagie & Krausz, 2003),
45
or using the language of this
dissertation, lower levels of temporal capital. Interestingly, shift work, while temporally
constrained on an hour by hour basis, may actually lead to greater degrees of temporal capital on a
macro-level, with the ability to schedule non-standard (non 9-5) work hours in order to balance
non-work obligations. There has been a shift toward flexible working hours, with a quarter of all
workers able to vary their schedules by around 2000 (Beers, 2000).

This percentage has leveled
off and has not increased significantly since then (Flexible Work Arrangements: The Fact Sheet,
2010). There are roughly two kinds of flexible work schedules. One is the “gliding schedule”
where one must work a set number of hours a day, but can alter the start and end times. The other
is when one can choose what days to work, as long as they reach a certain number of hours in a
certain period. Additionally, there is the rotating shift schedule, in which the day to day or week to
week schedule alters depending on industry and personal needs (Beers, 2000). Furthermore,
alternate schedules, or non-standard working hours, are common in industries that are needed
24/7, as, for example, the health care industry. Alternate hours, night shifts, and rotating schedules
are very common among health practitioners, and particularly in nursing, where shift work is the
45 The same study also found that whites had more flexible hours than Hispanic or black individuals. Strangely, but
perhaps unsurprisingly, Asian individuals are left out of the mix...
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prevalent schedule structure used.
Carol Peckham (2015b) found that the number of hours worked is the second most
common cause of physician burnout, but most interestingly, that having control over one's
schedule and number of hours worked, or in other words, being able to extract some modicum of
temporal capital and autonomy during one's work day, is the strongest predictor of a work-life
balance and emotional well-being (Keeton et al., 2007; Lyness, Gornick, Stone, & Grotto, 2012).
The RAND corporation, in a report on physician satisfaction, similarly found that satisfaction in
one's job correlated positively with the ability to choose one's own schedule, as well as having
flexibility to engage in non-work activities outside of medicine (Friedberg et al., 2013).
The Structure of Schedules
There are a few different levels of scheduling that are especially relevant for medical
residents. We can think of schedules from the macro-level to the meso-level to the micro-level. A
macro-level perspective of scheduling, or the rotation schedule works on the spectrum of months
and years and involves the schedule for the different rotations that medical residents must
undergo, which often involves rotating through different sites or facilities. For example, there are
9 residents in the second year ophthalmology residency cohort. The annual schedule for this
particular cohort is divided into roughly 9 rotations, with 6-week rotations each. Throughout the
year, ophthalmology residents will rotate through the 5 or 6 different sites that constitute the
ophthalmology program at University Medical Center. Each resident will spend 6 weeks at one
site, then 6 weeks at another site, and so on and so forth. Rotations are identified mainly by
facility or site, with the exception of the main University Eye Clinic facility, which is designated
by both site (University Eye Clinic, County Medical Center 1, County Medical Center 2, the V A
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Hospital, etc) and subspecialty (retina, cornea, glaucoma, ocular plastics, etc). The order of each
resident's rotation is scheduled out for the entire year before the year begins. The residency year
begins in July, so the rotation schedule is finalized sometime in the spring of that year. The
rotation schedule, which is made and finalized by the ophthalmology residency program
administrator, needs to take into account the residents' preferences, the residents' vacation
schedules (as some rotations do not allow for vacations), and the needs for each facility.
Then there is the meso level of scheduling, or the weekly schedule. For 3
rd
year
ophthalmology residents, the weekly schedule, which is loosely structured, dictates when each
resident will operate versus when he or she is in clinic. When there are two residents at a facility,
they will simply switch off every other day for surgery. A weekly schedule that includes operating
time is important because the program requires a minimum number of cases for each specialty in
order to graduate from residency. For attendings whose contracts require them to be at multiple
different locations, their weekly schedule dictates where they will be on what day. Additionally,
for the attendings in ophthalmology, a weekly schedule similarly dictates when they are able to
have dedicated OR time. Dedicated OR time is important because that is the time when an
attending can schedule their patients for surgery. For nurses, their full-time status is framed by the
weekly schedule. For a clinical nurse to be considered full time, he or she must work three 12-
hour shifts per week, with a fixed start date per week (usually a Sunday).
Finally, the micro-level perspective considers the schedules of an individual on a day-to-
day basis, or a night-to-night basis for night shift practitioners. Because the hospital is in service
24/7, there is a need for basic coverage for all hours, yet the extent of coverage varies depending
on the facility and the specialty. While there are a few different ways in which we could broach
the subject of day to day schedules – by facility (regional medical centers vs. community
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hospitals vs. county medical centers vs. VA clinics vs. private practice), by specialty, etc – I will
take one in which the health practitioner is the central unit of analysis. In other words, I will
concern myself with how the health practitioner experiences their schedule. These schedules can
be roughly parsed out into two different categories - those for which compensation is provided by
the amount of time worked (temporally-determined schedules), which is akin to shift work, and
those for which compensation is set regardless of number of hours worked. This is largely the
difference between non-exempt and exempt employees – the former of which is paid hourly,
while the latter is on salary. We can also roughly think of it as shift vs. non-shift work, wherein
shift work allows for overtime pay, while non-shift work does not. However, as we will see, the
other factor for compensation for the latter, exempt individuals often is the number of patients or
cases they encounter or complete.
For temporally-determined schedules, these are generally services that need to be covered
with a similar amount of coverage at all times.
46
Most nursing services, non-clinic services,
inpatient services like hospitalist/internal medicine and the emergency department (ED) adhere to
some form of shift work. Practitioners in these shift work services may have a more erratic
schedule from day to day or week to week, depending on when they are scheduled to work. An
individual practitioner may have a schedule that places them on a day shift for an entire week,
then a mix of day and night shifts the next week. As such, for nurses whose full time schedule
consists of three 12-hour shifts, they could conceivably work Sunday, Monday, Tuesday, then not
again until the next Thursday, Friday, and Saturday, allowing for a 7-day break. Unless they are in
administration, nurses tend to have non-set schedules from week to week. While there are some
nurses who consistently do day shifts, like Clara (geriatrics) and Kaylee (oncology), and those
46 Beers mentions this in his analysis of different types of schedules as well (Beers, 2000, p. 37).
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who do night shifts like Xander (intensive care unit) and Dawn (neonatal intensive care unit),
there are also nurses who have to do a mixture of the two, depending on demand and their
seniority. As a matter of fact, day shift nurses tend to be more senior and more experienced,
simply because overnight, patients are less active than they are during the day, since they tend to
be asleep,
47
requiring less active treatment and medicating. Therefore, we see that night shift
nurses have relatively more downtime during the night to engage in other non-work-related
activities without neglecting their duties.
Many nurses in inpatient units (not clinics) adhere to a strict 12-hour shift. Anyone who
stays over gets paid overtime, something that Dawn brings up. In her experience, her charge
nurses – the nurses in charge of staffing for their particular unit, were
big stickler[s] on is staying late past your shift. They almost always never
want you to do that. Mostly because there never should be a need, because
the next shift should always be coming in, so we have had some nurses that
are like, I don't know their motivation, some nurses are motivated by the
extra pay and will be, “Oh, I don't mind, I'll stay late.” And the charge
nurses will really be like, “No, you need to pass on report, and you need to
go home” (“Dawn”, personal interview, October 13, 2014).
In the case of these nurses, their hours are enforced directly by an authoritative figure, and also
enforced through the institutional labor rules governing work hours and overtime pay.
Additionally, the nurses' actual time worked is also influenced by the success of the scheduling
system – that the “next shift should always be coming in,” indicating that there is no systemic
shortage of staff, which leads naturally to a reluctance to pay overtime for an individual whose
labor is not needed. Therefore, in these nurses' cases, their actual time worked, and their temporal
47 Kaylee (July 3, 2015), Xander (November 12, 2014), and Dawn (October 13, 2014) have all expressed this
sentiment in their interviews with me.
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rhythms, are strictly framed within the structure of 12-hour shifts. If they stay a few minutes later,
or come in a few minutes earlier, that is on their own time, and their pay is not congruent.
Therefore, their compensation is tied directly to number of hours worked, and forcing the nurses
to leave work at a certain hour in a way also makes time the schedule structure of their labor,
rather than the patients. Put this in contrast to the resident who does not leave clinic until all of the
patients are seen. In this case, the resident's time depends on the completion of work, rather than a
clocking-in, clocking-out mechanism.
A slightly different structure is evident in the anesthesiology department at University
Medical Center. Anesthesiologists at University Medical Center technically have “core hours”
(Beers, 2000, p. 34), which for someone like Rose, the junior cardiothoracic anesthesiology
attending, is from 7am-3pm Monday thru Friday. Anesthesiologists get overtime pay as well if
they happen to work outside of these hours, which is very often, given that they are a surgical
specialty that often handles emergency cases. Similarly, these anesthesiologists are paid extra to
be on call, and even more if they physically have go into the hospital for a case. Because of the
varying combinations of call pay for different subspecialties and individuals, the anesthesiology
department at University Medical Center bases their structure of physician compensation on the
hours worked outside of a core number of hours. In this way, anesthesiologists function in a way
that is in between the nurses and “exempt” employees that I will talk about in the following
section. The reasons why anesthesiologists' compensation and schedule structure are this way may
be multi-fold. On one hand, if an anesthesiologist is needed, the case is likely to be very severe
and urgent. Therefore, the hospital will need coverage of personnel who can perform the functions
needed for an emergency surgery during any hour of the day. With the operating room (OR) only
scheduled during the day-time hours, with just a few rooms available in the middle of the night
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for emergency cases, there are more resources needed during the set OR day hours where
surgeries are guaranteed to happen, necessitating the use of “core hours” for anesthesiologists.
There is no need to have regular anesthesiologists staffed at night, because the OR is only used in
case of an emergency. Additionally, unlike other specialties,
48
an anesthesiologist needs to be
within 30 minutes of the hospital at all time when she is on call, severely limiting their scope of
non-work activities. In this way, an anesthesiologist's control over her own schedule must fit
within the constraints set out by the staffing requirements of the hospital. We will see later that
individual power dynamics are often negotiated and deterministic of an individual's schedule.
Finally, there are practitioners who function more akin to an “exempt” employee, and they
have what is similar to the anesthesiologists' “core hours,” which dictated by when their service is
“active” or “open.” Unlike the shift work practitioners, however, any additional time outside of
“business hours” - for example, when the clinic is open and actively seeing patients - is not
considered overtime, nor is taking call. For ophthalmology, their days are dictated by when the
clinic and the OR rooms are open for pre-scheduled patients who have appointments, or who have
been scheduled for surgery. Hence, an ophthalmologist's time, in this case, is determined by the
institutional system – by when the clinic and the OR are open. Their daily schedule is not of their
own doing, but governed by the institution of whichever health care system, hospital, or facility in
which they work. Anesthesiologists' core hours are also based on these institutionally-determined
“active” hours. As I had alluded to earlier, Rose's core hours are from 7am to 3pm Mondays thru
Fridays, which is when the OR is open. Of course, the OR is open on an as-needed basis after
hours, at which time Rose is then additionally compensated should she be required to work for
48 For example, Nicholas, an ophthalmology resident, in his interview, states that he will occasionally travel 45
minutes to an hour away for a basketball game even when he is on call, as the vast majority of eye cases are not
severely urgent in the way that many anesthesiology cases are (“Nicholas”, personal interview, October 9, 2014).
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longer, unlike the truly “exempt” or work-based practitioners.
In the ophthalmologists' cases, however, partially because of the lower acuity of the
cases/patients they see, and partially as determined by their department, they will be in clinic, or
in the operating rooms at set times for the most part. In their world, there is no such thing as
overtime. If an ophthalmologist gets called in to do an emergency surgery to fix a “ruptured
globe,” which is a condition in which there is some trauma or puncture to the eye that bursts the
outer tissue of the eyeball,
49
they do not get additional compensation for the time they spend
prepping and doing this emergency surgery. Likewise, they are not additionally compensated if
they are called in the middle of the night to answer questions or provide support and supervision
to their subordinate team members. Nursing administrators and unit directors also adhere to a
similar schedule. While they are at work roughly from 8am til 5pm, Monday through Friday, they
have some flexibility in terms of when they must start and end work. Their timed labor is not
under the strict regimented temporal prison as, say, the clinical nurses, who must be physically
present at the hospital at a certain time. For example, at the eye clinic in the County Medical
Center 1, the clinic opens at 8:30am, when the first patient is scheduled, and closes at 4:30pm.
Physicians will show up anywhere from 7am til 8am to prepare for the day, and stay until the last
patient is seen. This is an example of the need-based schedule discussed earlier. Additionally
outside of these hours, these practitioners often have to take call outside of the time that their
office is “open.” There are both pros and cons for this type of flexible schedule. Whereas this
gives the practitioner more autonomy throughout the day, and a stable schedule weeks or months
on end, there is also the danger of being overworked with no compensation. At least with shift
work, the practitioner is compelled to leave work and have a life. With flexible, exempt type
49 Yes, it is as horrifying as it sounds.
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work, which is often reserved for individuals higher up in the organizational ladder (ie: nursing
directors vs. clinical nurses), one finds that one works all the time.
50
This calls to mind the
contradiction of speed, or in this case, flexibility, that was mentioned in Chapter 2. The more
flexibility and autonomy that one has, the less time one actually might find oneself has outside of
work. This may not, though, necessarily mean a dearth of temporal capital, especially when one
considers one's work as meaningful (a dynamic that will be further explored in Chapter 6).
However, because of the lack of additional compensation for many specialties, the process of
scheduling and taking call, as we will see later, can often reveal interesting power dynamics that
can have an impact on the emotional well-being of the practitioners.
The different types of schedule often have differing levels of temporal capital in different
ways. Shift work allows for the disaggregation for work and non-work time more finely than non-
shift work, allowing individual practitioners to step away and absolve any work responsibilities
while at home, and potentially having more flexibility with their schedules on a macro-level. A
friend who is a nurse tells me that she is able to schedule her shifts as such that she gets a week-
long vacation every other week. With non-shift work, practitioners have more micro-temporal
flexibility to blur work and non-work time, especially with the plethora of communication
technologies that allow this (discussed more in Chapter 5). However, there is the danger of
working all the time and being unable to shut work off while at home. Hence, temporal capital
and temporal flexibility differs depending on the structure of the schedule that one's profession
dictates. Furthermore, the structure of the schedule, often as related to compensation, becomes a
decision-making factor in aspiring health professionals, as will be examined in Chapter 6.
50 Sabelis (2007) found that this was true for CEOs and academics, aided by technological advancements in
communication that allowed individuals to always be connected to work.
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Rotation Block Scheduling for Residents
While the varying types of schedule represents the institutionally mandated temporal
rhythm by which personnel work is framed, the power dynamics at work between individuals
given the relevant social hierarchy serves to negotiate individual agency within the constraints of
a schedule. Following the patterns that we have already seen, the higher up one is in the hierarchy,
the more temporal capital one ostensibly has. Work schedules, especially those in shifts, are often
determined by those more senior – either a senior attending or the chair of a department for other
attendings, a program director for residents, or a charge nurse or a nursing director for nursing
staff. For the most part, practitioners are able to put in preferences for work schedule, and for days
off, and again, for the most part, their supervisors will take their requests into account, usually as
one of the main factors in the schedule-making process. However, sometimes not all requests and
preferences can be honored.
At University Medical Center, the rotation schedule for residents is made out for the entire
year before the year starts. The residents themselves are categorized and labeled by, and their
duties based on, their year in the residency program – first year resident, second year resident, and
so on, with a strict understanding of hierarchy and seniority. Similarly, the idea of HOW to make
a schedule has been passed down form cohort to cohort. For ophthalmology residents, this ritual
of schedule making is also mediated by the same administrator, Cassandra, who has been at
University Eye Clinic there for 15 years (“Cassandra”, personal interview, July 2, 2015). The
scheduling of rotations is cyclical, with the residency year starting in July and ending in June of
the following year. A resident physician is considered a 1
st
year resident on June 30
th
with all the
limited duties and responsibilities thereof, and is suddenly then considered a 2
nd
year resident,
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with a different set of duties and responsibilities the day after on July 1
st
.
51
At the same time, the
rotation schedule for the entire 2
nd
year of that resident's residency would be determined by June
30
th
in preparation for the start of the new cycle.
Zerubavel (1979) has discussed this step-ladder model of residency training, pointing out
the rigidity of the expectations, and the way these expectations and scope of duties systematically
increase drastically within one day. Rather than gradually increasing the responsibilities for an
individual over the course of a year, new responsibilities are suddenly thrust upon them in the
course of a day, and the resident is expected to perform at the same proficiency the first day as the
last. Hence, there is a pervasive
mentality that, for example, all second
year residents, regardless of whether it
is their first day on the job or their 200
th
,
should be able to handle the
responsibilities of a Second Year
Resident, highlighting the
interchangeability, and the correlating
dehumanization, of individuals fulfilling
set roles in a training hierarchy. In
ophthalmology, second year residents spend most of their time seeing patients in the facilities'
outpatient clinics. In the course of one day, they become third year residents, and spend most of
their time doing surgeries. The shift of the day-to-day schedule and the expectation that seniors
51 The joke around the medical community is that one should avoid getting sick and hospitalized during the month
of July, because it is a time of transition where people's responsibilities increase and there are a lot of mistakes and
confusion as these residents, fellows, and new attendings step into their new roles. Perhaps it is not much of a joke...
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place upon them is quite drastic. This rotational schedule is felt less with nurses and attendings,
who tend to have a similar scope of duty and schedule all year round, barring individual variations
in promotions or schedule changes. There has been a recent exception related to University
Medical Center, however. One notable incident where an attending had to change her schedule is
with Sally, the junior ophthalmology retina attending. In 2014, University Eye Institute bought out
the other major eye institute in the area, which resulted in a complicated combination of faculty,
staff, and patients. Because of this, attendings were required to spend some of their time at the
various sites that belonged to this other eye clinic, and now belongs to University Eye Institute.
Sally was one of the attendings who now splits time at one of these new facilities, in addition to
the main University Eye Clinic site. Hence, her schedule was disrupted outside of the step-ladder
model of training (as she is no longer in training), yet was still dictated in large part by the needs
of the institution. Moreover, she found herself having to change her entire schedule around
beyond simply the time required for work because of the traffic and additional travel time to these
new sites. In order to avoid bad traffic on her way home, Sally says, “I just started to just hang out
in Pasadena after [work], because I have enough friends on that side that I don't see enough, so it's
been a good opportunity to see them regularly” (“Sally”, personal interview, June 17, 2015). In
this way, University Eye Clinic as an institution has imposed its expected temporal on Sally, yet
she is able to resist its total colonization and recuperate temporal capital by finding ways to
maintain her social capital and spend time with her friends.
The process of scheduling the rotation schedule for residents is paradoxically simple and
complicated. Each resident must rotate through each rotation at least once. Rotations include both
specialty (glaucoma, cataract, retina, ocular plastics, etc), and location (County Medical Centers 1
and 2, University Eye Clinic, the VA, etc), with locations corresponding to concentration specialty
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and duties (clinic, surgery, consult). The more residents there are in a cohort, the shorter each
rotation will last. Simple enough. However, this is complicated by the fact that each resident is
allowed 4 weeks of vacation, split up into 4 one-week vacations, throughout the year. Residents
are able to submit their preferences for vacations, which creates one limitation variable in
scheduling. Another limitation variable comes from the fact that some rotations do not allow
residents to take vacation if they are on that rotation. For example, 1
st
year ophthalmology
residents have a consult rotation, where the duties consist of answering questions that other
physicians might have for their inpatients (patients staying overnight at the hospital). Because
there is only one resident on that rotation, he or she is not allowed to take vacation for the
duration. Additionally, there are certain rotations, like the elective rotation during which residents
can either do research or practice surgery at a site of their choice, that cannot have two
simultaneous residents. Yet another limiting factor lies in when individuals want to do specific
rotations for fellowship purposes. In the 3
rd
year of residency, many individuals apply for
fellowships, during which they will subspecialize in something – glaucoma, retina, cornea, ocular
plastics, to name a few. If someone wants to do a retina fellowship, it would greatly behoove them
to do a retina rotation early on in the year so they have that experience to speak of when they
apply for fellowships. Because of this, in February 2015, when the negotiations for the 3
rd
year
ophthalmology resident schedule was in full swing, this caused much tension within the cohort, as
multiple people were vying for early retina rotations with the intention of applying for retina
fellowships. These limitations help create the framework into which individuals must wedge their
lives over the year.
The negotiating of the schedule itself amongst individuals, which was done in large part as
a democratic process with everyone hypothetically having an equal say. The residents discuss
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amongst themselves what kind of schedule they want, make the schedule according to everyone's
preferences, then report it back to the administrator. The reality is far from the hypothetical. First
of all, the question becomes, who amongst the nine residents, who are all 2
nd
year residents
entering their 3
rd
year and therefore theoretically of equal status within the University Eye Clinic
hierarchy, will take it upon themselves to (spend the extra time and) centralize the preferences and
the limiting variables, and take a stab at making a draft of the physical schedule? Whoever does
this, the other residents worry, might bias the rotation schedule to suit their own needs. Then there
is also the struggle of trying to please everyone in the group, and the larger the group, the more
difficult this is to do. This particular cohort of nine is one of the largest cohorts that University
Eye Clinic has had. The year above them has six residents.
What is interesting here is that that this is a not simply negotiating for certain rotations,
but this is a struggle to dictate one's schedule – to have control over one's time, not necessarily on
a micro hour by hour level, but throughout the year, on a macro-temporal level. The notion is that,
by having control over one's rotation schedule, one not only will have a sequence of rotations that
is desirable depending on non-work obligations like coordinating family vacations, but will also
have an impact on one's fellowship application. Hence, the residents try and negotiate for the
highest levels of temporal capital over a long period of time, which can be then exchanged for a
more desirable fellowship program,
52
perhaps one that is in a desired location, or one of a desired
reputation. This control, or autonomy, is clearly important to allow these individuals to be in
better positions to be able to map out their own future, not just for the next year, but also for the
52 “Desirable,” in this case, is pretty subjective. Like graduate school or academic positions, many different factors
impact desirability, and these factors are all different for different people. In this case, it is not so important to
define an objective sense of “desirability,” but rather to parse out the payoff that the individuals feel they will get
given their own definitions of desirability and the varying priorities they place on which fellowship is most
attractive.
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next several years. This future-facing mentality hearkens back to Robert Levine's work on future
oriented perspectives, in which this temporal investment goes into ensuring future-oriented goals,
delaying gratification. Most importantly, in accordance with studies on autonomy and happiness
that was discussed in Chapter 1, the ability to control one's own future on a macro time scale, the
autonomy over one's time over a course of many years, is instrumental in a higher quality of life,
and higher levels of happiness.
As far as the practitioners themselves understand, there are no laws or policies on the
governmental level governing the process of scheduling work or call. This is done by program,
and each different program at different institutions will have a different rotation schedule, similar
to how different universities have different requirements for different major tracks. This is
interesting to think about because the act of scheduling is then ritualistic, and few question WHY
their time is framed in this particular way. The co-option of time falls into the realm of “well, it
has been done before” rather than a more interrogative and rational process. The power of the
institution to dictate schedule requirements, then, while absolute, is also arbitrary, dictated less by
laws and policies, and more by the obligations that the health facility has toward its patients.
Daily and Weekly Scheduling
As I mentioned earlier, studies found that the predictability in schedules leads to higher
satisfaction, showing that temporal frameworks directly impact the emotional well-being of
individuals. More predictability indicates higher levels of control over one's time, decreasing
levels of uncertainty. Vera, the nurse in the ophthalmology clinic at County Medical Center 2,
switched from being a nurse in a convalescent home to being in an ophthalmology clinic. While
she laments the decreased levels of direct patient care she experiences, stating, “I was putting in
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G-tubes and trachs, and ventilators, and how I'm just putting drops in eyes (laughs) (“Vera”,
personal interview, February 18, 2015)”, she prioritized a more stable and predictable schedule.
For Vera, the ability to have a predictable schedule – to feel like she has control over her week –
trumps the fact that she was able to do more in terms of clinical duties at the convalescent home.
We can see here that her ability to control her schedule is highly important to her, and her
temporal capital is fulfilled through a predictable schedule.
Conversely, having little control over one's schedule can lead to frustration, and is often an
indication of one's lower power status within the organization. Willow, an emergency physician in
a military hospital the rural south, finds her schedule often at the whim of other physicians
contracted by the hospital. Because she is bound to the military, which pays for medical school in
exchange for 8 years of service,
53
what she wants is not a priority. Because she is stationed in the
rural south, where physicians are harder to come by, contracted physicians who are willing to
spend some time in service to the military hospital get first pick in terms of schedule. Willow and
the other military physicians must fill the hours that the contracted physicians do not want. The
military hospital as an institution has a certain number of hours of service that needs to be filled,
which are non-negotiable, and Willow furthermore finds herself in a position where she is unable
to negotiate for a more desirable schedule because of her obligation through the military's loan
forgiveness program, following the low power, low temporal autonomy pattern.
For the day to day micro perspective of scheduling, getting OR time in surgical specialties
and mixed specialties (like ophthalmology) can prove to be a challenge. In ophthalmology,
because the specialty consists of both outpatient clinic and surgical procedures, the fellows and
attendings are given blocks of OR time when they can schedule patients who need to undergo
53 There is information on how to pay for medical school at this website:
http://www.startmedicine.com/app/medicalloans.asp
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non-emergency surgical procedures. These blocks of time are a part of their weekly schedule.
Sarah Jane, junior ophthalmology attending, explains that junior attendings have very limited OR
time. She is in the OR about a half day a week, but only has around one day a month of OR time
that is dedicated specifically for her and her patients. She states that her scheduled time for
surgery is
like the 5
th
Thursday of the month, which rarely happens, so other
Thursdays. The room technically belongs to another attending, but if he's
out of town, which he often is, then I'll take it, by default...Most of the
time, well, if it's not an emergency, then yes, I'll say [to the patient], “Well,
we'll try to book you around a month or a month and a half,” it'll fall on a
day that I'm scheduled to be in the OR. [but then, t]here are often times
when the patient comes in and you're like, “Oh, you need surgery right
now” (“Sarah Jane”, personal interview, February 17, 2015).
In those emergency cases, she states, it becomes a balance of finding an open surgical room for
the next day. Fortunately, at University Eye Center, “someone's always being invited for a lecture
somewhere or traveling...so we manage. It's difficult though, it happens. You can't even say my
case is more urgent than your scheduled elective case. We can't ever bump them, because that's
their block time” (“Sarah Jane”, personal interview, February 17, 2015). She also goes to state
that “mostly the more senior attendings get the bigger blocks of time. That's just kind of how it is.
Or the busiest. If you can show the OR staff that [you have the need]” (“Sarah Jane”, personal
interview, February 17, 2015).
There are a few things going on here. For one, junior ophthalmology attendings seem to
constantly find themselves in a precarious scheduling position by balancing the time they have
dedicated in the OR with the patients who need non-emergency surgeries, but then also needing to
“borrow” time from more senior attendings who have larger chunks of dedicated OR time who
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may just happen to be out of town for various other activities. Seniority clearly plays a role here
in terms of the ability for these physicians to plan their schedule around the needs of the patients –
the more senior one is, the more latitude he or she has to schedule patients into dedicated OR
slots, rather than scrambling around to find an open room, or hope that a senior attending did not
fully book their OR time so an urgent case can proceed, or “go”. Junior attendings, subsequently,
exist in a state of uncertainty in terms of booking OR times, and are less able to control when
their patients get surgery. There is also an added level of stress of not being able to book an
emergency case because a senior attending has the OR blocked out for that time. In this way,
Sarah Jane's uncertain schedule compels her to exist in a lower state of temporal capital, ready to
snatch up OR time as it presents itself. Her daily and weekly schedules are at the whim of the
vacancies provided to her by senior attendings.
Sarah Jane also implies that if one can prove that one is busy and bringing in “business”
(also known as “surgical cases”) they will get allocated more OR time as well. The OR is
scheduled by University Medical Center staff. The salary of the attendings, either as part of
University Medical Center staff or contracted with the medical center, is intertwined with
University Medical Center's revenue. Therefore, if an individual doctor can prove that she can
bring in more surgical cases, thereby benefiting both themselves and University Medical Center
as the overseeing institution, more time will be allotted for that individual to access the OR,
thereby allowing that individual physician to have more control over her time. Hence, the
exchange of more temporal capital – more ability to schedule one's time between the OR and
clinic – has a monetary impetus as well, and the institution will seek to grant that temporal control
to those individuals who will reap the greatest monetary benefits for the institution. In this way,
the individual physicians themselves, through their ability to control their own time, cannot
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escape their roles as laborers in a capitalist institution, caught between the needs of their patients
and the capitalist impetus of the health care system.
Sarah Jane's surgical experience is that of an attending at University Eye Clinic. At other
non-University Eye Clinic facilities, the scheduling works a bit differently, especially when
residents are the ones responsible for scheduling patients and performing the surgeries. Residents
technically have no officially dedicated OR time, but OR time is readily available to them for
non-University Eye Clinic facilities (mostly County Medical Centers 1 and 2, and the VA)
because at all facilities other than University Eye Clinic (which is a private clinic with patients
who have insurance, so attendings are obligated to personally do the surgery), surgeries are done
by residents with an attending staffing the case.
54
The schedule of ophthalmology surgeries
depends on a wide variety of factors. Ophthalmology surgeries take place in the Main OR. Other
than at University Eye Clinic, where ophthalmology has its own dedicated operating rooms,
ophthalmology is generally allocated certain rooms at certain times each week for eye surgeries.
Therefore, when a resident needs to operate on a patient, the resident will tell the OR scheduler
that the patient needs to be seen. The OR scheduler will then consult with the rules by which they
have to abide,
55
and figure out when, for example, a retina case can be scheduled, depending on
when the retina attending will be working. Each case obviously has to match up with an attending
who can oversee the surgery being performed.
Figuring out when attendings are working, however, is a practice in unpredictability. Since
every case needs to be staffed by an attending, the resident must make sure that an attending
whose subspecialty matches the case is working at the time of the surgery. At County Medical
54 University Eye Clinic, unlike the other facilities where ophthalmology cases need to be scheduled in the main OR
which is shared by all specialties in the hospital, has its own OR with 5 rooms. What luxury!
55 Rules for when certain attendings are available and present in the facility (ie: retina cases on a Monday)
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Center 2, while there is set schedule for when attendings should come in to work, except for one
or two very consistent attendings, some of them occasionally forget to come in. As for the
residents, their hour to hour schedule depends closely on when an attending will work, and they
often resort to emailing the attending the day before the surgical date, and sometimes the day
before, confirming that they will, in fact, be present for scheduled surgeries. As such, the
residents' schedules are subordinate to the attending schedules, and are affected by the potential
fickleness and forgetfulness of attending schedules. Indeed, at County Medical Center 1, the
resident will not know who the patients are and what the schedule is like until the day before the
surgery.
56
I was able to sit in on a “signout” for the 3
rd
year ophthalmology residents. Signout is the
process by which previous practitioners at a certain site, or a certain shift, hand off patient
information and any other relevant information to the next person coming on to take their role.
This signout occurred the day before the new rotation for the residents began, and was a very
casual affair. The three individuals relevant to this particular exchange met at County Medical
Center 2, in one of the ophthalmology workrooms. Martha, who was previously at County
Medical Center 1, was signing out to Inara, who was going to County Medical Center 1 her next
rotation. Inara, who was previously at County Medical Center 2, signing out to Martha and
Nicholas, who were going to be taking over for her the next rotation. Nicholas would have done a
separate signout to the person who was going to take on his previous role at the VA Hospital, so
he did not have to sign out on this particular day. His role was to absorb the information given by
Inara about County Medical Center 2.
This particular signout, the first rotation change and signout of the year, took a little under
56 The information in this section was obtained through observation of a signout process between Martha, Inara, and
Nicholas on August 8, 2015.
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two hours on a Saturday morning. The residents themselves arranged for the signout to happen –
this was not institutionally imposed or structured. First and second year residents' signouts usually
only took about half an hour, but because of the intricacies of the surgical scheduling procedures,
as well as the complexities and challenges that I laid out above, the signouts for 3
rd
year residents
take quite a bit longer. Indeed, a very large portion of the two hours was spend talking about
schedules – the schedules of attendings, the process of scheduling a patient for surgery, when the
patient's surgical packet (discharge form, admit form, prescription medications, consent form, and
other notes – paperwork needed for the surgical process), as well as a demonstration of a rather
complex Excel spreadsheet on which the residents track surgery patients, which then gets
communicated to the OR scheduler (often simply by telling him or her in person or over the
phone).
What struck me was the fact that these residents did signout on their own time. Inara in
particular was very methodical, and wrote down the information that her co-residents needed to
know coming onto the next rotation. There is no institutionally sanctioned process for this
information transfer. Rather, the communication of this process happens in a ritualistic and
personal way. They also exchanged “soft” information, such as the personalities of attendings,
which included the certain surgical techniques that each liked to use, their frustrations at not being
able to get enough surgeries scheduled to fulfill their surgical quota (discussed below),
insecurities about the new rotation as well as reassurances and tips. Even though the time spent
for signout is technically supposed to be the transfer of “official” information, the time was also
unconsciously used to strengthen the bonds between co-residents and discuss some of the “softer”
aspects of the residency experience. The setting up of the signout was casual, with very high
degrees of temporal autonomy throughout the process. Indeed, Nicholas, who was supposed to be
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a part of this signout, did not arrive until considerably after Inara and Martha had already started,
trusting that Martha would convey any necessary information he missed. The building up of
social capital and goodwill between colleagues allowed for the temporal flexibility Nicholas
demonstrated, and the time spent, worthwhile for all involved, in turn helped bulk up a sense of
camaraderie.
In this case of the process of signing out during a rotation change, temporal capital works
on two different levels. On one hand, because of the lack of predictability in the schedule, the
temporal capital of the residents depend largely on the fickle schedules of the attendings, reifying
once again the structures of power through the negotiation of temporal rhythms and patterns. On
the other hand, the two hours that the residents spent of their own time doing signout with each
other reinforces the notion that I will discuss in Chapter 6 (about work life balance and temporal
investments in medical training) that residents will put in the temporal investment as an
investment in their personal future and growth, and as insurance that they will become good
physicians.
Finally, there is another stress factor in the scheduling of surgeries. The 3
rd
and last year of
ophthalmology residency focuses on honing the residents' surgical skills. They need to complete a
certain number of surgeries of each sort before they graduate from the program.
57
Therefore, the
stakes of being able to schedule surgeries while they are on a particular rotation are high not only
for the patient, but for the practitioner as well, and there is much consternation on the part of the
resident when they are not able to get enough surgeries within their last year of residency. For
most rotations, there are two 3
rd
year residents present, and they split surgical days, meaning one
person would get, for example, Mondays and Wednesdays, while the other would get Tuesdays
57 Over 300 cataract surgeries in a year is considered very good (observation, August 8, 2015).
136
and Thursdays. When one person is in surgery, the other person sees patients in clinic. The
process of scheduling patients for surgeries, which happens in clinic, during which the physician
determines if a patient needs surgery, can often be an anxiety-ridden process for residents. On one
hand, divvying up surgeries between the two 3
rd
year residents who are on the same rotation often
requires both parties to be on board with the goal of having equitable number of surgeries. There
would be not-so-occasional disgruntled mutterings during informal conversations with subjects
wherein they expressed their concern about whether or not their co-resident is saving enough
surgeries for them. Often, after patient surgeries have been scheduled, they are able to swap
surgeries, or give surgeries to each other if one person has more than the other. With the
ramification of scheduling of surgeries tied to the success of the resident as a surgeon, as well as
the amount of experience he or she has once residency is finished, the ability to control the
scheduling of patients for surgery is a commodity that can be wielded and exchanged between
individuals, not just for the control over their week, but most importantly, for control over their
educational experience through the residency program.
There is another factor of scheduling uncertainty. For County Medical Center 1, surgeries
are scheduled through an OR scheduler, who is a specific staff member. While the following
example is anecdotal, it does bring up unforeseen factors in the ease or difficulty of controlling
one's schedule when it comes to interacting with other staff members. Martha noticed that one of
her colleagues, Owen, a male co-resident, was better able to move his surgeries around and
reschedule them as needed, whereas the OR scheduler refused her single request to bump a
patient's surgery to an earlier time. She voiced her suspicions that there might be a difference in
treatment because of her gender that explains the OR scheduler's penchant for not honoring her
requests as much as her colleague's (“Martha”, personal communication, August 6, 2015). While
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there is not enough evidence to draw a pattern or trend for this particular OR scheduler's behavior,
this illustrates that, apart from the institutionalized structures of the schedule and the process of
scheduling, there are also likely invisible and subjective influences to the construction of a
schedule. As for how this conflict turned out, Martha wisely asked her colleague to “butter up” to
the OR scheduler to schedule the necessary surgeries for the following week, which he
successfully accomplished. If situations like this are indeed part of a larger pattern in health care,
which would not surprise me, as female physicians already have to deal with being perceived as
less capable than their male colleagues,
58
this would have great implications for how temporal
capital intersects with gender (which I discuss briefly in Chapter 6) dynamics as well.
The Night Shift
The scheduling of shifts can roughly be broken down into day shifts and night shifts,
mainly for nursing. The breakdown of shifts, and who gets scheduled for what shift, has some
interesting implications. Less experienced and more junior nurses tend to be scheduled for night
shifts. For example, when Kaylee first graduated and started working as a new nurse, she had a
rotating schedule in which she would “rotate one month days, one month nights, one month days,
one month nights for two years” (“Kaylee”, personal interview, July 3, 2015). The reason junior
staff is put on nights is because there is simply less to do – the physicians usually round on the
patients and give orders during the day, needing to interface more with nursing staff. Moreover,
the labs and other services are open during the day, requiring the expertise of more experienced
58 The gendered differences that physicians experience have been much discussed, with many patients mistaking
female physicians for nurses (Lemay, 2013). Additionally, Rose, anesthesiology attending, tells of a story where
she sees a patient with a male resident, and the patient indicates the male resident asking, “So, he will be doing
my surgery, right?” To which Rose responds, “Well, he is my student, but he can do your case if you'd like.” At
which point the patient frantically backpedals (“Rose”, personal conversation). Rose's story is only one of many
in which female doctors are mistaken for students or nurses, and are often falsely perceived as less capable than
their male counterparts.
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nurses to coordinate patient care across these different moving parts. Night shifts also mess with
the natural circadian and melatonin cycle of practitioners, making working overnight undesirable,
and actually increases risks of certain types of cancers (Schernhammer, 2003). Hence, the
hierarchy extends to the actual health of the practitioner, in some cases, based on these temporal
frameworks of shifts.
While she rarely works nights anymore since she is more senior, Kaylee mentions her
friend, Xander, who works rotating shifts where, “within one week he has to do three days of days
then three nights right after. I think it logistically makes sense for [University Medical Center]
because then they'll never have a shortage of day shift and night shift nurses. But for quality of
life, it's terrible” (“Kaylee”, personal interview, July 3, 2015). Although being on night shift and
rotating shifts tends to be overall less desirable than day shift, some nurses prefer night shift work
for its relative freedom. Xander, the intensive care unit (ICU) nurse, and Dawn, the neonatal
intensive care unit (NICU) nurse, both state their preference for night shift. Xander, speaking for
himself this time, says that while he has a rotating schedule which includes day shifts, “I usually
find people to take my day shift, and I'll take their night shifts for the most part” (“Xander”,
personal interview, November 12, 2014). Xander loves the night shift because he hates waking up
early, and the night shift allows him to sleep in and indulge in his night owl tendencies. In this
way, he has taken control over his schedule in way so he can live the type of lifestyle he prefers.
Furthermore, he mentions that there is typically more downtime at night, because patients are
asleep, so in terms of temporal autonomy, he has quite a bit more than some of the day shift
nurses, who are on the go their entire shift, as patients are awake, labs and clinics are open and
running, physicians are doing their rounds, and patient families are milling about.
Dawn prefers the night shift because “the crew tends to be younger, and a little more fun.
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And there's a big pay differential” (“Dawn”, personal interview, October 13, 2014). Because of
the sleeping patients and the downtime that is not found during the day shift, Dawn also enjoys
socializing with her colleagues, and talking to the parents of the infants. In this way, she
exchanges her non-standard hours for the benefits of a more social environment, which also
allows for a blurring of work and non-work activities (including playing on their phone and being
on social media, which is a discussion that will be expanded upon in Chapter 5). Like Xander, she
is a self-proclaimed “night owl” and “the thought of waking up at 5am was a lot more difficult for
me to swallow than having to stay up all night” (“Dawn”, personal interview, October 13, 2014).
Dawn also points out how the night shift allows for easier childcare scheduling with a partner:
I work from 11pm at night till 7am on Friday night, I come home, I'll sleep
all day, and my husband will watch the baby and then I'll work Saturday
night, and then Sunday night will be family time, so we don't need to pay
for daycare at all. So things like that are super convenient. And I know a lot
of nurses who have school-age kids love working night shift, because while
they're working, their kids are asleep. Then they come home, take their
kids to school, and while their kids are in school, they sleep. They don't
miss their kid as much (“Dawn”, personal interview, October 13, 2014).
Hence, there is the potential for the night shift to allow nurses who have kids and families to be
able to shift work around in a way where they create more temporal capital because most of the
world functions on a normal workday schedule. The night shift enables a sort of expanded time to
fulfill non-work obligations.
59
Hence, while junior and less experienced nursing team members
are relegated to the night shift, the night shift itself enacts increases in temporal capital through its
relative lack of hectic patient care activities as compared with the day shift. While it seems a
59 Craig & Powell (2011) did a study on how non-standard work hours make negotiating familial and non-work
obligations easier. This will be expanded on more in Chapter 6.
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personal preference in terms of who prefers a night shift, those who do like it point to temporally-
based advantages to taking on a night shift that allow for more flexibility and autonomy on both
the micro (hourly) and meso (daily/weekly) levels.
Call Schedules
Now we move away from the work schedule into the realm of call schedules. “Call”
schedules are schedules that govern which individual practitioners are “on call” for emergency
situations that may arise outside of normal work hours. The state of being “on call” is a
fascinating facet of the lives of health practitioners, particularly because it is neither strictly work
nor strictly non-work, and cuts into the non-work lives of these individuals. The process of both
scheduling and being on call can often be rife with emotions and stress because of this fact.
People often want the best schedule for them in terms of holidays, weekend call, and family
obligations, and when juggling multiple schedules, there is bound to be some conflict.
Interestingly, the lack of an authoritative figure directly overseeing the process in the name of
maintaining a democratic and open scheduling process often causes delays and challenges with
the too-many-cooks-in-the-kitchen scenario, which is common amongst residents. The process of
scheduling call and being on call itself follows a strict hierarchy that reflects the stratification of
temporal capital afforded to individuals, depending on their position within the institution.
The state of being “on call” applies predominantly to physicians. Nurses are on a shift
schedule, so there are nurses scheduled for day shifts and night shifts, as we saw in the previous
section, negating the need for call. There is always nursing staff at the hospital, and that
scheduling process has been institutionalized and does not add additional work time to a nurse's
daily or weekly schedule. There are exceptions to the rule, as nurse administrators and supervisors
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who work a regular day schedule may be on call for staffing purposes throughout the night. For
purposes of this section, though, I will stick to examining the intricacies and dynamics of call
specifically for physicians.
There are essentially two types of call – home call and in-house call. For home call, the
physician is physically at home (or non-work locations), yet carries a pager in case of
emergencies.
60
Home call is usually required for services that have set business hours or clinics
that are only open during the day. Ophthalmology is a great example of this. There is
ophthalmology clinic during the day for patients to come in to get their eyes checked (and then
they go home), with surgeries scheduled during business hours. However, this does not mean that
people do not get ruptured globes or detached retinas or have other eye-related emergencies after
hours and at night. So while ophthalmologists work during the day as their core hours in clinic or
performing scheduled surgeries, they must also, on occasion, take call, being the person
responsible for any patient that has an emergency when their clinic is closed. Many other
specialties have a similar call schedule. The exception is internal medicine, which takes in-house
call. In-house call is when the physician is physically at the hospital overnight in case there are
any urgent things that come up regarding the inpatients, or the patients staying overnight in the
hospital. The in-house physician may sleep or do other work while in the hospital, and during
nights when there are no emergencies, the physician may simply sleep the entire night in the call
room (a specific room for on-call physicians).
The policies and culture around call vary depending on the regulations governing
60 In spite of all of the advances in communication technologies, the health care field still relies solely on pagers as
the institutionally mandated and sanctioned form of communicating while on call. A practitioner may not always
pick up their personal cell phone, even if a work colleague calls them, but they must always answer their pager.
The answering of the pager, both culturally and institutionally, is the one sure way of getting a hold of someone.
This will be discussed in greater detail in Chapter 5.
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particular hospitals. At University Medical Center, because it is a major teaching hospital, there is
someone on call (all the way up to an attending) for each specialty. In ophthalmology, there is at
least one fellow on call for each subspecialty (retina, glaucoma, cornea, etc) overnight in case of
emergency cases. In contrast, the coverage at community hospitals or county medical centers
outside the University Health System is usually not quite as comprehensive. A community
hospital, for instance, may not have a urologist on call. If an emergency urology case came in, the
hospital would have to transfer the patient to the nearest hospital with a urology specialist.
Similarly, ophthalmology residents that get called during off hours often have to make decisions
regarding whether they will take a patient transfer from another hospital into their service. The
transfer-originating hospital, it is implied, does not have an ophthalmologist on call, so they have
literally no one who has the expertise to see the patient. In these cases, it becomes necessary for
the originating hospital to call another area hospital to request that the larger hospital receive the
transfer. In other words, the patient needs to be transferred to a facility where there is an
ophthalmologist who is able to come in and see the patient right away and determine a subsequent
course of care.
Whether a physician is willing to come in for a patient often depends on what type of
patient it is. For my interview subjects, who rotate through both the major University Medical
Center and the affiliate county hospitals, there is a difference between “county patients,” or
patients at the County Medical Centers who tend to be uninsured and of lower socioeconomic
statuses, and University Medical Center patients who are generally of a higher socioeconomic
status and have better insurance. Physicians seem to be less willing to put in the time to “show
their face” for non-urgent county patient cases, and feel more obligated to go into the hospital for
the same cases for patients at the main University Medical Center if called in during non-work
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hours, even if the case itself does not necessitate immediate care.
61
Residents are unofficially
taught to identify VIPs of the hospital and make sure they notify the appropriate attending. It
comes at no surprise, then, that patients of greater social power have a greater control, albeit
indirectly, of a physician's behavior and time, independent of the acuity and urgency of their
condition. This dynamic of power is similar to the trend that County Medical Center patients wait
much longer than private hospital or clinic patients for appointments, due to scheduling rules and
procedures. A County Medical Center will book more patients in any given hour than a private
clinic will, given the fact that the volume of patients they see is simply greater, due to the price
point of health care and the fact that the poorest and uninsured cannot afford a private health
facility, which reinforces the uneven temporal capital that these patients both have and can wield
in order to get care.
Finally, it should come as no surprise that, following the patterns of temporal control that
we have seen, the temporal capital of those higher up on the hierarchy get co-opted less than those
at the bottom, just by the nature of how call works. When an emergency case comes through and a
specialist (let us stick with ophthalmology in this case) is needed, the emergency room physician
or the internal medicine physician will page the specialist service. The call will go to the first
person in the chain of command, which is the first year resident or the on-call intern. If the first
year resident/intern cannot adequately handle the situation over the phone, she will physically go
into the hospital, usually informing a senior resident (a second or third year) of the situation. The
senior resident will then determine whether or not to meet the first year resident/intern in the
61 Let me clarify. I do not mean to imply neglect in the cases of county patients. Physicians will assess whether or
not a case needs to be taken care of immediately. If the case is indeed an emergency, the physician will go in,
regardless of the type of health facility involved. I mean to say that if there are two non-urgent cases that can wait
until the clinic opens, the physician may choose to superfluously go in for the private hospital patient for the
purpose of better customer service and patient satisfaction than an actual medical reason.
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hospital to help with the patient. If the senior resident has questions, the fellow on call will be
called, and if at that point, the fellow feels out of his depths, he will contact the attending.
However, the attending is the last line of defense, and the residents and fellow will not call her
unless the case is complicated and they feel inadequate to handle it on their own. Hence, an
attending at University Medical Center, even while on call, will rarely have to physically go into
the hospital (unless, of course, a VIP is involved). Furthermore, if one is a senior resident, a
fellow, or an attending, their time is freed up further through the labor of the first year resident or
intern who does the preliminary examination of the patient and sets up any procedure needed to
save their seniors time. At the end of the patient encounter, the senior resident/fellow/attending is
free to leave, while the first year must finish the patient encounter documentation as well. In this
way, the higher up one sits on the medical ladder, the less one's time will be co-opted both by each
individual patient encounter and by unforeseen circumstances. Although one is constrained by
being on call (perhaps making the decision to not go to dinner at a fancy restaurant an hour's drive
away), the constraints are relaxed more the higher up one moves, and the more temporal capital,
schedule certainty, and individual agency one has to do with one's time as one likes. Therefore,
while individuals cannot get out of taking call, as per institutional mandate, individual temporal
capital and subsequent temporal autonomy and agency varies depending on one's position in the
power hierarchy, which is also institutionalized. While this can be disheartening to feel like
individual physicians are simply cogs in a machine, with how flexible their schedules are dictated
by a systemic process, negotiation for higher temporal capital happens at the creation of the
schedule.
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Scheduling Call
There is perhaps nowhere time as a non-monetized exchangeable commodity is felt more
deeply than in the negotiation and creation of the call schedule. Scheduling and being on call have
the potential to cause substantial strife and stress in the lives of practitioners, although variations
in the stress levels related to call varies between the different levels of hierarchy, the probability
of having to physically go into the hospital in during non-work hours, and the personalities of the
individuals relevant to a particular call schedule. While I will focus on one particular “group of
relevance” in this chapter – the second year ophthalmology resident class
62
at University Eye
Clinic – I will also use the processes discussed to pivot and discuss the ways in which call can be
different for other groups of relevance, using the diversity in experience to paint a richer picture
of the situation. Group of relevance, in this case, refers to the individuals whose job descriptions
are similar and hence can be interchangeable for any day of call. For example, in the second year
ophthalmology resident class at University Eye Clinic, there are nine residents. For any given
weekend, any of the nine residents could potentially be assigned to cover call for that time period.
The data in the following sections draw upon a combination of interviews and participant
observations done with the second year ophthalmology residents in Spring 2015 as they
negotiated and created their weekend call schedule for the 2015-2016 academic year. Much of the
observations were done either first-hand in non-clinical settings, or told to me second-hand
through interviews and conversations.
In general, there are no hard and fast rules in terms of who takes charge of making the call
schedule. Depending on the department, the individual or authority figure making the call
schedule can potentially be a co-resident, a chief resident, a senior attending or chair of the
62 They are not second years anymore at the completion of this dissertation, but this case study is about how the call
schedule got scheduled in second year for the third year.
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department, or an administrator who answers to the chair of the department. Sometimes, the
relevant practitioners themselves will adapt a more democratic process with little authoritative
oversight. For example, some of the subspecialty fellows will talk amongst themselves, as there
are usually only a couple of them per subspecialty, and come up with a call schedule together, and
the process is very casual (“Nasreen”, personal interview, June 24, 2015). The third year residents
in University Eye Clinic, with a cohort totaling six people, created their call schedule as such as
well (“Faith”, personal conversation, July 14, 2015). Interestingly, the residents' call schedule is
officially supposed to be created by the administrator of the ophthalmology program, but there
were some extenuating circumstances which led to the residents creating their own schedule. In
the other residency programs, like anesthesiology, there are a small number of chief residents who
are in charge of making the schedule. When Rose, junior anesthesiology attending, was in
residency, she was a chief resident, and one of three senior residents responsible for making the
call schedule. She related to me then that people would count the number of call days they have,
and complain about having one more call day than a colleague, or having call on a weekend. Even
with an authoritative entity, like a group of three chief residents, making the call schedule, the
process of creating the schedule itself can be frustrating, but as we will see, being on call as an
attending breeds less resentment than for residents.
Similar to the power dynamics we saw in the OR time scheduling process, and as we have
seen throughout this dissertation, the higher up one is on the proverbial power ladder, the more
control over one's own time and others' time one has. For attendings, a designated attending
makes the attending call schedule, with senior attendings getting preferential dates over junior
attendings in terms of when they are required to be on call. This hierarchy sometimes exemplifies
how junior attendings must “pay their dues” with their temporal capital before ascending the
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career ladder. Rose had a child and was on maternity leave for six weeks, as permitted by
institution policy. However, upon returning, she found that she was taking five to six days of call
a week for the first couple weeks rather than the average one or two days of call she usually took
(“Rose”, personal conversation, January 5, 2015). While she willingly took the increased call
days, the discrepancy between the calls she usually took and the calls she had to take while
coming back to work did not go unnoticed, even though she was completely entitled to the time
she took off. The other dimension of this incident is the fact that many female physicians must
negotiate maternity leave, which is, but should not be, a contentious work benefit that often
disadvantages career women (Traister, 2015). As will be examined in greater length in Chapter 6,
familial obligations often have to be negotiated into a practitioner's schedule. Rose's experience
demonstrated that it was not only her junior standing that left her carrying the burden of call, but
was a symptom of a larger issue of reinforcing gender disparities in the workplace through the
manipulation of the call schedule.
Residents also encounter frustrations while making the call schedule, sometimes to a
greater extent than attendings do. An overprotectiveness of time as an exchangeable commodity is
evident, as time is their only bargaining chip, and the sting of being on call for an undesired
weekend is not soothed by a generous income. Gwen, a third year internal medicine resident,
spent a lot of time talking about the etiquette for call schedules, and her frustration when the
etiquette is not followed. She relayed a story (“Gwen”, personal communication, October 1, 2014)
of a fellow resident, let's call her Drusilla, who asked Gwen to take over clinic for three days
when Gwen was on vacation (a preciously limited amount of time), promising that she would
make up for this during her (Drusilla's) vacation. When it came time to pay back the time debt,
Drusilla reneged, saying she already had a trip booked out of town. To top it off, this Drusilla is
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pregnant, and has requested additional time off. This means that the other residents in the
program, including Gwen, would have to shoulder more shifts and more work hours in her
absence. Gwen's frustration was exceedingly palatable during her recount of this information,
sliding into talking about how she could not trust this co-resident anymore, and how she would
never do anyone favors anymore because "you never know." She clearly feels taken advantage of,
and upset that her time was not respected. It is interesting, in this case, that an equitable exchange
of time represents fairness, respect, and trust, and when that is broken, there are feelings of
betrayal. What makes this situation all the more frustrating for Gwen is that there is no
hierarchical imposition on this situation. Gwen and Drusilla are both on the same level of
hierarchy, both being third year residents. Hence, Gwen's frustration betrays her feeling of dis-
empowerment in the situation through the unequal distribution of time. In this case, time becomes
the vector of power distribution. Drusilla claimed more time, thereby placing herself in a position
of higher power over Gwen through the manipulation of time, causing tension and stress for
Gwen.
Attendings that I spoke with were less stressed about making the schedule, and would
sometimes inadvertently make comparisons between either their own experiences as residents, or
compare themselves with the current residents. Rose, who expressed her frustration at what she
perceives as an entitled attitude that her residents in the anesthesiology program have toward call,
relates two distinct environments that frame call. As mentioned earlier, during her residency, she
was one of three chief residents of anesthesiology, responsible for making the call schedule for
her residency cohort. Her co-residents sometimes complained that the schedule was unfair, and
would, in fact, count the number of days each person was on call, then say things like, “Well, I
was on call 6 weekends this rotation, while this person was only on call for 5 weekends” (“Rose”,
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personal conversation, June 23, 2015). This sort of pettiness, tit for tat, overprotective attitude
around one's time, similar to Gwen's experience in internal medicine, cuts across specialties and
pervades the consciousness of residents. In contrast, fellows (to an extent) and attendings function
with more of a sense of a team. Nasreen describes the ease of scheduling with her ophthalmology
subspecialty co-fellow (there are only two of them):
If both of us have something, we try to split it up or generally, if one of us
had something, then we're like, yeah, that's cool. Do this and I'll do it the
next time. One weekend actually, I had a friend's wedding that I was in and
it was [my co-fellow's] brother's engagement party, I think. His was here
and mine was [out of state]. I took call on Friday night for his brother's
engagement party and I left Saturday morning or something, and he took
call. Something like that...It makes it so much better if you're very
reasonable and you can work together and just be reasonable (“Nasreen”,
personal interview, June 24, 2015).
In even a situation where there are pretty major conflicts, Nasreen and her co-fellow were able to
work it out in an amicable way without many feelings of resentment or frustration. They both
seem to acknowledge that call must be covered, and were willing to relinquish temporal capital in
order to do so. Similarly, Rose, the anesthesiology attending, talks about having to take call for
colleagues, and does so willingly, even though when she is on call, she ends up getting called into
the hospital (as in, having to physically go to the hospital to take care of a patient) about “90% of
the time” (“Rose”, personal conversation, June 23, 2015). Finally, when asked, Joyce, a family
medicine attending who works in a private clinic, made scheduling call into a non-issue stating
that she would submit her requests, and accept whatever the schedule happens to be (“Joyce”,
personal interview, January 26, 2016). While there are still tensions around scheduling as
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attendings, there is more of a willingness to just get the job done, and more willingness to take the
time to go into work.
While not a hard and fast rule,
63
residents tend to be more protective, and dare I say, more
stingy of their time in the negotiation of making the call schedule, likely due to the relative lack of
temporal capital that residents have as opposed to attendings, as well as the great discrepancy in
the compensation. As Martha so eloquently put it, “We're petty because we have to deal with more
bullshit when we get called in – attendings have residents to deal with the little menial tasks like
charting - we have limited time as it is, and we're not compensated. If someone paid me $1,000 –
no, even $100 to take call, I'd be taking call every weekend” (“Martha”, personal communication,
March 7, 2016). This again reflects the power differentials between different levels of physicians,
and very succinctly demonstrates the willingness turning time into economic capital, if enough
economic capital is involved. With residents, there is a greater sense of frustration when work
encroaches on their non-work time, when schedules are unpredictable, and when there is any
perceived unfairness in the schedule, since there is no return on the investment for uncertain and
uncontrollable time. As such, the way they exchange their time is like counting change, the units
of meaningful time are sliced into smaller bits and haggled over during the process of making a
call schedule.
For all cases of call scheduling, a priority factor is perceived fairness, and the ideology of
fairness can potentially devolve in an over-rationalized and dehumanized algorithm to determine
the call schedule. In a case that I will present in the last section of this chapter, which was the
process of the second year ophthalmology residents “democratically” scheduling themselves for
63 Nasreen, ophthalmology fellow, stated that people in her residency were very helpful and worked together as a
team to cover call. She mentioned that she is “lucky” to have had agreeable co-residents and a co-fellow,
implying that her situation is not quite the norm.
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weekend call for the entirety of their third year of residency, one member of the group, Nicholas,
came up with an algorithm that he perceived to be the most fair. Each resident would get
randomly assigned a number 1-9, where number 1 would get their first choice of holiday or
weekends off, and number 9 would get the last. Nicholas spent a number of hours during a non-
work weekend afternoon of his own accord using the algorithm to mock up a call schedule and
came to realize that his method would not yield the fairest schedule. He then stayed up the rest of
the night trying to come up with a fairer method, eventually considering a method involving a
random number generator for both resident and holiday. Without going into too much detail, the
process, needless to say, was complicated. Not to mention, Nicholas spent hours of his precious
free time figuring out this schedule. To him, the fairness aspect of the schedule was so important
as to warrant the sacrifice of temporal capital. However, while this method was very well thought
out and (over)rationalized, the impulse to be unfailingly fair ends up treating the residents more
like cogs in a machine than actual people with lives and feelings.
Sometimes, encouragingly, the residents remember that they and their colleagues are
human. Occasionally, someone has a non-work-related emergency and needs a colleague to take
their call for them, usually in exchange for taking a call for the colleague at a later date. When this
happens, because it is uncommon, people tend to be understanding, especially when there is a
genuine family emergency, rather than a conference or work-related event that was unforeseen
and unplanned. For example, Martha was on call the day of the funeral of a friend who
unexpectedly passed. Her co-residents were more than willing to take call for her. One of her co-
residents even assured her that she did not have to “repay” him. When life events disrupt the neat
organized rationalization of call, the process of taking call becomes humanized, and people are
more willing to help out a colleague who may be going through a challenging moment. These
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instances rupture the mechanized routine of making a call schedule renders the human actors
within the process into a non-agentic laborer. The temporal rigidity of the call schedule, and the
corresponding ideology of fairness, is denied in the face of affective human suffering.
Given that a call schedule is an institutionally imposed and mandated tool to which all
relevant practitioners must adhere and submit in order to fulfill certain regulatory obligations of
the hospital or health system, the act of negotiating call schedules presents the enactment of
individual agency and struggle for temporal power within its confines. The less temporal capital
one has, the more ardently they will fight for their time. While attendings tend to be driven by a
logic of teamwork and compensation, residents tend to be driven by a logic of fairness and
defensiveness of personal time. Residents generally have lower levels of temporal capital and
have fewer people to whom to delegate tasks. They also recognize that their position is transitory,
which liberates them from potentially long-term social ramifications as they likely will not work
with their co-residents after residency, while attendings need to maintain some modicum of social
capital through the exchange of temporal capital, as they may be working with the same
colleagues for an indefinite period of time. The difference between the transitory state of a
resident and the (relatively) permanent state of an attending can be seen in how they perceive
what they invest their time for. Residents tend to have a future-looking temporal mentality
because they have not yet reached the end of their training process, willingly (more or less)
trading in their time for the promise of becoming an attending. Furthermore, because they are not
well-compensated,
64
time is the only form of capital and asset they have, which they overprotect.
Attendings, on the other hand, have reached the end of their training goal, so their motivation are
a bit different, more focused on lifestyle and compensation, the promises made during residency
64 “Indentured servitude” is a term that I have often heard used to describe residency.
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having come to fruition. This dynamic will be expanded upon more in Chapter 6. What is notable
about the schedules is that the transitory phase almost allows one to be more selfish with one's
time – partially because there is so little of it, but also because the greatest benefit reaped from
going through residency is one's own personal career growth. When one becomes an attending,
there is more of an incentive to not anger colleagues or alienate oneself from the group, as
maintaining a positive work environment becomes important, because there is no longer the
automatic process of training that transfers one to a different facility after a set period of time.
Case Study: 3
rd
Year Ophthalmology Weekend Call Scheduling
In June 2015, I was fortunate enough to witness first hand the culture of scheduling
weekend call for the soon-to-be third year ophthalmology residents at University Eye Clinic.
While the responsibility of the call schedule technically falls to the residency program
administrator, it has been outsourced to the residents themselves. The residents attempt to go
about this in the fairest and most “democratic” way possible. I present this case as an example of
the time, energy, and thought process, as well as the personal dynamics and less obvious
considerations that factor into the creation of a call schedule. The process also demonstrates the
patterns of overprotection of time through an intense desire for a fair scheduling method that is
uniquely seen in residents.
For this particular call scheduling process, the residents are scheduling just their weekend
calls. As they all work Mondays through Fridays either running clinic or doing surgeries, they
take call in accordance to the location they are at and the rotation they are on, and is irrelevant in
the scheduling of weekend call. The structure of the weekend call schedule is as follows: for each
of the 52 weekends in a year, two 3rd year residents must on call – one for University Medical
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Center and Eye Clinic, and one for County Medical Centers 1 and 2. This amounts to each
resident taking about one weekend call per month. Sounds simple enough, in theory. However, the
reality is much different than the theoretical, particularly when one factors in holidays, where
temporal capital tends to be the most desired, the least available, and the most challenging to
negotiate, due to the confluence of social expectations and family obligations.
Although this call schedule process proceeded with democratic intent, there was inevitably
a de facto authoritative figure – the person who first volunteers to make the schedule, centralize
everyone's requests for weekends off, play Tetris on the calendar with these requests, and commit
a draft of the schedule onto figurative paper. The residents inconclusively went back and forth
over email for a number of days trying to figure out the best method by which to make a schedule.
Nicholas even (unsuccessfully) testing out an algorithmic method to ensure fairness, as I
mentioned above. Some people were worried that if charge of the schedule were given to specific
persons, the schedule would be biased toward this de facto authority figure. Conversations were
happening between individuals out of earshot of the group resembling the political intrigue and
backroom dealings found in House of Cards.
65
Finally, Martha and Toshiko decided to join ranks
and think up the fairest method of scheduling they could. Full disclosure, because they asked, I
was also involved in this process.
During the time we came up with a reasonable and fair algorithm (this all happened in the
span of a few hours one weekend afternoon/early evening), another resident in the group, Inara,
came up with a schedule without using any set method. This schedule worked quite well for
everyone, but a few other residents expressed their hesitation with this schedule on principle, with
the reasoning that the method Inara used was not a transparent, replicable algorithm. At this point,
65 Wildly popular Netflix original series, started in 2013.
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Martha and Toshiko had an algorithm, but not an actual schedule. In an offline phone
conversation, Martha and Inara agreed to present Inara's completed schedule and Martha's
algorithm, and put the whole thing to a vote.
66
When the votes came in, Inara's schedule won the
day, and was the schedule eventually sent to the administrator and codified for the next year.
There was a sense of stress felt by the residents throughout this process because no one
felt like they had control over the making of the schedule. In the two options given to residents
detailed above, one schedule was made by Inara, giving no one else much say in the process, and
no guarantee that the schedule was created objectively by a method that was replicable
67
; and the
other would subject everyone's schedule to the whims of an algorithm. Being subjected to the
unpredictability of the results of the algorithm seemed to ultimately be the reason why the group
voted to keep Inara's schedule, since, as it turned out, was very fair for everyone. Moreover, in
addition to the uncertainty, there was so much time is spent discussing how the schedule would be
made – not even the actual making of the schedule. A small group of the cohort went to dinner
one night of the week when the schedule was being discussed, and debated the method for making
the schedule for two hours. Then, both Inara and Nicholas spent "all afternoon" making schedules
may potentially not be used. There were also undercurrents of distrust, where some people trusted
some to make the schedule, others trusted no one but themselves to make the schedule, and still
others felt the only way to be objectively fair was through an intricate algorithmic scheduling
process. While some of this could be chalked up to the large size of and the unique personalities
in this particular cohort, the anxiety around negotiating call schedules are a clear symptom of the
lower levels of temporal capital and the lack of control over their own time experienced by the
66 For the record, Martha and Inara were not in contention. They both wanted the whole process to be done in a way
that would make the most people happy.
67 We are talking about a bunch of physicians whose educations and perspectives were heavily influenced by a
rational, scientific approach...
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residents in most aspects of their training. When given a chance to have a modicum of agency in
determining the temporal structure of their year, they have a tendency to overcompensate and
become overprotective of what they perceive to be a very valuable commodity (their time)
because they have so little of it.
The more the process of making the call schedule is rationalized, the more dehumanizing
the process itself becomes. The algorithmic randomization methods that were considered reflected
the fact that the residents saw themselves as cogs in a machine, and their anxiety and the time
they spent debating about the process of scheduling was a way for them to resist the
mechanization of their temporal experience, even as they watch as their temporal capital is slowly
eradicated by the demands of the residency program. Perhaps this is why, at the end of the day,
Inara's schedule worked. As she jokes, she employed the “human touch” to the making of the
schedule. While her method was not replicable, it resulted in a schedule that everyone felt was
fair. Inara's schedule, in a way, is symbolic to the struggle of scheduling call. Some of her co-
residents resisted the schedule on principle, preferring dehumanizing algorithmic methods that are
more “scientific” and logical in its replicability and transparency. And yet, in reality, they all
accepted the human-made schedule in the end. In this way, a small shred of humanity, a small
instance of resistance to a totalizing rational mentality, happened in a process that then, ironically,
becomes itself a new structure of logic (the set weekend call schedule) into which the residents
must force their temporal experiences. While the residents' anxiety betrays their perceived lack of
temporal capital, the negotiations that comes from those feelings of anxiety allow for moments of
agency within an institutionally rigid scheduling process.
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Conclusion
The schedules by which practitioners must abide are usually a result of institutionalized
regulations and policies outside of individual control. Even within private practice, schedules
must adhered to in order to ensure the trust of patients and maintain a steady stream of revenue
and reimbursements. More often than not, schedules themselves relegate the bodies, behaviors,
and labor of physicians into a rationalized logic. However, even within rigidly imposed
regulations about schedules, both working and call, individual practitioners are able to negotiate
their levels of temporal capital. While shift work practitioners have more non-flexible work hours,
they are able to make clearer distinctions between work and non-work time, whereas practitioners
with more flexible hours may have more instantiations of temporal capital, yet may find
themselves working all the time. Similarly, call schedules lock physicians into a state of
uncertainty and anxiety, not knowing if an emergency will happen and zap them of any time they
stole away from work while on call. Negotiations of temporal capital happen here as well, though.
An attending can willingly take more call time in order for higher compensation, or a resident can
take on making the call schedule in order to ensure fairness in the distribution of temporal capital.
Therefore, even though schedules themselves are manifestations of institutional and
“official” entrapment of individual temporal autonomy, reifying the existing power dynamics
between individuals in different hierarchical positions, individual agency can be garnered through
various forms of negotiated behaviors, whether it is socializing during night call when patients are
asleep, or being flexible enough to jump at a moment's notice when an OR unexpectedly frees up
so a junior attending can perform a last minute surgery. At the end of the day, schedules are
necessary for health care facilities and hospitals to function and provide the necessary patient care
and coverage. It is not that different from the scheduling ballets that airline pilots or restaurant
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waiters or police officers must undergo to do their jobs. Beyond that, developed and capitalist-
leaning societies function on schedules because schedules ensure the coordination of labor (and
subsequently the production of capital), and reinforce logics of productivity through a temporal
framework. Health care is simply an industry that must endure more complex processes of
scheduling because of its many moving parts. And yet, despite the grumbling and the frustrations
and the anxiety over schedules, it serves as a crucial tool to regulate the temporal rhythms and
patterns of health care providers in order to ensure consistent service to the patients.
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Chapter 5: Health Practitioners' Use of Communication
Technologies
It has been argued that technological advancements and mobile communication devices
contribute to an increasingly accelerated society that is spiraling out of control (Agger, 2004;
Eriksen, 2001, 2007; Gleick, 1999; Hassan, 2009). Other scholars, like Wajcman, while rejecting
the technological determinist perspective that technology in some way compels or causes
acceleration of the pace of life or increased temporal density (like multitasking), acknowledge that
technology is altering the temporal rhythm of life. Some people find having communication
technologies and mobile devices liberating in the sense that they have more flexibility to take care
of work activities away from work, and vice versa (Wajcman, 2015). Others find it stressful to be
constantly connected to work. But it is too easy to blame technology on the changes in our lives,
and rather, Wajcman opens the door to talk about how work culture and expectations have
changed given these technologies to compel a sense of altered social relations and temporal
practices through the use and availability of mobile technologies.
Indeed, today's advertising for mobile technology often evokes the sense that mobile ap-
plications can save one time, or allow one to have more control over one's time. For example, a
recent Chase Bank ad on the radio entices people to download the Chase Online Banking mobile
application by listing the ways one can bank on-the-go and organize one's finances - while wait-
ing in line at the shopping center or waiting for a flight at the airport.
68
Why is saving time so at-
tractive to people? By saving time, one ostensibly has more time with which to do whatever one
pleases, and to do projects and pursue endeavors that are meaningful and/or give the individual
68 This was often heard on the radio in Los Angeles in the spring of 2014.
160
pleasure, fulfillment, enjoyment, and happiness. In other words, saving increases the amount of
time that one has under one's control, or one's temporal capital. But if the value of time is differ-
ently felt by different people, the need for technology changes given the social status of the indi-
vidual.
As developed society becomes increasingly connected through advancements in wireless
communication technologies, the pace of communication can feel accelerated and sped up. The
acceleration of society, according to Agger (2004), is directly related to the pursuit of capitalistic
interests. Newer, faster technology is created in the desire for more efficient processes, which
then, in turn, decrease turnover time for activities and processes, allowing for the reproduction
and accumulation of capital. The measurement of time happens in smaller and smaller increments,
with more and more precision. For example, the field of high frequency trading banks on deci-
sions being made in nanoseconds and milliseconds, reproducing and turning over capital in higher
rates than ever in a high-risk, temporally precise game of transactional economics (Slavin, 2011).
Therefore, for some segments of society, the exact delineation between seconds and minutes, a
micro-level perspective of temporality, is a normal way of life, and punctuality is crucial. This
perspective of temporality is especially pervasive in cultures and individuals interpellated into a
capitalistic society (Levine, 1997). Hence, whether someone values time as an incrementally mea-
surable resource, and how incrementally time matters, depends on that individual's position and
role within society, as well as the normative expectations of society's value for that individual's
time.
This acceleration and the fact that individuals from different positions in the social stratum
may experience it differently is not that recent. John Robinson & Geoffrey Godbey, in their 1997
study on the ways in which Americans use time, found that people in the 1990s feel more time
161
pressure than people in 1965, and that college-educated and affluent people feel more rushed.
However, they point to a slight decrease in stress levels due to time pressures in 1995 as com-
pared to 1993, and posit that Americans may have simply normalized a faster pace of life.
Communication technologies used within the health care sphere, both official work
technologies and personal devices, have undoubtedly impacted the organization of time, and the
structures of communication and hierarchies within health care practices and facilities. From
electronic medical record (EMR) systems
69
to smartphones to pagers, the ecosystem of health care
has inevitably come to include these new technologies, and their impact is quite complex. In this
chapter, I not only consider how practitioners use their phones, but I also examine the “specific
forms of power and authority” (Winner, 1986) that technologies embody and communicate. While
most of the people I spoke to through interviews worked in environments where personal cell
phones were either not allowed, or severely frowned upon, many inevitably would use them
during their work days for a variety of reasons, both work and non-work related. Communication
technology devices used within the hospital fall roughly under two categories – those that are
institutionally sanctioned, and those that are not. What is remarkable in this scenario is the extent
to which non-institutionally sanctioned devices are employed to circumvent the often temporally
tedious institutionally processes by which health practitioners are supposed to abide in an effort to
save time, increasing a sense of temporal capital and autonomy. Hence, this chapter will take two
devices in particular – EMRs and personal mobile devices - as examples of how communication
technologies play upon the temporal patterns in the lives of health practitioners.
69 Also called Electronic Health Records (EHRs). Technically, there is an industry-based difference (that is, at the
very least, insisted upon by the industry white paper referenced here) between EMRs and EHRs, but it is mostly
relevant within the scope market priorities for EMR/EHR systems (Garets & Davis, 2006). For simplicity, I will
be sticking with “EMR” throughout this chapter, since conceptually for the purposes of this dissertation, the
nuanced differences are insignificant.
162
The implications of the use of communication technology throughout the day arise in main
research question that guide this inquiry: how does the use of new technologies by health
practitioners impact social power relationships from a temporal perspective? This question is
mediated through the examination of two themes that emerge regarding the impact of technology
on temporality – the blurring of work and non-work time, and the acceleration of the pace of life.
By looking at how practitioners use the EMR system and their personal phones, we are able to see
how not only the temporal patterns of individuals is negotiated, but also how practitioners
negotiate their own temporal agency within the constraints of institutional requirements, thereby
resisting the neoliberal subjectivity that systemically rules their temporal rhythms.
Technological advances in communication and the proliferation of digital media has, rea-
sonably, transformed and reconfigured perceptions of time. The relationship between time and
technology is deeply intertwined and complex, and deeply entrenched in the ways in which differ-
ent people are situate in the relevant social hierarchy and behave differently given their access (or
lack thereof) to the two. Technology has a powerful relationship with social and cultural dynam-
ics. As Langdon Winner (1986) states, "technologies are not merely aids to human activity, but
also powerful forces acting to reshape that activity and its meaning" (6). While new technologies
may not necessarily change the fundamental power dynamics within a society, it necessarily re-
configures social relationships, giving new meanings and avenues to the ways individuals experi-
ence their everyday.
As differences in temporal capital are often due to some type of hierarchy, be it
socioeconomic, organizational, institutional, or other, and indicate certain social and
organizational power dynamics, a discussion of how communication technologies impact
temporal capital would be remiss if we did not address and describe some of these relevant
163
hierarchies. In essence, the potential expansion of temporal capital given the use of technology
varies based on one's position within the relevant hierarchy. In this chapter, I identify three
different types of hierarchies. One is the socioeconomic hierarchy that occurs, for example,
between senior attendings versus junior attendings, or physicians versus nurses. The second is the
organizational or training hierarchy that places residents, fellows, and attendings in ascending
slots based on position within the training process as discussed in previous chapters. The third is
professional group affinity, wherein the hierarchy occurs in degrees of closeness to an individual
in question, which plays a role in terms of who has whose number, and therefore, who is able to
effective circumvent institutional processes in the interest of saving time, ostensibly increasing
productivity.
There has been a good amount of work done on the impact of communication
technologies on the practice of medicine. In 2005, Van Eaton et al found that computerized
rounding decreased the number of hours it took for residents to complete rounds by 3 hours per
week, presumably because they did not have to traverse physical space during rounding, and
information was easily accessible. Computerized rounding also decreased the number of missed
patients, and increased the perspective of quality and continuity of patient care on the residents'
part (Van Eaton, Horvath, Lober, Rossini, & Pellegrini, 2005). In 2009, a review of existing
literature on the impact of mobile handheld devices concluded that the use of mobile technologies
“demonstrates the greatest benefits in contexts where time is a critical factor and a rapid response
crucial” (Prgomet, Georgiou, & Westbrook, 2009, p. 792). This should not be surprising, as we
are now “perpetually connected” (Katz & Aakhus, 2004) through the normalization of mobile
devices, and have cultivated an expectation of instant and simultaneous communication.
70
70 Robert Hassan (2007) talks about how technology has created this expectation, and then he goes on to talk about
how communication is not actually instantaneous, but asynchronous. Yes, an email will arrive in the recipient's
164
Much of the current research on the ways in which health practitioners use communication
technologies and EMR systems are confined to the medical field. My intervention here is to take a
critical cultural perspective by engaging in the implications of the usage of such technologies not
only on quality of patient care and the efficiency or non-efficiency these technologies enable, but
how these technologies impact the temporal rhythms within the lives of the practitioners
themselves, both at and away from work. By examining the cultural practices of using
communication technologies both in the work place and during non-work times, we are forced to
consider the humanity of practitioners, who not only juggle stresses at work, but also have
families and friends and other non-work priorities that may often be in tension with their work
obligations.
Two Main Themes: Blurring and Acceleration
In this chapter, we see two theoretical frameworks emerge through analysis of the data.
One is the quest for efficiency through the speeding up of information exchange thanks to
communication technologies. As we have seen in Chapter 2, many scholars have discussed the
acceleration of society,

often in service to the capitalistic impetus for the quest for speed and
efficiency. The health care system is not impervious to these capitalist priorities. Indeed, the pace
of work and life for health practitioners have become increasingly harried because of the
increased number of patients they have to see in a limited amount of time, decreasing their overall
temporal autonomy throughout the day. Communication technologies can either help or hinder
efficiency at work and at home, as we will see, complicating the discussion of how
communication technologies impact the temporal dynamics of many individuals, and the temporal
mailbox as soon as you push “send,” but the person may not actually receive it right away, nor might they
respond right away for the actual communication itself to be instantaneous.
165
rhythm of one practitioner. However, the potential of accelerating the speed by which tasks are
completed, thanks to the perpetual connectivity and instantaneous delivery of messages, is an
attractive aspect of these communication technologies for practitioners as they negotiate their
temporal autonomy throughout the day.
Another framework seen not only in the health care field, but in society in general, in
relation to the use of communication technology, is the ability to connect at all times, which leads
to the pervasive blurring of work and non-work time – something that both the EMR system and
personal cell phones have enabled and encouraged. Judy Wajcman talks about this in terms of
allocation, or a “notion of boundaries that separate practices” (Wajcman, 2015, Chapter 3, sec.
“Temporal Density”, para. 1), which has diminished given the affordances of mobile
communication technologies. People check their work emails while at the dinner table, or on
family outings, and personal smart phones facilitate non-work activities during downtime at work.
In the realm of patient care, the electronic medical record systems allow practitioners to keep on
top of their work and coordinate patient care from wherever and whenever they are. Similarly,
work calls on personal cell phones during non-work times ensure that one is never completely
away from work.
Conversely, communication technologies have allowed for non-work activities to be
conducted at work. Wajcman cites the Networked Workers survey that shows that while at work,
“22 percent of workers shop online, 15 percent watch videos, and 10 percent use online social or
professional networking sites, while 3 percent play games. News consumption has also moved
online and into the workplace as has pornography. The workplace use of communication
technologies is by no means confined to work purposes, and for some, these technologies provide
access to forms of relaxation at work” (Wajcman, 2015, Chapter 4, sec. “The Networked Worker”,
166
para. 6). The personal cellphone, in a way, allows us to exchange our time for different forms of
capital more easily and quickly than before – we can send a text to a friend, thereby maintaining
social capital, or read the news which accumulates cultural capital for the individual. Moreover,
because of our perpetual and instantaneous connection to other individuals enabled by these
mobile devices, both the expectations and the processes by which we communicate through
devices have altered accordingly. Within the ecosystem of the health care system, the archaic
pager has been supplemented (not supplanted) by mobile phones as an additional means to reach
the desired physician. As we will see later, who has access to which kind of technologies have
potentially great implications for temporal capital along the axis of the hierarchical power
structures of the health care system.
Through the modern-day logics of productivity, and the individual's body as a subject of
neoliberal capitalist ideologies, all activities done throughout the day can be thought of as striving
to increase in some form of capital – economic, social, cultural, etc.
71
Bodies and actions are
interpellated into logics of productivity – that time must be exchanged for something that is
productive. The pervasive notion that time must be spent productively has led to an anxiety-filled
culture in which busyness is a badge of honor, as Tim Kreider (2012) discusses.

It seems as
though we now value life through our ability to exchange temporal capital into another form of
capital – economic, social, cultural, etc. Communication technologies help reinforce the impetus
to follow logics of productivity through its ability to allow users to be constantly connected
regardless of setting (work, non-work, travel, waiting, etc), enabling both blurring of work and
non-work situations and acceleration of communication, furthering a mentality that desires
efficiency in the hopes of either being more productive, or giving one more temporal flexibility at
71 I expand on this quite a bit more in previous work (Wang, 2013).
167
any given moment.
In the following sections, we shall see that the blurring of work and non-work time and the
potential for acceleration for health practitioners are enacted through the use of EMRs and
personal cell phones by practitioners. Both are put in place and used with the hope that it will
provide a means for higher temporal capital and greater efficiency at the service seemingly of the
patients, but also, on a deeper level, at the service of capitalism. At the same time, the ways in
which these two types of device – one institutionally sanctioned, and one not - are used reveal
dynamics of power that are imposed upon individual practitioners as well as the means by which
these impositions of power are resisted. The differences in the ways in which these devices are
used display how practitioners use technologies to circumvent institutionally-sanctioned processes
of communication in a quest for greater efficiency and a modicum of agency for workers
throughout the day.
Method
Because the method by which I obtained data for this chapter is a little bit different than
the other chapters, it warrants a mention here. This chapter draws data both from the interviews
and observations, as well as an online survey that focuses on the use of communication
technology in the hospital. The participants of the interview are affiliated with University Medical
Center and its affiliate sites, while respondents to the survey are practitioners from multiple
institutions around the US. To stay true to the intent of drawing out the nuances and complexities
of the temporal patterns of health practitioners through the use of these communication devices, I
steer clear of doing deep statistical analysis on the data. Rather, I present descriptive data as
appropriate, and draw upon the written responses that respondents have given in the survey itself,
168
as well as the patterns that are evident in the data, using interpretive analysis to examine the ways
in which communication technologies impact the cultural practices of health practitioners.
Respondents were recruited through my personal and professional networks. I posted the
link on social media, and also sent out emails to friends and acquaintances, asking them to send it
out to health practitioners they know. Participants, if they completed the survey, were given a $10
Amazon gift card (which I was told might not actually be worth the time of some of the
practitioners). More than half of the respondents did not provide an email address for the gift card
– only 51 out of 119 respondents did. I suspect the reasons for this is that participants wanted to
retain their anonymity completely, as some of the survey questions ask about their use of personal
devices for non-work activities at work, despite being reassured that their anonymity would be
preserved.
72
At the time of this writing, there were 119 respondents to the “Health Practitioners' Use of
Communication Technologies” Survey (hereafter known as the CommTech Survey), with a 40%
drop off rate. Because of the inconsistent responses, my analysis takes each relevant question or
group of questions based on the lowest number of respondents for the question(s) in question. For
example, if I wanted to compare the responses that I got for Question A, which had 76
respondents, to the results of Question B, which only has 42 respondents, I would look only at the
entries in which the individual responded to both questions.
Electronic Medical Records
Electronic medical record (EMR) systems are becoming ubiquitous in this country, driven
by a “key provision of the American Recovery and Reinvestment Act of 2009” mandating that all
72 Although, my favorite response when asking for their email was, “Dont worry about it. Academic research is
thankless enough.” (sic)
169
health facilities must be on an EMR system and demonstrate “meaningful use” by January 2014
(“Federal Mandates for Healthcare: Digital Record-Keeping Will Be Required of Public and
Private Healthcare Providers,” 2013).

Hospitals, health systems, and health practitioners must be
using EMR systems in order to be reimbursed through Medicare and/or Medicaid. Not being on
an electronic records system results in a percentage decrease of reimbursements, with the
reduction increasing each year that an EMR system is not in place.

Therefore, managing patient
care through EMR systems, and gaining competency in the use of these electronic systems, is
becoming crucial to the process of patient care for practitioners. In 2015, the Office of the
National Coordinator for Health Information Technology found that three out of four hospitals
(75.5%) non-Federal acute care hospitals have a basic EMR system (Charles, Gabriel, Searcy,
Carolina, & Carolina, 2015). Indeed, the CommTech survey found that the greatest percentage of
practitioners answered they use EMRs for more than 4 hour per day. When asked to specify how
many hours they spend, most of these subjects responded that they use EMRs up to 8 or 10 hours
each day. Hence, the use of EMRs are framing the ways in which practitioners practice, manage
information, and manage their own time.
When you use the EMR system from WORK, how much time on average would you say you spend on it EACH DAY? (n=92)
170
In terms of its effect on time and efficiency, EMR systems are found to be a mixed
blessing in hospitals and health facilities (Holroyd-Leduc, Lorenzetti, Straus, Sykes, & Quan,
2011). EMRs replaced physical patient charts, and in a profession where written documentation of
patient condition and care is the main mechanism to ensure high quality continuation of care,
practitioners spend a lot of time using the EMR system, as evidenced by the above chart. As
discussed in previous chapters, the act of charting, or documenting the entirety of the patient
encounter including the patient's condition as well as the course of care that the physician orders,
happens constantly. The reaction to EMRs in my interviews and in the CommTech Survey were,
for the most part, mixed. Some people loved the accessibility of the EMRs, while others
expressed frustration at the design of the system. Transitioning to an EMR system also came with
a lot of growing pains, slowing down care drastically for a period of a few months, where people
who are unable to adapt to the new system simply leave and look for jobs in health facilities that
still chart with paper and pen. However, as EMRs continually roll out to more and more sites,
individuals are forced to learn the system, adapt, or be forced out of the profession entirely. This
transition is apparent from from the findings in the CommTech Survey, which shows that 49 out
of the 75 respondents (65%) stated that they either never, rarely, or sometimes use pen and paper
to document patient encounters. Only 10% (n=7) indicated that they use pen and paper often or
very often. As we can see, pen and paper charting is rapidly fading out, and EMRs are only
becoming more and more ubiquitous with each passing year, having an increasing impact the
patient care process and the temporal patterns of work for health practitioners.
EMRs systems are developed by various private companies that then sell the program
software to hospitals. Much like word processing programs include Microsoft Word, iWorks Page,
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LibreOffice, and others, EMR companies include EPIC, Cerner, eClinicalWorks, Computerized
Patient Record System (or CPRS for short, used exclusively across the board by all V A Hospitals),
and McKesson, to name a few of the more popular ones.
73
Because University Medical Center
includes multiple sites, many sites use different EMR programs. University Medical Center's main
campus uses EPIC, while the County Medical Centers uses Cerner and ORCHID (yet another
brand). Because University Hospital's health system encompass multiple facilities, practitioners
rotating through more than one facility (most relevant for residents) need to learn multiple EMR
systems. For example, when my partner was doing her post-graduate year internship – one year
following graduation from medical school of internal medicine or general surgery internship
before a specialty residency that residents must complete in order to prove competency in
comprehensive medicine – she had to rotate through a few different sites. Her first few days at the
new locations were very long, because each site was on a different type of EMR system and she
had to take extra time out of her day learning a new system.
The Blurring
For physicians in particular, having the EMR system has helped with not having to be
bound to a certain location for work. It has liberated communication and information from the
physical body, in a way, blurring the bounds between work time and non-work time, as well as the
activities that traditionally took place in work and non-work spaces, allowing for individuals to be
in non-work locations while doing work. Sarah Jane, junior ophthalmology attending, states,
I think having the advent of EMR, having your cell phone and tablets really
improves access because, I mean, obviously, but then you don't have to go
back to your office to do these things, so sometimes I'll go to the coffee
73 A list of the top 20 most popular EMRs in 2012: http://www.capterra.com/infographics/top-emr-software
172
shop nearby and sit there because I feel like I have some semblance of a
life, like I'm not sitting in my office alone. I'm with other people who are
doing whatever too. Or I'll go hang out at a friend's house and just work on
my stuff while she has the TV on or something. So I think it really
improves quality of life that way (“Sarah Jane”, personal interview,
February 17, 2015).
In this way, Sarah Jane not only blurs her work and non-work lives, but through having access to
the EMR system anywhere, she is able to have “some semblance of a life” which, in context of
this statement, clearly has an impact on her quality of life. The EMR system also allows her to
work on maintaining friendships by being physically present with a friend while still keeping on
top of her work obligations.
Similarly, Amy, psychiatry resident, talks about how she will finish writing up patient
notes while sitting next to her husband while he watches television. While she admits that she
would probably get her notes done a lot faster if she went upstairs to her office, she says that that
is “a lot less enjoyable, and I feel pretty lonely doing that” (“Amy”, personal interview,
September 22, 2014). Harriet, third year internal medicine resident, raves about the EMR system,
gleefully stating that she can finish her notes for the day from bed in her pajamas (“Harriet”,
personal interview, October 6, 2014).

The option of being able to keep up with work in the comforts of one's own home or out in
the world, is seen as a positive attribute of EMRs for many physicians.
74
In a way, communication
technologies, for certain individuals, encourage a meshing of doing work in non-work locations,
thereby layering work time on top of non-work time, and allowing work to be done in a relatively
more relaxing environment. Amy admits that she does about 4 hours of documenting each night at
74 Interestingly, the CommTech survey showed that very few (12 out of 74 respondents) practitioners use the EMR
system on their phone, if the particular EMR system is even available on mobile devices.
173
home, which is made possible by having an EMR system. Even though Amy admits that
interacting with her husband while documenting patient notes may take more time than if she
were to focus solely on the work activity, this is a fair tradeoff for her to layer work time on top of
time spent with her family. This does raise the question of whether or not the time spent away
from work or with family for these physicians is “quality” time, but one could argue that
communication technologies in these cases increase temporal capital as practitioners are able to
do work in the comforts of their own homes, on their own time. In this way, EMR systems
facilitate the exchange of temporal capital for familial capital and other forms of social and
cultural capital through the blurring of work and non-work time. Moreover, EMR systems enable
higher degrees of temporal flexibility and temporal autonomy for these practitioners.
However, as we have seen, not all hospitals, and hence, not all EMR systems, are created
equal. Some EMR systems, like the ones used at University Medical Center, are accessible from
home. Others, like the one used at County Medical Center 1, where Rory, junior internal medicine
attending, works is not accessible outside of the hospital. County systems tend to evolve very
slowly, according to Rory, and therefore, have less advanced systems than the well-funded
University Medical Center. Rory, who completed his residency at University Medical Center, with
a fully accessible-from-anywhere EMR system, however, does not mind the fact that he cannot
access the EMR system from home at his current position at the less “advanced” Country Medical
Center 1:
Even if I wanted to work from home I don't even have the luxury to do so.
In that sense, it's actually a good thing for me because there's a complete
difference between my personal life and my professional life. It's just
things you do not mix (“Rory”, personal interview, May 29, 2015).
174
So whereas EMR access outside of the work space may enable more flexibility in terms of where
practitioners are able to complete their work, not having this ability to work from anywhere does
not seem to bother some folks. We do have to remember that Rory is an attending, and County
Medical Center 1's Internal Medicine program is 100% teaching, meaning that Rory is always
working with residents and interns. Therefore, most, if not all of the charting and direct patient
contact is done by his residents and interns. Being in a higher position on the organizational
hierarchy, and being able to delegate charting to subordinates decreases the advantages of the
EMR system to blur work and non-work time. To someone like Rory, being able to do work from
home simply does not matter, because he is not doing most of the charting anyway. His time is not
trapped in an institutionally mandated process because he is able to offset that time to his
residents and interns.
Furthermore, EMRs do not necessarily create a compulsion to do work in non-work
settings. Rather, it simply offers more options to exercise the temporal flexibility afforded by the
technology. Similar to Rory, none of my other informants mentioned that they feel more pressure
to keep connected with the EMR system while not at work. Indeed, this is reflected in the
CommTech Survey where 64% of the respondents stated that the use the EMR system for less
than 30 minutes a day from home. Therefore, we see that there are roughly two methods by which
people work – on one hand, there are individuals like Rory who finish work at work. Granted,
Rory does not have the option to work from home given the limitations of the EMR system used
at County Medical Center 1, but even those who do have the option to work from home often opt
not to work from home. If they do, it is to finish up a simple task that takes less than half an hour.
On the other hand, there are individuals like Amy, who choose to take work home in order to
spend that time with their families. Therefore, EMRs' ability to allow physicians to do work
175
liberated from the work location is seen as a bonus option that the technology provides.
When you use the EMR system from HOME, how much time on average would you say you spend on it EACH
DAY?
Potential for Acceleration
In addition to allowing practitioners to work in locations outside of their work offices,
EMRs also embody the potential for practitioners to be more efficient in writing orders and
completing tasks throughout the day. No longer does a physician have to track down a physical
paper chart to find out what the last physician or nurse had written about the patient. All patient
information is available with a few clicks of the mouse, greatly facilitating patient-related
communication between individual practitioners. Because of this, Rory, like many of his fellow
physicians, recognizes the usefulness of having a full EMR system on his daily temporal
organization and, having worked in many different facilities and undergone an EMR transition at
University Medical Center, shares his experiences. He mentions that County Medical Center 1
uses a hybrid EMR system as a stopgap during their transition from paper charts to a fully
176
functional EMR system. In the hybrid system, notes and laboratory results are handled in the
EMR system, but medication and nursing orders, like diet restrictions or placements of Foley
catheters, need to be handwritten, forcing Rory to contend with the physical space of where his
patient are. Handwritten nursing orders are written at the nurse's station on each unit. Because his
internal medicine service has patients all over the hospital,
they're on the fourth floor, they're on the fifth floor, they're in four different
units. What that also means is, if you want to write order you have to
physically go to these nursing stations and write orders. Throughout the
day if I forget something I have to actually physically go back over there
and write an order. A lot of time is spent doing that (“Rory”, personal
interview, May 29, 2015).
Because Rory himself was a resident at the time that University Medical Center was undergoing
the transition to an EMR system, he reflects upon how the EMR system has changed the way
space is differently perceived and overcome from the beginning of his residency without an EMR
system to the end of his residency with a full EMR system:
I had to sit through an eight hour class to learn how to use EPIC [at
University Medical Center], but I think it was very well worth it, in terms
of the time I saved...I could do whatever I want from a computer without
running anywhere to write orders at…I still remember the old University
Medical Center system, before they had the electronic system. Let's put it
this way, if you were unfamiliar with the hospital layout, that even takes
more time because I've been lost at University Medical Center trying to
find out exactly where my patient is. Finding the chart, writing the order it
just eats up so much of your time. It's very inefficient (“Rory”, personal
interview, May 29, 2015).
Rory, as well as other practitioners, recognizes the time that he saves in walking from department
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to department to complete tasks, give orders, and access patient information through his use of an
EMR system. The EMR system essentially liberates information from physical location, granting
almost instant access to patient charts, whereas before the implementation of EMRs, practitioners
would have to be in the same location as the physical chart. Information can now be accessed
everywhere, eradicating the need to traverse physical distance. Thus, EMR systems potentially
increase temporal capital by giving practitioners greater control of their time by minimizing travel
time both within the hospital and between work and non-work locations.
However, not all is rosy with the mandated implementation of the EMR system. EMRs
tend to roll out piecemeal throughout the hospital, by department or specialty. In the beginning of
2015, the ophthalmology department at County Medical Center 2 rolled out the EMR system that
was already being used in other areas of the hospital. Ophthalmology is largely frustrated with the
EMR system, feeling that the digital format drastically slows them down. Since a lot of their
charting is visual and full of images indicating where on the eye an abnormality is found, it is
easier to draw out an eyeball, then mark an x on the image, rather than having to construct the
eyeball through a series of paintbrush-like tools on the computer. Sarah Jane, junior attending in
ophthalmology, elaborates:
I was excited about it at first because I can't tell you how many times I sit
there and try to read someone else's handwriting. Like, I can't decipher this.
Or I'll write so much that my wrist starts to hurt, and I'm like, I wish we
had EMR. And then it comes, and it's a disaster because it slows down the
clinic...you have to click to go to the eye exam, click to go to the pupil
exam, click to go to the, and it's just so much unnecessary clicking. And I
asked them to have it where, can't you just have a page come up with like
everything in it? Instead of like clicking back to do these tiny little things.
Anyway. It took like so much more time, so for each patient, where it used
to take, um, 20 minutes maybe for an exam by the attendings, now it takes
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at least 30-40 minutes because they're trying to navigate this (“Sarah Jane”,
personal interview, February 17, 2015).
Indeed, the potential efficiency of EMR systems is hampered by the design of the systems
themselves. A study found that emergency room physicians in Pennsylvania would complete more
than 4000 clicks navigating the EMR system over the course of a shift. Similarly, Angel, an
ophthalmology resident, distinctly makes a point to emphasize the amount of clicking that needs
to be done for the EMR system when I spoke to him (“Angel”, personal interview, September 23,
2014). As these EMRs become widely implemented, the trend is that physicians spend more and
more time on EMR systems. The study done in the Pennsylvania emergency department found
that physicians spent 44% of their time on EMR, and only 28% of their time with patients (Hill,
Sears, & Melanson, 2013). This over-administrating physician trend is becoming increasingly
pervasive as more health systems transition to an electronic system. While there were fewer lost
or misplaced charts and fewer problems with illegibility in physician orders, the time-saving
aspects that were expected were not realized after the implementation of the EMRs (Holroyd-
Leduc et al., 2011). The CommTech Survey found similar results (see previous figure), where the
largest percentage of respondents (39%) spend more than 4 hours a day accessing the EMR
system. For these 39%, 17 out of the 24 (70.8%) respondents stated that they are on EMR for at
least 8 hours a day, or “basically all day.” EMRs, for all of their convenience, seem to be time
suckers for practitioners.
Interestingly, though, when asked if they agreed with the statement, “I feel the EMR
system is good for efficiency,” the majority of the 74 respondents answered that they strongly
agree, agree, or somewhat agree (n=62), while only 12 individuals disagreed to some degree,
indicating that, the number of hours spent on the EMR system aside, there is still faith in
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technology's ability to make lives easier. What is interesting to note, though, is that the two
previous questions on the survey asked respondents to agree or disagree with the statements, “I
feel the EMR system is good for patient care” and “I feel the EMR system is good for billing”,
and the numerical mean response (where 1 indicates strongly agree and 6 indicates strongly
disagree) for both questions was x=1.99; sd=1 and x=1.99; sd=0.77 respectively. The question
about efficiency yielded a mean of x=2.49, with a standard deviation of sd=1.37, indicating that
people agreed to a lesser degree that the EMR system is good for efficiency compared to its
positive impact on patient care and billing.
This contradiction of faster technology slowing things down is a common theme. As
technologies for transportation advanced, and automobiles over-saturated the highways, cities run
into problems with gridock, drastically slowing the down the speed of transit (Wajcman, 2015). A
car undoubtedly can reach much higher speeds than a bicycle can, and yet, during rush hour, a
relatively technologically archaic bicycle can bypass cars and clip along at a faster rate than the
more technologically advanced cars stuck in traffic (Gallegos, 2013). In this case, we see that
physicians are spending more time on EMR systems, and there have been complaints about the
inefficiency of the EMR system for certain specialties, specifically ophthalmology. However,
there is still the perception that technology moves us into a more efficient direction, despite the
worrying trends of more time spent on the computer than with patients.
Another issue with EMRs is that through trying to save time, the process, while in some
cases works to reduce medical error (Jacobs, 2007), can also dehumanize patients by assuming a
treatment plan for specific conditions or diagnoses that can often facilitate errors (Koppel et al.,
2005). Indeed, this latter perspective is shared by my interview subjects:
[EMRs make] things a lot simpler and mistakes can happen. Let me give
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you an example. [For] electronic orders like EPIC for example, there are
order sends that you can't do. So patient comes in with a specific diagnosis
like pneumonia for example, the computer automatically auto generates a
list of orders that come standard in patients that have this specific type of
diagnosis. Because they come so standardized, the idea behind it is
hopefully mistakes won't happen and you won't click anything. One thing
that can happen is if your patient is not a standard patient, for example,
what you may do for a standard patient may not apply for this particular
patient and medical errors can happen (“Rory”, personal interview, May
29, 2015).
The dehumanizing of patients is incentivized by the fact that doing so saves time. The EMR
rationalizes the disease and assumes the standardization of disease to ostensibly make the
physician's life easier by speeding up the charting process. However, just like the process of
gridlock that comes from the desire for technology with greater potentials for acceleration, EMR
systems' attempts to save time for physicians not only dehumanize and rationalize human patients
with unique conditions and issues, but can also backfire on the temporal aspect. Other
practitioners, such as Mickey the internal medicine resident, echo Rory's point, talking about how
the EMR's design of autopopulating orders and medications for a specific medical condition takes
up more time, as the physician has to read through the autopopulated information and revise it
according to their specific patient, unchecking boxes and changing orders (“Mickey”, personal
interview, September 18, 2014). In this way, although EMRs purport to save time, in addition to
providing a system where all patient information is accessible with a few clicks of a mouse, the
design of the system itself sometimes cause more frustration and time consumption than
anticipated. Because EMRs are federally mandated and are increasingly being implemented in all
hospitals and health facilities in the US, its use is transforming not only how patient care
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information is managed, but also how practitioners manage their time throughout the day. And
there is no opt-out option.
Challenges in Transition and Implementation
Transitioning to the EMR systems for a hospital or health system is a challenging process,
and subject to substantial resistance from health professionals. The learning curve for
practitioners is steep, and there is inevitably time lost in during the transition due to unfamiliarity
with the new system. At the time of my field work, County Medical Center 2 was in the process
of transitioning to an EMR system. According to Martha, the ophthalmology resident at County at
the time, the transition process was rather painful because procedures and charting simply took
more time as practitioners figured out the new system. She would often have to stay at the
hospital until very late at night because there were so many delays in the clinic due to the new
system. In essence, practitioners learn an entirely new framework of patient information
management, which is a major part of their profession.
Moving to EMR had very real implications for the employment of individuals. Because of
the mandated transition, health practitioners have no choice but to make this transition. The
transition itself came with a lot of emotional upheaval, “challenges and frustration” (“Alaya”,
personal interview, October 27, 2014). According to Alaya, medical/surgical nursing unit director,
“a lot of people talk about hating it the first six months, but...you know what, we don't have any
choice” (“Alaya”, personal interview, October 27, 2014).

There is a feeling of resignation, as
Alaya's words belie the power that the institution, through the implementation of mandated
technologies, sometimes to the detriment of temporal control or efficiency, co-opt individual
agency and temporal capital, and practitioners are expected to adapt and conform to the new
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policies, create new cultural practices, and fall into new temporal rhythms that these new
technologies demand.
The transition to electronic health records, while challenging at first, and, seems to have
also led to a shift in the demographic of the work force, as, Alaya illustrates,
there's a lot of nurses here that are, have been here for a while. So, a lot of
older nurses...you have a lot of nurses that has been accustomed to paper
writings and chart documentations. And so when we transitioned to
[EPIC], mind you, there was probably about...two years of planning before
we actually went live. There's a lot of anxiety. There's actually doctors that
have resigned, and nurses that have resigned due to the anxiety of having to
do computer documentation....So, as years go by, I think people just kind of
settled and said, you know what, we really don't have any choice, but just
to get ourselves better when it comes to computer documentation.
Otherwise, either they're in, or they left. So, but now, I can see the
transition from 2012 to 2013, mid 2013, 14, that we have a lot more
younger [nurses, and] no question about it, they love it (“Alaya”, personal
interview, October 27, 2014).
With the implementation of EMRs, technological literacy determines employment for a
profession for which technological literacy is not necessarily on the primary job description.
Similar to the unintended consequences of the invention of the tomato harvester, which not only
required biogenetic alterations to thicken the skin of tomatoes to withstand the harsher handling
of the harvester, but also centralized agricultural production to large operations that could afford
the new technology, pushing smaller business out of the market, as told in Langdon Winner's
(1986) treatise on the sociocultural impacts of technological advancements, EMRs have altered
the structure of the patient health care team in unforeseen ways. The anxiety that technology
instills causes some individuals to either leave the institution in search of a facility that still uses
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paper charts, or to leave the profession completely.
There is also another way that the implementation of EMRs reveal structure of privilege
and power within these health care professions. Pre-existing familiarity with computer techniques
help tremendously in the transition to an electronic medical system, as Sarah Jane, junior
ophthalmology attending, illustrates:
One of my attendings, he can type, but just not that [efficiently], and
because he started noticing that he was so behind on all his patients, he
doesn't close his charts, meaning that, you know, he'll just document at that
time what he needs to remember the exam, and then after, and then just go
onto the next patient. Then he'll stay in his office and close all these charts,
meaning document everything completely, write letters to the referring
physicians, write down the problem list in more detail. And I've seen him
go from spending his Saturdays and Sundays to like, for work on research
or lectures to just closing charts the whole day. Like he's there at 7:30 in
the morning, and he's there till like 6pm just closing these charts for days
previous (“Sarah Jane”, personal interview, February 17, 2015).
Sarah Jane describes an apt example of how technology can zap someone's temporal capital and
act counterintuitively to the hope that technology increases efficiency. Here, we can see a
predictable correlation between technological literacy and temporal capital, whereas literacy and
competency in technology is a major factor in using that technology to save time.
75
However, if
we dig a bit deeper, we also see that technological literacy, and hence temporal capital, can be
bought if one is high up enough on the relevant hierarchy, and can afford to do so. Physicians with
the economic means to do so are able to bypass learning the system completely by hiring a scribe
- individuals who are trained to do patient documentation for physicians on the EMR system.
75 Given that the task at hand has a limited scope, like finishing up charting, and one is not endlessly browsing
social media.
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While the residents, fellows, and junior attendings at University Eye Clinic do not have scribes
and have to take the time to become technologically proficient with the EMR system, senior
attendings who are better established and make higher incomes are able to independently hire
scribes. By doing so, they essentially use economic wealth to buy technological literacy, which in
turn allows their temporal capital to not be co-opted by the act of charting. For private practice
physicians, hiring a scribe also ensures that the physician is able to remain in business by
adhering to the federally mandated requirements for Medicare reimbursements without having to
spend time grappling with the EMR system. Despite the many positive aspects with the
implementation of the EMR system, most obviously the organization of information for whoever
needs access to it, this new technological system not only impacts the temporal rhythms of
practitioners, but also reinforces hierarchies of temporal capital for those who have access and
literacy to this technology.
The hierarchy that colludes with temporal capital can also be simply seen in the
organizational structure of a teaching hospital. In Chapter 3, I spoke of how the interchangeability
of duties between residents and attendings facilitates the increase of temporal capital for those
higher up on the organizational ladder. This interchangeability, however, can sometimes backfire,
especially when there is too much of a reliance on underlings to handle the basic mechanisms of a
task – patient documentation, in this case. Some attending physicians simply are not familiar with
using EMRs because all of the charting is done by residents. Rory, the junior attending in internal
medicine, describes the dire straits in which his department's attendings found themselves during
a resident retreat, where the residents travel out of town for a number of days:
It becomes a huge issue every single year when your residents are not
there. The attendings have to figure out the system. And yes, some of these
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physicians have been there for many years, but they're on a superficial
level. They don't really know the nitty-gritty's of how the system works and
because of that it becomes very difficult for them to write a note, to write
an order because they've just been out of the loop for so long. They've had
residents writing notes and orders for them all these years. I can guarantee
you, when we switch to a new system starting February of next year, I can't
imagine what kind of issues we're going to have at that time. It's a learning
process, you know. Anytime you have a new process or a new system, the
more you do it, the more familiar you get and I'm hoping that we'll be able
to adjust through time (“Rory”, personal interview, May 29, 2015).
The situation described here was a result of attendings taking too much advantage of the
interchangeability of their duties with that or their residents in order to increase their temporal
capital. While relying on the institutional hierarchy to determine and increase one's temporal
capital, in the attendings' cases, seems to be par for the course on a normal basis, the practice of
outsourcing one's skills in order to save time can potentially slow down the process that the EMR
system was supposed to accelerate. Hence, while the utilization of EMR systems, through virtue
of its presence and its impact on the differing temporal rhythms of health practitioners, embody
the power dynamics between individuals that are institutionally reified, not to mention the
disciplining of that temporal rhythm through the mandated use of the system, it clearly behooves
attendings to invest the time in learning the system to prevent the temporal bottleneck that
happens when their subordinates are not around.
Personal Cell Phones for Work
While EMR systems are not only institutionally sanctioned, but institutionally mandated,
personal cell phones tend to be looked upon as the pariah of productivity and attention to work.
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The concern tends to be around whether cell phones are able to meet the Health Insurance
Portability and Accountability Act (HIPAA) standards of patient privacy, as well as the potential
for personal cell phones to be distracting during the work day. However, since personal mobile
devices are fairly ubiquitous amongst health practitioners (who have assured me that they are very
conscientious that their text usage complies with HIPAA regarding patient information), these
personal mobile devices are in fact used in a variety of different ways, from coordinating patient
care on the go, to knowledge gathering on the spot, to allowing practitioners to connect with their
non-work lives during downtime or break times at work. Therefore, mobile communication
technologies in particular have also greatly impacted not only the act of caring for patients, but
also potentially expands the temporal capital and affects the overall temporal rhythms of the
practitioners themselves through its enabling of the blurring of work and non-work time, as well
as the ability to allow the practitioner to be easily and quickly reachable, circumventing
institutionally-sanctioned processes of communication between practitioners, thereby serving to
accelerate instances of workflow throughout the day.
The mobility of cell phones has transformed the experience of work for health
practitioners. The fact that the use of personal cell phones are generally not institutionally
sanctioned has not deterred its proliferation and usage amongst practitioners at work. Mobile
applications targeting both practitioners and patients are easily found in app stores. While patient-
facing apps are many and varied, there are only a few practitioner-facing applications that survey
respondents repeatedly mentioned. Medical Economics named the top 5 applications used by
physicians in 2013 (Glenn, 2013), one of which was the drug and medicine app, Epocrates, which
was mentioned by nine individuals in the free response section on the question in the survey that
asked about how practitioners use their personal cell phone for work-related activities.
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Additionally, Epocrates was cited 14 times when respondents were asked specifically about which
specific work-related apps are used. Use of the app also came up in interviews and conversations.
Many health practitioners use their personal cell devices for work-related activities, while also
using their device as a way to keep in touch with friends and family while they are at work,
enacting a blurring of work and non-work time. From looking up medications to coordinating
patient care with fellow practitioners, to looking up journal articles in order to keep up to date
with the latest medical research in one's field, to simply using their cell phone as the primary way
to reach them while they are on call, to being reachable by a nanny or a spouse or a child's school,
mobile technology allowed for both the blurring of work and non-work time, as well as created
potential avenues for greater efficiency and speed in communication within the health care team.
The implications of using different devices (ie: personal mobile phones vs. pagers vs. a
work phone) and how the ways that these physical devices are used demarcates the ideological
lines between work and non-work deserves some attention. A physician in a nursing facility in
New York states that, while she is not technically supposed to use her personal device for work-
related activities, her personal social networks are intertwined with her professional networks so
that she sometimes uses her personal device for work-related activities:
We are not supposed to use our personal devices for work related activities,
however, it is sometimes easier to reach someone via text on my iPhone
than on the blackberry given to me by work. So, occasionally I use my
personal iPhone to text. Also, at times I am called from work during a time
I am not officially on call. Some of these times my staff uses my personal
iPhone to reach me by phone. In addition, I have used social media for
networking. When we are trying to recruit staff I sometimes communicate
with old colleagues via Facebook. Since we can not access Facebook
through any approved work device I am forced to use my iPhone at work
for this purpose (CommTech survey response).
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This physician's testimony is interesting in that the institution she works for seems to insist that
personal and work devices are separate, denying the increased blurring of work and personal time
by designating certain work activities on a physical device. Devices, then, are used as a tangible
separation of work and non-work time. One device is for work, one device is for non-work. The
best example of this is the persistent use of pagers in the medical field. Why would medical
professionals need pagers when it is easy to get a hold of someone via cell phone? Yet the rules of
engagement can be set for a hospital-sanctioned device more easily than it can be for a personal
device, and when a physician is on call, the pager is required to be on his or her physical person at
all times.
There are some interesting implications around temporal capital with the use of pagers, an
institutionally-sanctioned, and often mandated device, in the hospital as well. Because the pager is
a physical device – a piece of property – that belongs to the health care system, the act of having
the device dictates one's behavior, and can potentially co-opt the time of the physician. The
physician is required to call the hospital within a certain amount of time after receiving the page.
Similarly, that pager could also be the factor that forces them to physically go into the hospital to
take care of a situation or a patient, which takes even more of their time. Because the pager is
tangible material that represents the control that the institution has over an individual's time, the
act of having a pager can ostensibly be interpreted as having lower levels of temporal capital. If a
physician is on-call, he or she must have the pager on his or her body (or within arm's length) at
all times. As we have seen in Chapter 4, the state of being on call is a major imposition on one's
temporal autonomy for the duration of that call period, and the pager is the physical manifestation
of that temporal co-optation. Later in this chapter, I will discuss how the use of the pager also
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reinforces hierarchical structures of communication between different professional groups within
the health care system.
While there are attempts to separate out work activities and non-work activities through
using different devices, in practice, the separation of work devices and non-work devices is not so
clear. Things like pagers are official work devices, but more and more, practitioners are
communicating with each other about work-related issues on their personal devices because it is
“easier,” as the New York physician above states. Even in this physician's case, where the
Blackberry, another smartphone, would ostensibly have similar functionalities as her personal
iPhone, she still uses the iPhone as a personal channel to connect with her old colleagues – a
personal connection – for work-related purposes. In this way, the personal cell phone embodies
this blurring of work and non-work activities.
Health practitioners use their personal devices for work both at work during work hours,
and away from work, especially when they are on call, or need to coordinate patient care or
schedules with other practitioners. Practitioners use their personal cell phones for two main work
purposes, both at and away from work – organizing patient care and scheduling with colleagues,
and actual patient care (looking up medical conditions and drug interactions, sending images and
information for consultations or updates). In each of these categories, we see how the blurring of
time and the acceleration of workflow processes enabled by these cell phones play out.
Scheduling and coordinating
From scheduling meetings, coordinating staffing, or even letting a colleague know that a
surgical room is ready for the patient, personal devices are important as a tool to help practitioners
communicate logistics and organize their time. From the CommTech Survey, of the 79
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respondents of the question, “Please describe how you use your personal cellphone/smartphone /
(iPhone, Android phone, etc) at work?”, 13 state that they do not use their personal cell phones at
work, while 43 of them (65% out of the 66 remaining that actively use their phones at work)
indicate that they use their personal cell phone to coordinate schedules or patient care with fellow
practitioners. Alaya, nursing unit director, readily states that she uses her device to deal with
scheduling issues on her unit and keep on top of the appointments she has throughout the day
(“Alaya”, personal interview, October 27, 2014), while Amy, the psychiatry resident, similarly
emphasizes the importance of communicating with her phone to determine where she physically
has to be:
I could not survive without a smartphone. I don't know anybody, I don't
know any residents who don't use it on the floors. We use it for, I mean,
besides inter-communication between other like, teammates, other
residents on our team, there are times when I get called away by a nurse to
go do something, and then the team is literally rounding in some room and
I don't know where they are, and I'll text, hey which room are you in, and
then I'll get a response. We always have our phones on us (“Amy”,
personal interview, September 22, 2014).
In the way that Amy describes, her phone allows her freedom to do a second task (being called
away by a nurse) during the process of completing a first task (rounding) if she needs to, then
easily find the people she needs to in order to finish the first task. In a sense, the smartphone
expands her temporal capital, and her options of being more flexible with her time – to take care
of something necessarily immediately – without having to worry about wasting more time trying
to get back to the first task. It also allows her to accelerate the workflow for the first task as well
through the multi-tasking she is able to do thanks to her cell phone.
The CommTech Survey also reveals the penchant for people turn to their personal cell
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phones to communicate with other practitioners. When asked how people get a hold of them while
they are on call, out of the 43 respondents, 32 stated that people would call their cell phone with
16 (50% of cell phone callers) stating that they are reached exclusively by cell phone calls while
on call, while only 19 said that they would be paged with a mere 7 (36.8% of pager users) saying
they are reached exclusively by pager. Another 14 said that people would text them, but only 2 out
of the 14 stated that they would be texted exclusively if they needed to be reached while on call.
Interestingly, residents tend to use pagers more exclusively. In fact, there was not a single resident
who responded stating that they are reached exclusively by cell phone.

When you are on call, how do people get a hold of you? (respondents allowed to choose multiple)
While the data does not necessarily explain why,
76
through my interviews and
observations, we can likely take a gander. Residents, as we have seen earlier, are the first line of
defense when something happens during call. Pages will generally come from nurses, or
76 A limitation of mass surveys and the inability to ask probing questions...
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physicians asking for a consult (meaning they are from a different service or specialty), or other
hospital staff, and the primary call resident will receive the page. Therefore, it is likely that the
main channel of communication from whatever is happening in the hospital to the resident who is
either on home call, or taking in-house call at the hospital, is the pager. As we will see later, there
are interesting informal hierarchical dynamics that determine who has whose cell phone number,
and nurses and physicians from other specialties rarely have the cell phone number of the
physician they are trying to reach. Hence, the pager is the primary means of communicating
across these professional lines. Attendings, on the other hand, especially in a major medical
teaching center, will not be on primary call. If a resident needs help, he or she will call a fellow,
who will then call an attending. The closer in status a physician is to an attending, the more likely
that person will have the phone number of the attending who is on call. Therefore, it makes sense
that the attendings in the survey will state that they are reached exclusively by cell phone, since
the person calling them is someone who is considered internally within their direct chain of
command. There are some interesting implications here – the pager dictates that residents must
respond to the page immediately, so they are lower on the hierarchy, and therefore their temporal
capital is taken up by the act of having to answer the pager when paged. On the other hand,
attendings can wait a little bit – they have a bit more flexibility in terms of when they respond to a
call or a text, as they are not required to have their personal cell phone on their person at all times.
The survey data also show that nurses use their cell phones exclusively, but this is likely because
nurses are generally not on call in the way that physicians are, as they are generally on shifts,
although Alaya, as an administrator, states that the unit directors take turns being on call.
The scenarios described above reveals the differences in temporal capital between
different individuals on the training hierarchy (residents vs. attendings) in their uses of different
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devices while on call. During the day, when all members of the team are active, and the
communication protocol is not quite as linear as calling up a chain of command, the somewhat
illicit cell phones are often used in lieu pagers to quickly get a hold of a team member. Rose,
junior anesthesiology attending, described the laborious process of paging someone (“Rose”,
personal communication, November 6, 2015). First, she has to physically walk herself to a
computer, as the paging system is online and not liberated from physical location. She then has to
log into the hospital computer system, navigate to the website that sends out pages, search on the
site for the name of the person to page, then finally actually paging them. After the page is sent,
she then has to wait for the person she paged to call her back. This is a very slow, time consuming
process. Rose often oversees multiple residents in multiple operating rooms with multiple surgical
procedures, so it is imperative that she is kept up to date with the patient situations as quickly as
possible. In this way, we see that personal cell phones are actually more efficient than going
through the official proper channels of paging, or even physically finding the person or being in
the OR. Texting via personal cell phone allows this attending to communicate faster with multiple
people. By using her personal, non-institutionally-sanctioned device over the institutionally-
sanctioned pager, she accelerates each individual instantiation of communication between herself
and her team, not only making her hourly workflow more efficient, but allows her to experience
greater temporal and physical flexibility and autonomy.
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What is the most common way you coordinate patient care using your personal cellphone/smartphone? (n=44)
While both calling and texting are used, the two methods have different temporalities that
bear upon one's temporal capital. Calling requires a higher degree of “co-presence” (Petranker,
2007) and synchronicity than texting does. Co-presence eradicates temporal autonomy, as
individual actions are held at attention to the communications of the other person. Conversation
occurs in real time, like on the phone, where long pauses become awkward and socially
unacceptable, thereby compelling the individuals to set aside other activities to prioritize the
ongoing synchronous conversation. My previous work takes the idea of co-presence to a more
precise level, making a distinction between temporally-bounded (low temporal autonomy) and
non-temporally bounded (higher temporal autonomy) media, simply stating that there is an aural
aspect (versus solely visual) to the temporally-bounded media, as sound only exists with the
passage of time (Wang, 2013). In a similar strain, the act of being on the phone, because of its
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aural nature, exists in a state of lower temporal capital, and lower temporal autonomy, because of
its temporal boundedness. When on call, the urgency the call is congruent to the immediacy of
communication, and the co-presence, that phone calls provide. When physicians are on call, they
exist in a state of having potentially lower temporal capital, and that potential of co-opted
temporality is realized as soon as they are needed, and their cell phone rings. The person on the
other end of the line commands their full attention for the set period of time for the call. Hence,
fewer people use exclusively text messages while they are on call. The phone call itself compels
the physician on call to sit there on the phone with her colleague at the same time and attend to
the situation at hand without distractions – she is co-present with her colleague on a temporally-
bound medium that allows her to be synchronously. Being called while on call means that there is
an urgent situation happening, and people must be informed right away, whereas text messages, a
medium that allows greater temporal flexibility, are used throughout the day for communication
that is not urgent enough to require the complete co-option of an individual's time and attention.
To put things really simply, Martha, ophthalmology resident, says that if she is on call, she picks
up her phone all the time because she knows her colleagues will only call her for a time-sensitive
issue or an emergency. During a regular work day, she uses text to communicate with her
colleagues more, but if there is an urgent issue that arises, she will call (“Martha”, personal
communication, February 22, 2016).
Personal cell phones are being used by practitioners for work activities in an effort to
streamline their tasks and their communication. By and large, the most common way for people to
coordinate patient using their personal mobile phones is through texting, an activity that is largely
only available through the use of personal cell phones. There are clearly privacy concerns, yet
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there are also a number of technology companies like TigerText,
77
which seeks to marry the habit
of texting with encrypted patient information on their platform. Companies like TigerText are
recognizing the evolving communication practices of health practitioners and finding ways to
increase privacy policy compliance within these changing practices. Similarly, hospitals and
health systems often mandate the installation of encryption programs on the personal phones of
physicians who use work email and EMR on their personal devices (personal observation,
February 19, 2016). The non-temporally bound, lower levels of co-presence aspect of texting,
allows for higher levels of temporal capital, which is more attractive to practitioners like Martha.
With texting, she can either respond right away, or take a few seconds or minutes to finish up a
task before responding. It is less intrusive than a phone call for her, and conversely, whoever is
calling her similarly does not have to wait for the phone to ring, and for her to pick up, resulting
in greater temporal autonomy for all parties involved (“Martha”, personal communication, August
24, 2015).

In the same vein, though, personal phones are used to call colleagues as well,
particularly in urgent situations, accelerating the process of communication between practitioners,
as long as both practitioners in question bypass the institutionalized communication flow and
have access to personal cell phone numbers.
Patient care
In addition to using phones to schedule amongst themselves, practitioners also use their
personal cell phones to coordinate patient care, while carefully following HIPAA regulations and
taking care to protect patient privacy. Respondents to the CommTech survey mentioned that they
would call consults using their personal cell phone. One rheumatology physician stated that he
77 http://www.tigertext.com/
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“take[s] photos of pathology seen without patient identifiers for consultation” (CommTech survey
response). Similarly, the ophthalmology residents I observed use cell phones to take pictures of
their patients' eyes in order to send them to senior residents, fellows, attendings, or other
colleagues to get additional opinions. Texts are also sent to get opinions and advice from
consultants or colleagues, or to “send texts to attendings on clinical updates” (CommTech survey
response). As long as there is no patient identifying information, there is no HIPAA violation, and
most patients are amenable to the doctors taking pictures, especially to get another opinion. This
is also a way that doctors are able to get quick feedback without the other person (the recipient of
the message) having to physically come see the patient, or pick up a physical copy of the picture.
The sharing of information is sped up and made easy through the use of personal cell phone
technology. Although, we have to remember that while information is sent instantaneously, it may
not be seen nor responded to instantaneously, as when the recipient actually views the image will
vary according to what the recipient is doing at the time. In this way, the use of texting not only
instantaneously delivers information to the recipient in a timely manner, but it also allows the
recipient a higher degree of temporal capital and flexibility as to when she looks at the text and
deals with the situation.
Beyond the sharing of images and information amongst colleagues, phones may also be
used and useful during a patient encounter. Amy gives an interesting example of how she, as a
psychiatry resident, uses her personal cell phone for direct patient care that saves her time:
It's really frowned upon to pull out your cell phone, but I find that I end up
doing it anyway, just because it's a matter of assisting the patient better.
Like, if we're in a closed room, and they need to, you know, let's say I've
been trying to get a hold of collateral information, like, let's say there's a
patient who's unwilling to have you get information about them, and then
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they finally say, “Ok, I'll let you talk with my mom who knows me very
well, and I've been living with,” and you know, we need this information
about them, but “I want to be present and, because I'm a little paranoid” -
they don't say they're paranoid, because they're paranoid. So [they say], “I
want to be present, but you talk with them.” Well, that's not gonna happen
in the work room where I have a real phone. I can't take them off the unit,
the work room is not on the unit, and I wouldn't have them in the work
room anyway, so I pull out my phone, I dial star six seven, which blocks
my number, I have them dial, that way they're sort of giving a consent to
have their family member be talked to, I have them start the conversation, I
talk to them, get the information right there with the patient. So, I mean, it's
critical to get this information, and without the cell phone, there's no way
to get it (“Amy”, personal interview, September 22, 2014).
In this scenario, the cell phone plays a crucial role in allowing Amy to deliver the requisite quality
patient care in a timely manner, allowing her to avoid pesky delays that may compromise her
patient encounter. In essence, the cell phone was necessary for her to do her job effectively. These
are some considerations that ironically would benefit from being more institutionalized
throughout a health system.
As alluded to earlier, cell phones are often used in the pursuit of knowledge or research
during the day. This can often be connected to direct patient care, as physicians will use
Epocrates, a mobile application that describes different types of drugs, dosages, and their
interactions with other drugs to double check the medication being prescribed to the patient. The
CommTech survey revealed that many practitioners use their personal devices at work to look up
information, drug interactions, and medical conditions and interventions. Out of 66 respondents to
the question, “Please describe how you use your personal cellphone/smartphone / (iPhone,
Android phone, etc) at work?” who indicated that they do use their phones at work, 25 (37.8%)
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stated that they use their personal phones to look up drug information or medical conditions,
which has a direct impact on their patient encounter. In this way, having a personal cell phone
provides a quick and easy way to access references directly related to their patient encounter, and
we are seeing that there is a substantial percentage of practitioners who regularly use their
personal cell phones both to coordinate patient care, and communicate and consult with other
practitioners, as well as using it for direct patient care purposes. Cell phones, for better or worse,
have become a permanent part of the health care working landscape.
Personal Cell Phones for Non-Work
It is perhaps not a surprise, given the blurring of work time and non-work time, that
communication technologies, especially personal mobile smartphones, would facilitate a practice
of incorporating non-work activities and into the work day. In 2015, McBride et al found that
there is a substantial percentage of nurses that use personal cell phones in the hospital for things
that have nothing to do with work (McBride, LeVasseur, & Li, 2015). The main activity for which
people used their cell phones in this study was to text or email friends and family. Indeed, it is
often connection with loved ones outside of work that compels the use of personal cell devices.
Cordelia, a fourth year medical student, confirms this sentiment in expressing that being in the
hospital does not allow for a lot of downtime, especially given the demands of medical school, so
that being on Facebook provides a way to keep up with people she cares about, that it is almost
like being able to hang out with them (“Cordelia”, personal interview, February 11, 2015).
The state of being “perpetually connected”

(Katz & Aakhus, 2004) with mobile devices
means that a world of connections, entertainment, news, music, and media are available at the
touch of a finger. Interstitial time, or time spent waiting, traveling, or otherwise in between other
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“productive” activities, usually known as “dead time”, can now be recouped by the individual
through the consumption of media and/or connecting to people outside of work.
78
Not
surprisingly, a number of respondents admit to using their cell phone to complete non-work
related personal activities, including social media and texting/emailing friends/family, playing
games, and reading news articles while at work “during lunch or break,” “during downtimes,” or
“if there is nothing else to do.”

One respondent stated, “between patients, I use my cell phone for
personal texts, phone calls, social media.” Another respondent, a resident, admits to watching
Netflix during overnight call when it is slow.

With these cases, we can see that, despite being at
work, health practitioners will “fill” interstitial time between work activities with personal labor –
labor geared toward exchanging the little pockets of time available to them to maintain social
capital by texting friends or checking social media,
79
or, in the case of the Netflix watcher and the
news readers – their cultural capital as well. Keeping both in touch with loved ones and with the
rest of the world seems to be an important aspect of filling time during the in-between.
This particular aspect of the use of communication technology (personal device use for
non-work-related activity) was slightly more challenging to get at. Asking about using personal
cell phones for non-work related activities was a sensitive and touchy subject, as most health
facilities heavily frown upon using personal cell phones at work, and many people shied away
from openly admitting that they would use their smartphones for anything other than work-related
activities. Even with work-related activities, multiple respondents were careful to add that their
communication about patient information was meticulously curated to comply with HIPAA
78 Waiting time is often also called “dead” time (Klug & Klug, n.d.). There are even sites that instructs one on how
to use dead time to become more productive (A. Robinson, 2011), while others go even further by suggesting that
one can “fill this time up with valuable things” (Marshall, 2010), placing a gradient of value on certain activities.
79 Scholars like Nicole Ellison and Mark Granovetter have espoused importance of “weak ties” in social networks
(Granovetter, 1973) and the affordances of social media in general and Facebook in particular in maintaining the
“weak ties,” that contribute to bridging social capital (Ellison, Steinfield, & Lampe, 2007).
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standards. However, the fact that people use their personal devices to keep in touch with family
and friends while at work is indisputable. In order to not directly ask about personal device used
at work, I asked respondents to the CommTech Survey to agree or disagree with the statement, “I
feel that having access to my personal cellphone/smartphone has allowed me to keep in better
touch with family and friends when I am at work.” Out of the 74 respondents, 58 of them stated
that they either “strongly agree” or “agree” with this statement, indicating that, whether or not
they want to admit it, most of the respondents use their personal cell phones to some extent.
There are two interesting things to note here. On one hand, these personal devices allow
for the blurring of work and non-work life, enabling people to stay connected to loved ones,
letting practitioners “relax & get away from the realities of work” (CommTech survey response).
On the other, there is a prioritization of work wherein it is a given that the health care institution
monopolizes workers' time to the extent that workers will undergo this sort of self-surveillance,
only glancing at phones at institutionally sanctioned non-work times (ie: lunch and break). The
latter can be seen by the defensiveness in the responses that mention breaks or downtime. This is
not to say that health professionals should NOT prioritize work – in fact, because of the acuity of
many patients in hospitals, distraction by mobile device could have detrimental ramifications for
the care of patients. Rather, it is interesting to note that while mobile communication technologies
have the potential to expand one's temporal capital by putting into one's pocket a device that can
allow one to complete work, maintain social ties, entertain oneself, and gather knowledge, the
weight of one's work responsibility monopolizes a large chunk of one's day, lessening the
temporal autonomy that these mobile communication technologies potentially enable.
Therefore, a Panoptic process of self-surveillance (Foucault, 1975) makes individuals
reticent to overtly use non-institutionally sanctioned technology (or, at the very least, admit to it
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openly), even if it gives them more control over their time and often makes communicating
between colleagues easier, emphasizing not only the institution's control over when they have to
be at work, but how they are to organize their time while at work. During these interviews, I
found myself reminding my informants that their answers would be anonymous, and even so,
many informants shied away from the question, or answered the question in context of how they
use their mobile phones for work-related activities. The individuals themselves are interpellated
and disciplined to the official logic of the institution, which is that their time belongs solely to the
institution, for labor done for the benefit of the institution. There is an element, though, that has
not yet been addressed, and that is the meaning and worth of their work that practitioners that
cannot be easily quantified. To speak of health care as a solely capitalistic venture is simply not
sufficient. As a consultant friend told me once, in context of why he does NOT consult for health
care, there is the X-factor, or the human factor (personal communication, October 10, 2015). It is
impossible to place a monetary value on human life (nor should we try, even though we try all the
time). In health care, as we will see in Chapter 6, the reasons for working in health care extends
beyond the monetary compensation for labor. There is the hope for personal growth, the joy of
helping other people, the pursuit of knowledge, and the love of the science, the pathologies, and
the medical process. These motivation are not solely restricted to the field of health care, but in a
way, the shying away from being “distracted” and using time for something outside of patient care
can be attributed to this X-factor as well – that the practitioners themselves garner meaning
through their work, and to be distracted from this noble pursuit is, well, shameful, especially
when there are patients' well-being on the line.
At the same time, it is necessary, in this particular discussion, to table the implications of
temporal capital on a meaningful career until the next chapter, and focus on the impact of mobile
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technology on the felt temporal experiences of physicians. If we follow the logic that mobile
communication technologies have the potential to expand one's temporal capital – to allow one to
maintain social or cultural capital at the same time that one is accruing economic capital – then
we see that the reclaiming of this temporal capital through the use of these mobile communication
devices is not quite sanctioned by the institution, which seeks to recapitulate the bodies and
activities of practitioners into that of a neoliberal subject. This interpellation and discipline unto
the system is reinforced by the reluctance to entertain (or admit to) the idea of this expansion of
temporal capital during work time through the use of personal mobile devices. In this reluctance
is the internalized mentality that there is a narrow relationship between labor and time, wherein
the expenditure of their time and the subsequent gain of economic capital can only be used in
exchange for work. Not to mention, the ability to accrue economic capital could be jeopardized if
they were to capitalized on using mobile technologies to extend their ability to maintain non-work
relationships.
However, in the cultural practices and reality of work in the health care system,
practitioners are not so strictly controlled as it may seem, as evidenced. While people are careful
not to overtly laze around during work hours checking Facebook at the expense of patient care,
they do take advantage of connecting with the non-work world during interstitial times of the day.
Hence, the use of personal phones during the work day for non-work activities, similar to how
they were used for work activities, present a resistance or subversion to the totalizing imposition
of temporal control that the institution has over the practitioner-laborer, allowing for not just some
agency for individuals outside of the workspace, but a way to recoup temporal capital by
transforming dead time into productive time put toward maintaining social or cultural capital.
With the blurring of work and non-work time, and the hope of communication
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technologies to save time and render processes more efficient, there is also the contradiction of
speed akin to the idea of gridlock. Additionally, the blurring and perpetual connection potentially
places an expectation for an instantaneous response, as Sally, junior ophthalmology attending,
attests:
It's always blurred. When I'm home, I'm always getting work emails and
work texts. And when I'm at work, I'm always getting personal texts,
personal email. So there's no boundary. I think I would concentrate better if
I could compartmentalize. Maybe it's just an excuse, but it is distracting.
Like, super distracting [to get personal texts at work]. It gives me anxiety
[to get work texts at home], actually. I feel like I need to do it right now. A
lot of it isn't urgent, or it can wait, but I just feel like I need to answer the
person. I need to go answer them (“Sally”, personal interview, June 17,
2015).
Sally goes on to state that she feels anxious when she gets work texts at home, because she feels
compelled to answer them right away, which drags her away from her non-work time and into the
work arena. The interruptions by communication technologies also displaces time on her tasks,
whereby the interruption that communication technologies enable results in a task taking more
time than the time it purportedly saves. So while communication technologies give practitioners
more options and more agency throughout the day, the blurring of time and the expectation within
an accelerated norm for correspondence can sometimes backfire and create stressful and anxiety-
ridden situations that zap any potential temporal capital that may have been possible through these
technologies.
Hierarchies of Communication Technologies
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Variations in temporal capital on an individual and a group level are related to power
dynamics that determine and are determined by use of and access to different forms of
communication technology. By having access to certain technologies or certain information, one
could ostensibly be more efficient than one who does not have access to that technology. Indeed,
access itself is not just physical or by permission, but also encompasses pre-existing technological
literacy, or how familiar one is with using similar devices and technologies. When introducing
EMRs to hospitals, Holroyd-Leduc et al (2011) found that “there was a positive relationship
between prior computer experience and expected utility” for EMRs (733). As discussed earlier,
nurses who are unable or unwilling to learn the system leave, and physicians who are more senior
who do not want to bother learning the system can hire scribes to do their charting on the EMR
system for them. However, access to certain technologies, or people through these technologies,
especially those like personal cell phones that are not provided by the institution, provide avenues
to make one's workflow more efficient. As I have alluded to throughout the chapter, the access to
individual cell phone numbers, and the subsequent ease of contacting these individuals, tend to be
determined both by institutional hierarchy as well as affinity to professional group.
Practitioners tend to have more phone numbers of people within their professional group
than outside of it. For example, one medical resident on the CommTech Survey responded that he
has “almost all” of the phone numbers of his co-residents, while he has “none” of the phone
numbers of nurses and other staff. Indeed, only two respondents indicated that they had a greater
proportion of the phone numbers of people within their professional group than outside of it,
which has interesting implications for temporal capital and efficiency in communicating.
Physicians tend to have physicians' cell numbers, and nurses tend to have each others' as well.
Therefore, a physician trying to reach another physician will be able to do so with greater
206
efficiency, either through texting or through a phone call, than a nurse trying to reach the same
physician.
But even amongst physicians, there is a hierarchy that follows the levels that frame the
physician training process. Sarah Jane, junior ophthalmology attending, describes a conversation
she had with one of her attending colleagues:
So it's 6 months into a fellowship, right, and one of the other attendings
asked me, “Oh, can you text the other fellow this, blah blah blah?” [I
respond], “Oh, don't you have her number?” [He says], “Oh, I probably do,
but I know she's contacted you before on text...I don't know, I might have
her number, but I didn't list it as a name.” So, and I was like, “Why
wouldn't you, so it's just like, this random number in your phone, like, it's
your fellow, right?” And he was like, “Well, they don't really get names
until they're done with fellowship.” He was saying it in a joking way, but I
think it's true! I think like, they try to keep this level of separation, so the
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residents don't know the attendings' cell phone numbers (“Sarah Jane”,
personal interview, February 17, 2015).
While this is rather funny to read, Sarah Jane touches upon a very interesting point about how
communication happens across different levels of hierarchy in a hospital. A pager is the “official”
form of communication between practitioners. If a nurse needs a physician, he or she will page
that physician, then have to wait until that physician calls him or her back. Similarly, a consultant
(a specialist from another department) is paged by the referring physician, and the referring
physician must wait until the consultant calls back. Personal cell phones have ruptured this nicely
packaged protocol and facilitated communication between individuals by working outside of the
official, institutionally sanctioned processes of sharing information. In a way, communication
technologies facilitate the exchange between temporal capital and social capital. If someone has
enough social capital – that they have the phone number of other practitioners – they are able to
capitalize on that social capital to save them some time. Indeed, rather than waiting for someone
to call them back,
80
with the right amount of social capital (ie: a phone number), they can get their
issue resolved right away.
Hence, there seems to be a hierarchy of who gets whose numbers. Physicians of similar
positions in the training hierarchy (co-residents in the same cohort, for example), and physicians
in general, will generally have each others' numbers – more often than individuals outside of their
physician circle, whereas nurses communicate with physicians largely through the paging system.
Sarah Jane points to this when she says, “I don't page the residents, I just text them” (“Sarah
80 Waiting is dead, interstitial time – time that, but for the accessibility of mobile devices, would be empty and
unproductive – the antithesis state of being for the neoliberal capitalist individual who is interpellated within
logis of productivity… waiting is when one has the lowest amount of temporal capital, since one's time is at the
whim of someone else's action – in this case, calling back.
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Jane”, personal interview, February 17, 2015).
81
Similarly, a psychiatry resident from the
CommTech Survey states, “Other residents text me or call me if they need to talk. Nurses and
other staff page me.” In a way, then, the ease of access and getting a hold of someone immediately
is bracketed within professional groups, where each professional group has an advantage over
others to get a hold of someone quicker within their own professional group. A nurse, then,
arguably, will spend more time trying to get a response from a doctor than another physician, who
can simply text or call the practitioner directly. In fact, Vera points out this exact point on the
difference between paging a physician and calling or texting them directly:
You see the doctors all the time, and I don't think they're just taking
random phone calls, they're looking at medicines, they're texting other
doctors, you know, doctors that might be in the OR and you probably didn't
sign a prescription, or we didn't get the orders correct, can I clarify? A page
might take too long. A phone call or text, it gets there faster (“Vera”,
personal interview, February 18, 2015).
In this way, accessibility to phone numbers is the gatekeeper for organizing the hierarchies of time
and temporal capital, which reinforce these power dynamics, organizational structures, and group
exclusivity along these hierarchical lines. The hierarchy works on two levels. As we can see, a
number of physicians indicated that nurses and other staff will have to page them. If we were to
take salary and income as an indication of social power, physicians, in this case, hold the upper
hand, allowing them access horizontally to peers much easier than to nursing and other
medical/hospital staff. However, phone numbers circulate more within a professional group, or
within a specialty group, indicating that, regardless of a broader socioeconomic hierarchy, there is
a hierarchy given the membership of an individual into a certain professional group. In this way,
81 The norm of attendings and residents texting to each other may also vary depending on the attending. Sarah Jane
may be unique in that she was a fellow the previous year, so many residents have her number from when she was
a fellow, and close in the training hierarchy to residents.
209
the closer one in status one is to the individual in question, the more temporal capital can be
realized by communicating with that person through the technological means afforded by one's
position in this circular hierarchy. Social capital, in this case, becomes a determinate for temporal
capital.
Conclusion
The use of communication technologies by health practitioners reveals interesting power
structures as they relate to the use and control of time and temporal capital across health care
professional hierarchies. As communication technologies have gained a position of ubiquity in
developed society, it makes sense that health practitioners are using them to manage their own
work and lives. We see more blurring between strictly work and strictly personal activities, with
communication technologies enabling practitioners to work while at home, and keep in touch with
loved ones while at work with the use of personal mobile devices. We also see the blurring of the
use of these devices on another level, with work activities being conducted on personal cell phone
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devices, circumventing institutionally-sanctioned, and often slower, processes of communication
between health professionals in an attempt to gain more agency over one's time through the hope
of technologically-enabled efficiency. All three technologies discussed – EMRs, personal cell
phones, and pagers – transcend these boundaries between work and non-work, presumably
allowing communication (and hence, labor) to proceed easier. While EMRs and pagers sit on the
side of “official” institutionally-sanctioned technologies, the use of these “unofficial”
technologies like personal cell phones are becoming increasingly the norm for how health
practitioners communicate. While the benefits and costs on temporal capital of using technologies
are complex, one thing that we can conclude is that temporal capital still determines and is
determined by one's position in the relevant power hierarchy, whether the hierarchy is
institutional, or based upon closeness in position to a particular individual. Furthermore, the use
of technologies, through its enabling of blurred time and instant connectivity, demonstrates
practices of resistance to institutional impositions of temporal control, giving individual
practitioners increased levels of temporal capital, agency, and control throughout the day.
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Chapter 6: The Long Game - Work-Life Balance and Long-Term
Career Considerations
At the age of 32, Rose is finally a full-fledged physician, a junior cardiothoracic anesthesiology
attending at University Medical Center. It was a long road to get here, and culmination of 13
years of training. Apart from the formalized training that she underwent, she also had to
negotiate a relationship with her now husband, with medical school and residency playing a toll
on their relationship both with the demands on her time throughout her training, as well as her
relative lack of control over where she would end up. During her four years of undergraduate
studies, she not only had to take pre-medical courses – courses required for entry into medical
school, but she also had to prepare for the Medical College Admission Test (MCAT), while
volunteering at the local hospital to make sure she was a competitive applicant. With medical
school acceptance rates hovering around 50%, she had to go beyond minimum requirements.
Luckily, she was accepted into a prestigious medical school in California. The first two years of
her studies were almost purely academic, with her clinical rotations beginning in the third year of
medical school. Between studying for exams and successfully completing her clinical rotations,
she was also navigating a long-distance relationship with her boyfriend turned fiance, and
planning a wedding the same year she applied for residency programs in anesthesiology. On
March 20
th
, 2008, Match Day, the day when graduating medical students would find out where
they are assigned for residency, she and her husband stood in the courtyard of her medical
campus, the tension palatable in the air. Her husband had a good job as a computer programmer
locally, but three of Rose's top five residency programs were outside of the local area. When she
opened the thin white envelope, her husband breathed a sigh of relief to find that she had matched
to University Medical Center, a major teaching hospital in the area. The next four years of
residency were filled with long hours and interrupted sleep, and in the last of the four years, a
newborn. However, Rose was not content to do just general anesthesiology. After completing her
residency program, she pursued a one-year fellowship in cardiothoracic anesthesiology. Finally,
she was hired by University Medical Center as a junior attending just before she turned 32, her
long road of training finally at an end.
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The pathway to becoming a health care practitioner requires a substantial amount of time
investment. Physicians undergo a long, arduous journey, with a minimum of 11 years to becoming
board certified in a specialty. Becoming a nurse is no walk in the park either, particularly because
the path toward becoming a nurse is often filled with uncertainty, in an over-saturated nursing
education system, shutting people out of classes that they need to take in order to advance to the
next step. One hopes that the years invested into the process of training to become a health
professional, which sometimes total more than a decade for physicians who choose to sub-
specialize, will one day be worth it – that the time spent will transform into a meaningful life (not
to mention a comfortable income) during and at the end of the training process when the students
finally become health practitioners in their own rights.
This chapter focuses on the macro-temporal aspects of organizing one's life, not just across
one day or even a week, but across months, years, and even decades, taking the years of training
into account. Because the training processes itself takes a great temporal investment, it inevitably
impacts individuals' temporal capital on a long-term scale, from the moment an individual decides
to pursue a career in health care, and factors into the timeline of a lifetime. Moreover, the
temporal investment of training is held up against quality of life and temporal autonomy on the
micro-level, instigating questions like, is the years of investment into being a physician ultimately
worth it, especially given, as we had seen in Chapter 3, the lack of temporal capital and temporal
control that physicians must endure on a day to day basis? I also examine how health
professionals negotiate some semblance of a work-life balance, focusing particularly on how
having a family, a partner, children, and/or other types of social life or meaningful activities factor
into their temporal landscape. While I would not go so far as to say that Jack Halberstam's
concept of “queer time,” in which temporal landscapes for queer individuals emerge from “the
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potentiality of a life unscripted by the conventions of family, inheritance, and child-rearing”
(Halberstam, 2005, p. 2) applies directly to health practitioners, the fact remains that practitioners,
especially female practitioners, must sometimes consider alternate macro-temporal rhythms
outside the normative timeframes of reaching certain milestones like marriage or having children.
The tension between the biological timeline for women to have children and the realities of a
demanding training process, as well as the societal expectations on women to put more time in
domestic forms of labor like childcare and household maintenance, belay an interplay between the
macro-temporal and micro-temporal aspects of practicing medicine.
Perhaps more importantly, what is the role that a meaningful career plays in this temporal
investment. How do these practitioners negotiate a sense of meaning in what they do beyond the
mere monetary compensation and strictly capitalistic exchange of time for money? My consultant
friend from the last chapter who told me that while he consults for multiple industries, he “will
not touch” health care because of what he calls the “X factor” (personal communication, October
10, 2015) asks the provocative question, “How do you put a monetary value on the life of a
human being?” And yet, while not directly taking this question into account, practitioners must
balance their own temporal constraints and commitment to their work with this “X factor,” the
hope in doing something for a greater good that extends beyond income. The sense of
identification with one's career and one's self-growth can be clearly seen through the interviews in
how physicians talk about their career trajectories, and the self-identification may be an added
layer of meaning to the temporal investment in training.
Studying medicine is a privilege, both in the sense that one is privy to the intimacies of
patients' lives, but also in the socioeconomic sense. A 2015 study found that the majority of
medical students come from the top two national quintiles of family income, and the
214
socioeconomic status of an individual's parent is strongly correlated with their entry into the
medical profession (Grbic, Jones, & Case, 2015). Indeed, it is hard to justify putting oneself in a
decade or more worth of schooling and up to a quarter million dollars worth in debt if one does
not have a safety net of some sort. Moreover, despite the fact that physicians are the highest
trained members in health care, their compensation is average, trailing substantially behind that of
health insurance executives and health system administrators (Rosenthal, 2014). Even amongst
physicians, the differences in pre-existing economic wealth plays a role in shaping their lifelong
narrative. Rory, junior attending in internal medicine, comments on his own privilege in going
into not just medicine, but internal medicine, which is a potential pathway to a primary care
position:
Financially speaking, I think there's a joke among a lot of our residents is
that, medicine's actually not a lucrative field. You would think so, the
salaries that we make. A lot of time is spent pursuing the education, like
you mentioned. There's a lot of significant student loans, tuition, then
depending on the institution that you go to, all said and done, financially
it's not worth it for a lot of people. I think, for me personally, circumstances
were a little bit different. Let's just put it this way, I have the luxury of
pursuing my interest without the burden of the debt and loans. Because of
that I've been able to really figure out what I want to do in my life. I have
time to do so. Unfortunately, I have spoken to a lot of my friends and a lot
of my friends and colleagues all have similar aspirations in life.
Unfortunately because of their financial situation are tied in terms of
specific fields that they can go into. In some sense I am very grateful for
my upbringing. At the same time though I sympathize for my friends and
colleagues that are not able to do the same thing that I do (“Rory”, personal
interview, May 29, 2015).
Not only does Rory describe the freedom he has to choose a future career path because of his lack
215
of debt and loans, but he also acknowledges the constraints some of his peers face because of the
monetary factors – peers who may not be in as privileged a position as he is. In a way, he implies
that one's ability to follow a path of one's choosing over the long-term depends a lot upon pre-
determined factors, like a financially well-off family who is able to pay for medical school.
Indeed, shortly after our interview, Rory left County Medical Center 1 to pursue a global health
fellowship working with under-served communities in another state. While he has already
completed his training, he is still looking toward the future for other opportunities, taking the path
less traveled to figure out where he wants to land.
Jack, a junior ophthalmology attending at County Medical Center 1, has a similar path.
County Medical Center employees are compensated at a lower rate than at University Medical
Center and in private practice facilities. Jack made the decision to go into private practice right
after his fellowship, where he was better compensated, but was miserable and left, saying that
“everything was the same,” that it was boring and isolating. He is paid less now in an academic
position, but he enjoys the higher degree of flexibility and control throughout his day. He states
that “[If I am] bored, I can do something that is inspiring. Any given day, I have the control to
make it a better day. That's worth a lot” (“Jack”, personal interview, March 6, 2015). Because of
the autonomy his position allows, he was able to oversee a study that was done in conjunction
with an external automobile corporation in an attempt to improve overall efficiency in the eye
clinic, and in County Medical Center 1 overall. Given his relatively high levels of temporal
capital, he is well aware that this is a luxury he can afford given the fact that his parents are well
off, allowing him to graduate medical school with no debt, describing his colleagues in private
practice who, if given the opportunity, would make the same decision to go into academia, but
that “it is hard to turn down half a million” in salary that they get in private practice. For Jack,
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because of his pre-existing position within society (or, his parents'), he is able to choose a life that
may not be highly compensated, but allows him both the temporal flexibility and what he
perceives to be greater meaning in treating patients and finding ways to benefit the relatively
disenfranchised patient population at County Medical Center 1 as purposeful ways to exchange
his temporal investments.
Martha, ophthalmology resident, similarly comes from a family that was able to pay for
her medical school training, and as such, she is taking a one-year chief residency position before
applying to sub-specialty fellowship programs. This path is a fairly unconventional option, as
most residents enter into a fellowship directly following their residency in order to minimize the
contiguous time spent in training. For many, a chief residency year is an additional year of
training, a lost year of sustainable income, and a delay in repaying medical school loans. While
Martha will be compensated at the rate of a junior attending during that one year, her appointment
is based on a one year contract, after which she will be entering into a fellowship, and her income
plummets again. One of Martha's senior residents, upon hearing that Martha was taking this
unconventional route, asked if she had any student debt. When Martha responded in the negative,
this senior resident's response was something along the lines of, “Oh, well, then yea, you should
do that” while also commenting that she would not have been able to take this path because her
student debts compel her to finish training as soon as possible (“Martha”, personal
communication, Spring 2015). In this way, we see that temporal capital over the long term – the
amount of time that one is able to invest in a certain life-long pathway or narrative – colludes with
the amount of economic capital that has been offset during the training process, and more
generally, the socioeconomic status of the family in which the physician-in-training is embedded.
Martha has more flexibility in this macro-temporal setting, delaying a “real” job for a year
217
because she is not laden with student loans that her peers are trying to pay off as soon as possible.
Amy, psychiatry resident, represents one of those peers for whom truncating training as
much as possible and starting to make a real attending income is a priority. She took out student
loans to pay for medical school. Her journey required a lot of investments and sacrifices on her
part:
It's not just investing in residency time. We've invested the best years of
our lives, college time, we were not going to frat parties and we invest our
time in studying, getting good grades, so we can be a good premed, and get
into medical school, because only half of people get in. In medical school,
we invest the time to get into a good residency. And now we've finally got
into the residency, now we invest our time, and it's to be a doctor, and to be
respected, and to be good role model for [my daughter], to complete
something that I started so long ago, and there have been times where I've
wanted to quit, like, after I had [my daughter], and I wanted to stay at home
with her, and it was hard going back, you know. But the very fact that I set
out to do this, you know, I just wanted to complete it, just because it was a
goal that I had. But then, there's monetary reasons. Um. Once you're in it,
once you've gotten to the medical school point, I'm $250,000 in loans. I
can't stop. The only way out is forward. So no matter what, I HA VE to
keep going. I mean, there's no way to to stop at this point, just logistically
practically speaking. I mean, sure, I suppose you could find another job,
but you'd be paying off loans for the rest of your life, and even as it is,
you're still paying off loans for the rest of your life (“Amy”, personal
interview, September 22, 2014).
For Amy, while the meaningful career is a factor in her temporal investment, her other reason is
monetary. Unlike Rory, Jack, and Martha, she had to take out a quarter of a million dollars in
student loans. Her temporal investment in her career is not separate from her economic
investment. She cannot walk away from residency, no matter how hard it gets. She goes on to
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describe her day to day schedule, the seemingly never-ending cycle of patient encounters,
documenting, picking up her daughter, making dinner, putting her daughter to bed, then “do more
work, and do it again the next day. And you wake up early, you just have to keep going, cuz that's
the only way out” (“Amy”, personal interview, September 22, 2014). The way Amy describes
physician training almost makes it sound like a form of indentured servitude to the economic
realities of her student loans, and she suffers the day to day of low levels of temporal capital in
hopes of a better balance later.
The Long Road of Training
The training process for health professionals, especially physicians, takes a long time. The
biggest difference between physicians and nurses in terms of just how long the training process
will take, is that physicians' paths tend to be more rigid and narrow, which I will discuss in greater
length below. The question becomes, then, for these physicians, whether or not the temporal
investment put into training is worth it, and what is the payoff? The answer tends to change
between physicians and nurses, and between attendings and residents, and much of this has to do
with the micro-temporal aspects of their day, as discussed in Chapter 3, correlated with how much
power, within the framework of temporal capital, they have.
Aspiring physicians in the US must first complete four years of undergraduate studies,
completing a series of prerequisite courses
82
and earning bachelor's degree before being eligible to
start medical school. Medical school itself is four years of intense study and training. After
graduating from medical school, these newly minted doctors undergo another three to five years
of residency, depending on their medical specialty. Then, for those who want to focus even more,
82 In 2004, when I applied to medical school, it was one year each of the following: General Chemistry, Organic
Chemistry, Biology, Physics, Math, and a humanities course
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they enter into a subspecialty fellowship, which will take another one to three years. Hence, the
path to medicine will often take up to 11 or more years to finish, depending on specialty and
fellowship. This temporal investment is also in addition to the large amount of debt that they rack
up through the years as well. While hospitals pay their residents, the recompense pales in
comparison to that of an attending's, with the average annual resident salary of $55,400 in 2015
(Chesanow, 2015).
Howard Becker, and his team of researchers point to these long-term temporal
implications in their book, Boys in White, in which they examine the culture of medical students,
who were mostly men at the time. While writing in the 1950s and 60s, they mention that some
occupations have increased the time of education or training, and medicine was one of the
professions affected. Thus, “[t]he time between the point of crucial decision to enter the
profession to actual admission to full and free colleagueship in it is thus increased. The aspirant
must decide earlier; he will reach his goal later” (Becker, Geer, Hughes, & Strauss, 1961, p. 6).
Therefore, the decision making process becomes all the more crucial, as individuals planning on
becoming physicians must take into account the substantial temporal investment in education and
training before they can begin to reap the full benefits (often objectively measured in the form of
compensation) of the profession. While the decision to embark upon the journey of physician
training is often made in the 3
rd
or 4
th
year of college, when aspiring physicians take the Medical
College Admissions Test (MCAT) and apply through the American Medical College Application
Service (AMCAS) (both of which weigh heavily upon the minds of to-be medical students), there
are a number of programs that offer Bachelor/MD programs (T. Johnson, 2014), allowing students
admission to medical school contingent on the maintenance of a minimum GPA and MCAT score.
In cases like these, the decision to invest in substantial time training comes much earlier, and,
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given the low acceptance rates of medical schools, often makes it hard to quit.
The temporal investment for nursing is a bit different. Unlike physicians, who can
generally calculate out how long it will take for them to complete undergraduate courses, medical
school, and residency, there is a lot more uncertainty as to how much time it would take an
aspiring nurse to complete a nursing program. The nursing education path is highly saturated and
impacted, resulting in a bottleneck that throttles the growth of a nursing population. For nurses,
depending on how advance a nursing degree they want, have the option of getting an Associate's
Degree in Nursing (ADN), a Bachelor of Science in Nursing (BSN), or a Master of Science in
Nursing (MSN). They also have the option of going into training to become a Nurse Practitioner
(NP) or pursue a PhD in nursing or a Doctorate in Nursing Practice (DNP). The first temporal
uncertainty that ADNs and BSNs, which make up the vast majority of Registered Nurses in the
US
83
in particular, encounter is taking prerequisite courses. These prerequisite courses are needed
in order to apply into a nursing program, and, because of the aforementioned bottleneck and lack
of educational resources (namely, nursing professors), aspiring nurses find it difficult to get into
necessary prerequisite courses. Then, to get into an actual nursing program is another barrier,
thanks to these limited resources. The American Association of Colleges of Nursing in 2014
found that more than 53,000 qualified applicants for nursing school were turned away due to
“shortage of faculty, clinical placement sites, and funding” (Rosseter, 2014a). Anecdotally, Cal
State Channel Islands, which offers a bachelor's degree in nursing, gets over 400 applicants to
their nursing program, which only takes 40 students per year.
84
Indeed, the California State
83 From data from 2006, 84.4% of nurses had either an ADN (46.6%) or a BSN (37.7%) (“ADN vs. BSN: Which
should you choose?,” n.d.).
84 These were the numbers anecdotally given to me by students in Nancy Chen's health communication class at Cal
State Channel Islands who have applied to the nursing program and have not gotten in (personal communication,
October 1, 2015). Similarly, in my own experience in health workforce development from 2004-2008, one of the
community colleges that we worked with, Ventura College, had a nursing program. At the time, they admitted 30
students into nursing school per year, with over 300 applicants.
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University system puts out a matrix on its impacted programs – programs that are fully at capacity
– at each of their campuses. In 2014-2015, basic nursing is the only program that is impacted
across the board, on every campus that offers it (2014-2015 CSU Undergraduate Impacted
Programs Matrix, 2013). Similarly, nursing forums are abuzz with aspiring nursing students
talking about the impaction of nursing programs, and trying to find programs that are not so
impacted, especially in California, which has proven difficult, as one respondents (unhelpfully)
shared their own experience about their program, which is impacted (Apple, 2014). Others on the
same forum suggest the original poster look in rural areas outside the state of California.
However, as a respondent points out, if the individual wishes to practice in California, going out
of state may be detrimental to their chances of finding a job back in California. The students who
are unable to get into nursing programs that particular year must then put their plans on hold and
try again the next year, or consider less desirable locations and/or life plans in exchange for less
of a wait time. Following the former path and waiting to get into a desired nursing school
elongates their temporal investment in their training, increasing levels of uncertainty as to when
they will be able to get their nursing license and start practice. As such, lower levels of temporal
capital are seen here, as they have less control over their time and their life-plan over the long
term, impacting questions that range from where they will live to when they might settle down
and start a family.
While there is more uncertainty over the long term with nursing, there also seems to be
fewer constraints temporally within nursing, and more options. The path is a bit less rigid than
with medicine, and this is a function of cultural expectations. Anya, a nurse practitioner,
mentioned that she took five years to complete her ADN, because she toggled between going to
school part time and full time (“Anya”, personal interview, October 11, 2015). Moreover, there
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are stop gaps built into the progression to becoming an advanced nurse. As I mentioned, any of
the nursing degrees are considered terminal degrees, and nurses have the option of stopping at any
point after each terminal degree. For example, one can practice as an RN with just two years of
schooling with an ADN. Then, if one chooses, one can pursue a BSN or an MSN. But one is not
compelled to put in additional years of schooling in order to be hired and perform the clinical
duties required of a registered nurse.
In contrast, there is no sunk-cost fallacy and very few exit routes once an aspiring
physician starts medical school. A career in medicine in the US demands a minimum of 11 years
of commitment to training in order to be board certified physician. While an individual earns his
or her Medical Doctor (MD) degree upon graduating medical school, the newly minted physician
may not independently practice medicine until after he or she completes all three steps of the
United States Medical Licensing Exam (USMLE), which is usually completed at the end of the
first year of residency, which is also known as intern year, or post-graduate year one (PGY-1).
Then, the physician becomes board certified in a medical specialty at the end of residency.
85

While a physician technically is not required to be board certified, according to the Federation of
State Medical Board data, 74.5% of physicians practicing in the US are certified by the American
Board of Medical Specialties (Young, Chaudhry, Rhyne, & Dugan, 2011). Therefore, this pathway
to becoming a full-fledged board-certified physician is very structured, with few chances for
deviations once one is accepted into medical school.
86

One exception to this are individuals in MD-PhD programs, where they go to medical
85 A physician can be “board-eligible” without becoming “board-certified” in that they have completed the
residency but have not taken, or failed the board exam. In 2012, the American Board of Medical Specialties put a
limit on the number of years one can claim to be “board eligible” before they must become “board certified,” or
face sanctions (C. Johnson, 2012).
86 Getting into medical school, on the other hand, still presents a barrier. Less than half of applicants will
matriculate into any medical school (Hause, 2014).
223
school for two years, then start and complete a full PhD program, then start up their third medical
school with clinical rotations. This journey often takes seven to eight years, with the individual
earning both a medical doctorate and a PhD degree. As a user, “chirurgino”, put it on
StudentDoctorNetwork.net, a popular discussion forum for aspiring and current medical students
and residents, in response to an individual's question of choosing between just applying for an
MD, or pursuing an MD/PhD:
[I]t's critical to think very very carefully about what you want to do with
your career before committing to an MD-PhD. It's hard (at least, it was for
me) to do that when you're coming out of college, but you have to think
about what the PhD is going to do for you, because it's a LOT of time. If
you want to pursue clinical research, a [Master of Public Health] with a
strong emphasis on biostatistics is probably more useful than a basic
science PhD. (I suppose you could also do a PhD in statistics for clinical
research, but I've personally never seen this) Also remember that you can
take a year off during medical school to do research full-time, which meets
the needs of many people who want to get some research experience.
Beyond med school, many residencies offer research experience as well
(e.g., 7 year research track for [the medical specialty ear-nose-throat] at
some residencies), and [principal investigators] typically will jump up and
down for joy if a motivated resident (and with funding, usually!!!) wants to
spend some time in the lab. The MD-PhD program is not an easy program.
Attrition rates are high (less so at my institution). You will return to
medical school and I guarantee you will have attendings, fellows, and
senior residents from your original med school class with a lot of power
over you (and likely not as bright as you are)--you have to think hard if all
that is OK for you (“chirurgino,” 2006).
Because medical schools are so cohort-driven (each cohort completes each stage of medical
school together), there is a sense of being left behind, for people who do their MD-PhDs, not to
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mention a significant temporal investment that lasts longer than MDs. Because of the length of a
PhD, it is very common that once one is done with the PhD portion of the degree and starts 3
rd

year medical school rotations, one's fellow cohort-mate with whom one started medical school
together may already be nearing the completion of residency. The synchronicity of the training
process is also disrupted for the individual, which leads to uneven power dynamics that shift
between individuals because of the prolonged training period for MD-PhDs. Finally, the user
highlights the decision point that I mentioned earlier that individuals make before embarking on
the journey through medical school, whether or not that is paired with a PhD or an additional
degree. There are considerations in terms of temporality that affect the power dynamics between
individuals that are solely dictated by the temporal synchronicity of the training process.
Another potential delay in the medical training process, which is becoming increasingly
common, is to take a gap year – either one year of research sometime during medical school
(Martha took a gap year to do research in Southeast Asia between her 3
rd
and 4
th
years of medical
school to make herself a more competitive before applying for residency programs), or one year
off after graduating from college and before applying to medical school – to get more real-world
experience and pad up one's resume to make one a more competitive applicant (Fu & Joung,
2015). The increasing popularity of gap years relax the expectation that medical students go
through training in one fell swoop. While both gap years and the MD-PhD path increase the
number of years an aspiring physician spends in training, both the MD-PhD path and the concept
of gap years are sanctioned by the medical community, which institutionalizes the training process
to include these alternate temporal experiences. In particular, the gap year before entering medical
school, which used to be fairly rare, has become increasingly popular to the point where the
website for the Association of American Medical Colleges (AAMC), gives advice on how to
225
make the best of the gap year (“Making the Most of Your Gap Year,” n.d.).
Hence, the training process for physicians is more rigid and longer than the training for
nurses, without many opportunities to walk away, creating an all-or-nothing mentality. Whereas
nurses can work on their education by steps, and choose to pursue a higher degree, knowing that
their lower degree is adequate with which to work, physicians are not licensed to practice until
they finish residency. While the nursing path is filled with more insecurity and uncertainty, which
makes it hard to plan for the long term, there are more options of working while applying for
various nursing programs. Medical schools, on the other hand, are more rigid in its workings.
Moreover, to say that one can plan one's life around getting into medical school is a fallacy as
well. Less than half of applicants matriculate into medical school any given cycle, according to
numbers from the AAMC (“Medical School Applicants, Enrollment Reach All-time Highs,”
2013). Therefore, it is probable that someone with their heart set on medical school will have to
wait a year or a few before being accepted. In either case, the decision to go into a career as a
health care professional is also a decision to invest temporally (as well as financially) in the future
in hopes that one's career will not only reap the economic benefits at the end of a strenuous path,
but will also allow for a modicum of work-life balance and a sense of meaning in one's actions.
These three factors – compensation, work-life balance, and a sense of meaning, all come into play
during decision-making points and continue throughout the training process and well into their
careers.
The Spectre of Debt
The question of whether or not being a physician is financially worth the investment is one
that bears some addressing. To spoil the suspense, there is no clear answer, often because whether
226
or not the investment is worth it is tied to both the lifestyle (ie: level of stress, work-life balance,
etc) as well as the eventual monetary compensation. While the compensation evens out within a
decade, the stress and debt of practicing medicine not be ultimately worth the sacrifice for some
individuals. There is a temporal aspect to the financial question for medical school. Financial
situations that physicians find themselves faced with over the long term is one that is tied to the
temporal investment and temporal capital over the long-term. Physicians spend not only years in
training, but also incur massive amounts of debt in medical school, which hangs over their heads
for years. Directly after medical school, they spend additional years in residency with a pitifully
low salary given the amount of time and energy they expend – not to mention the lack of temporal
autonomy - on a day to day basis to complete their training. Moreover, and possibly more
importantly, they lose a decade of salary earning and savings investments while in training. While
their compensation once they become physicians is quite high, because of lost earnings, debt
accrued over time, and rising interest rates, by the time they are finished with training in their
early 30s, they are about a half million dollars behind their peers who entered the job market right
after college (“Is Medical School Worth it Financially?,” n.d.). To add insult to injury, when these
young physicians start their careers, they also must contend with the changing health care policies
and regulations that govern their ability to get paid, wherein getting Medicare to pay out
reimbursements for patient care is getting increasingly more difficult. This leads to physicians
seeing more patients in any given amount of time, spending less time with each patient.
Physicians nowadays must see more patients in less time in order to make a comparable amount
of income as they did a couple decades ago.
87
This has an impact both on the practitioner's level of
87 The fact that physicians keep “one eye on the patient, and one eye on the clock” is a result of the current fee-for-
service model of medicine, where physicians see more patients per day, spending less time per patient (Rabin,
2014).
227
stress as well as the outcome for patients, especially when it comes to preventative health
measures and education, as physicians simply do not have the time to spend conversing with
patients.
This ability to invest temporal capital over the long term to undergo medical training goes
hand in hand with the privilege embedded in the families of medical students. As mentioned
before, most medical students come from families within the top two quintiles of annual income.
With the more than a decade loss of income during training, a long game of medical school may
not be worth it financially for individuals who are of a lower socioeconomic status without a
financial safety net, where getting a paid job earlier is more advantageous than the promises of a
higher income years later. This reinforces certain social power dynamics as well. What happens
when the vast majority of physicians out there are from middle to upper class families?
While opportunity cost considerations made for going into medical school are not specific
to the US, the US does rank amongst the most expensive countries to get a medical education.
Medical training the UK is comparable, both in financial and temporal investment, even with a
slightly different training process. In the United Kingdom, for example, students enter medical
school right after secondary education or high school, where they undergo 4-6 years of medical
school. After medical school, they must undergo another additional 5 years (2 years of Foundation
School and 3 years of Specialty Training for a General Practitioner, and up to 8 years for other
specialties) at least of training before they can practice autonomously (“Studying Medicine,”
n.d.). And like the US, despite potential support for medical school through the National Health
System (“Financial support for medical and dental students,” n.d.),
88
debt in the UK is also piling
up, with inflation and interest further astronomically the amount of money students owe,
88 The US has a similar program through the military (“Army Medicine,” n.d.).
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compounded through their years of training, potentially discouraging aspiring physicians from
entering the field (“Debt ‘putting off’ medical students, BMA warns,” 2012). In contrast,
attending medical school in other countries – for example, Germany - is free (“Admission to
Medical Study in Germany,” n.d.) or very low cost (Rakoczy, n.d.). Even Canada's tuition per year
at the high end of $20,831 at McMaster's School of Medicine in Ontario (“How much does
medical school cost?,” 2010) is much less than the average cost of a medical school in the United
States – over $52,500 per year for a private medical school (Friedman, 2016), or a $31,291 for in-
state tuition for public medical school (Haynie, 2014), which does not include cost of living.
Annual tuition at the least expensive medical school, Baylor College of Medicine in Texas, is
$31,663 for the 2015-2016 academic year (Friedman, 2016). Hence, US (and UK) physicians
have a unique stressor placed upon them wherein being able to make enough money to pay back
their student loans becomes a consideration both in the decision to become a doctor as well as
what type of doctor to become.
Specialties Matter!
In the fourth years of medical school, students undergo the process of choosing a medical
specialty and applying for residency programs. Residency programs are specifically intended to
train a physician for the specialty of his or her choosing. At the end of residency, the physician is
required to take their specialty's board examination to become board-certified in that specialty.
Examples of medical specialties are internal medicine/hospitalist, emergency medicine,
ophthalmology, radiology, neurology, dermatology, anesthsiology, etc. As each specialty is very
different, the choosing of a specialty not only dictates the future duties of a physician, but also
dictates the type of work-life balance and temporal autonomy that a physician will have in the
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future. Medical folks often refer to the ROAD to Happiness – the four specialties, radiology,
ophthalmology, anesthesiology, and dermatology, that have a more “controllable lifestyle” (Blair,
2007) in that the physicians in those specialties can better control their work hours. Recently,
emergency medicine, which is mainly shift work, has been added to the mix to create the E-
ROAD to Happiness.
The choice that physicians make about their specialty has a major impact not only on the
physicians, but on patients themselves – indeed, whether or not to go into a medical specialty has
great impact on their patient populations in a system where there is an increasing shortage of
primary care physicians (Crist, 2013). The projected shortage of over 40,000 primary care
physicians by 2025 (Petterson et al., 2012), underscores the problem with the emphasis on
specialization and the overall systemic challenges that the medical field faces. Moreover, there is
a substantial financial difference between primary care and specialization. Medscape finds that
the average annual income in 2015 for primary care physicians is $195,000, and $284,000 for
specialties (Peckham, 2015a). The discrepancy is a problem, as primary care physicians (PCP) are
sorely needed. They are first in line for patients to approach for any medical issues. Limited
access to primary care means that more people will wait until their conditions become acute
before entering the health care system, rather than seeking care from a PCP when their condition
or disease is more manageable or treatable. More people will go through the emergency
department with these acute conditions, creating long waits and driving up costs of health care.
And while this is not a primary responsibility of PCPs (though arguable it should be), shortages in
primary care resources also means that there are fewer avenues to educate the public on
preventative health issues. Mid-level practitioners like physician's assistants and nurse
practitioners are in line to fill in the gap, but are still limited by legislation in terms of their scope
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of duties.
89
Whether or not medical school debt factors into the decision for medical students to
pursue specialty training in residency rather than primary care or family practice is unclear. The
AAMC found that debt plays a very minor role in the decision to specialize, behind factors like
work-life balance, personality fit, and family obligations (Kahn et al., 2006; Youngclaus &
Fresne, 2013). According to Rupert, a primary care physician who has been in practice for over 25
years, the problem with the shortage of primary care providers,, is not necessarily debt, but the
fact that the work of primary care is not as fulfilling as it is for specialty physicians (personal
communication, October 16, 2015). This sentiment is echoed by Martha, who stated that she
chose to specialize partially because of the greater monetary compensation, but also because
primary care outsources a lot of procedures to specialists so “you never feel like you are doing the
actual work” (personal communication, October 16, 2015). Additionally, mainstream media tends
to glorify surgeons over primary care practitioners, which affects popular perception of
physicians, and in turn, inevitably influences decisions of medical students when choosing a
residency specialty. Moreover, with the changing landscape of Medicare reimbursements,
physicians, particularly those in primary care, are increasingly required to spend time on
administrative duties while cramming more and more patients into their practice daily just to keep
their doors open. Time with patients is limited – an ongoing pattern that we saw in Chapter 3 –
that affects both their connection to their patient, and the patient's ability to absorb the health
education the physician provides in order to make healthier choices in their day to day life.
Although Rupert seems to feel like student debt has little to do with the decision of
89 A bill that would allow nurse practitioners to practice autonomously, Senate Bill 323, was passed by the
California Senate (McGreevy, 2015), but killed by a state assembly committee a month later (Aguilera, 2015).
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specializing, and this sentiment has been reflected in some studies,
90
there are also other studies
that have found trends of medical school loans impacting both the decision to specialize, and
choice of specialty (Rohlfing, Navarro, Maniya, Hughes, & Rogalsky, 2014; Rosenblatt &
Andrilla, 2005). As student loans have increased in the last few decades, faster than the rate of
inflation, it has “transformed an education that was once a path to public service into a significant
financial investment that needs to yield returns” (Chen, 2011). While Rupert may have a point in
that the trend away from choosing primary care may have to do with the work itself, the economic
landscape of medical training was much different back when he was a resident than it is today.
Specializing provides a higher income that can more effectively combat student loans and the
additional interest accrued, in the hopes of diminishing the time needed to finish paying back the
loans. As we have seen earlier, when asked why she specialized rather than pursue a primary care
career, Amy, psychiatry resident, admitted that it was because of her student loans (“Amy”,
personal interview, September 22, 2014). According to the AAMC, 81% of medical students in
2015 graduated with student loans, at an average of $180,723 (Medical Student Education: Debt,
Costs, and Loan Repayment Fact Card, 2015), and Rosenblatt & Andrilla (2005) found that
already in 2002, when arguably inflation and debt were not so bad, there was already evidence
that med students were less likely to go into primary care if they had higher debt levels. The
interviews reflect the sentiment that medical loans are not only ever-present in the minds of young
physicians, but they can play a factor in the decision to specialize. Rory, junior internal medicine
attending, mentions that he is able to go into internal medicine because he graduated medical
90 The academic studies find that while debt may not have a direct effect on the choice to specialize, they
acknowledge that the factors that go into choosing a specialty are multifaceted and complex. Moreover, some of
the reports may be suspect and biased. One of the reports that I referenced earlier in this session is from the
Association of American Medical Colleges, which arguable has a vested interest in making sure that people
continue to pay for medical school...
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school with no student loans and was thus able to have a broader range of choices in specialty,
while watching his colleagues forced into “specific fields” because of debt (“Rory”, personal
interview, May 29, 2015). Hence, while it is difficult, if not impossible, to draw a causal
relationship between rising student debt and the shortage of primary care practitioners, medical
students are increasingly factoring in loans when making decisions about whether or not to
specialize and which medical specialty they want to pursue in residency.
Once the decision has been made to specialize, the choice of specialty has huge
implications on the individual macro-level temporal capital for providers, and the decision to go
into a specialty often happens years before a fully-fledged physician will either reap the benefits
or suffer the consequences of that decision, since the residency experience itself tends to be fairly
universally grueling (although some specialties have it better than others – surgical specialties
often have the worst residencies in terms of time commitment, constraint, and schedule). Often,
lifestyle and the ability to control one's time, or to minimize the amount of time being controlled
by work factors, plays a major role in the decision-making process for to-be doctors. Simon, a
junior attending in radiology, mentions that while he was interested in surgery, he chose to go into
radiology because “for radiologists, our schedules are a little more relaxed, which is probably
why we go into it, actually is to be able to have a more flexible schedule” (“Simon”, personal
interview, March 11, 2015). In the same vein, Amy, psychiatry resident, mentioned that she chose
her specialty in psychiatry because of the better schedule, the flexibility to work full or part time
as needed, and the ensuing compensation. Both cases, among others, allude to the fact that the
choice of specialty results in increased levels of temporal capital, and greater individual agency to
pursue a balance between work and non-work time.
Similarly, nurses will also enter into areas of specialized nursing, but specializing is not
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usually institutionalized in their training as it is for physicians. Nurses are trained for general
practice, then specialize as tickles their fancy. A nurse may specialize for motivations other than a
work-life balance, as bedside nursing functions within a preset structure of shifts across all
specialties, and nurses are able to move from specialty to specialty more easily than physicians.
Anya, the nurse practitioner who used to be part of the ophthalmology department at County
Medical Center 2 (she recently left) started her career as an emergency room nurse, and is now at
another county medical center in their ambulatory care clinic. Hence, for nurses, because of their
ease in switching specialties (and consequently, pay rates), if they choose to specialize, it is
usually for reasons other than the rigid compensation patterns that physicians face. Take Kaylee's
testimony about why she went into oncology:
What I like about it is that I see patients I'm saving over and over and over
again. I think it's a fallacy when people say that oh you've got to not
personalize and not be really enmeshed in this type of medical profession.
For me it's easier to do my job when I'm a little more passionate about it. In
oncology, it really brings that out. I mean, you have patients that are sick
not because of ...See sometimes it's some lifestyle modification but
sometimes it's pure bad luck. A little genetics, but ... People that go into my
unit, they're really fighting for their lives and it's not something like
diabetes management where they're like oh if I eat a little less or try and
modify my diet ... These patients, for the , not all of them, for the most
part, they are really active in their care, and not just them, their families are
too and I like that. They do come back, so it's a lot like family. You see
them over and over again. I can tell you everything from the way that they
want their medications to what they like to order for dinner and what cycle
they're on, what medications have helped them before. For me it's a
memory thing and a connection thing. It's that connection absolutely. I'm
serious about it (“Kaylee”, personal interview, July 3, 2015).
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For Kaylee, she chose her specialty not for the compensation or lifestyle, but for the continued
connection she has with her patients. She demonstrates an emotional investment in her patients
that runs counter to the conventional wisdom of health care to detach, and her specialty allows her
to use her time at work to create greater avenues of meaning that she finds within her own life.
Because nurses are not necessarily locked into their specialties, with potential for moving from
specialty to specialty,
91
a choice of specialty today will not necessarily determine future potential
earnings for nurses as it is for physicians, Kaylee's choice of specialty comes as a more organic
interest in the specialty rather than one of necessity in order to pay off student loans. In a way,
shorter training times and a more general training curriculum for nurses leads to more potential
temporal capital and more options and directions for a nurse's career. There is a flexibility with a
nurse's career path that is not at all seen in a physician's. In this way, ironically, nurses on a
macro-temporal scale, have higher degrees of temporal capital and greater spaces for different
choices than physicians. They are not bound to one narrow path of specialty that dictates lifestyle
and income, nor are they bound to the years of investing in school and training the way that
physicians are. Perhaps more importantly, unlike physicians, they are often not saddled in
mountains of student loans, nor are they delaying their wage-earning as much as physicians do.
Work-life Balance
A good work-life balance in addition to fair compensation in the practice of medicine or
nursing is the holy grail for practitioners. In general, outside the realm of health care, the idea of a
work-life balance as a health practitioner has been an issue has gotten increased visibility and
discussion, especially among younger health practitioners and workers. Colette Fagan (2001)
91 Even for nursing specialties that need certification, the certification process consists of an exam, which is a far
cry from the years of residency for physician.
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talks about working time schedules which consists of when and how long one works as well as
how much autonomy the individual has over working hours (1200). Citing Glucksmann, she
points at temporality as the “structuring and exchange of time within employment, domestic labor,
and leisure” (1200). The amount of time devoted to each of these different categories, while
broad, constitutes work-life balance, as time spent at work happens at the expense of time spent
performing domestic labor and leisure, and vice versa.
To revisit some of the data that was
discussed in the introduction, Shanafelt et al
(2012) found that, amongst other factors like
rates of burnout, depression, and suicide ideation,
US physicians experienced greater work hours
and greater challenges with work-life balance
than other US workers. More interestingly, they
also found that burnout, work-life satisfaction,
and depression/suicide were also differentiated
by specialties, where the front-line access
services had the highest rates of burnout:
“Emergency medicine, general internal medicine, neurology, and family medicine had the highest
rates of burnout, whereas pathology, dermatology, general pediatrics, and preventive medicine
(including occupational health and environmental medicine) had the lowest rates” (1380). Almost
1 in 2 (45.8%) of physicians surveyed had at least one symptom of burnout, indicating that this is
a rather dire situation for a population of professionals that has broader implications on the overall
ability for them to deliver quality patient care. Unfortunately, even Shanafelt et al admit that there
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is very little that is effectively done to address this, and most of the work has been done on the
individual level of managing stress, rather than on an organizational level. Even when an
institutionalize intervention is implemented, it does not often percolate into the functional
interpersonal interactions that perpetuates a malignant culture. Rose, junior anesthesiology
attending, who has, during the course of my dissertation research, taken on the role of assistant
director of the anesthesiology residency program, concedes that while the residency program
offers and mandates a class on mental health, and encourages struggling residents to reach out for
help and support, actually doing so in a culture of go-getters and gunners is a sign of weakness,
perceived both by colleagues, peers, and supervisors (“Rose”, personal communication, February
19, 2015). In other words, this culture of maintaining a strong countenance is so pervasive in
medicine, and especially medical training AKA residency, that it counters any attempts to
institutionalize a more supportive environment.
The threats to a physician's well-being is not limited to work spaces. The “life” bit of
work-life balance often causes stressors that lead to burnout as well. Dyrbye et al (2013) discuss
work-home conflicts that arise between physicians and their employed partners and found an
association between work-home conflicts to greater work hours on the part of the physician,
which in turn, leads to higher rates of burnout and depression, and lower satisfaction and quality
of life. However, Keeton et al (2007) found that while physicians struggle with work-life balance,
which is a function of work hours and control over their schedule, they can still be highly satisfied
with their career. This implies that there are other factors, like personal accomplishment and
emotional resilience, more complex than quantifying the number of hours at work that contribute
to career satisfaction for physicians, suggesting that the meaningfulness of the work itself is worth
the time spent at work, working as a sort of backdoor for individual agency and temporal capital
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(ie: the mentality of “spending copious amounts of time at work to better my career is meaningful
and is my choice - I choose to put myself in situations of low temporal autonomy in order to
achieve a greater purpose”), which will be explored later in this chapter. Despite this, the
protectiveness of one's time in an attempt to achieve some sort of work-life balance, or to reclaim
one's time for one's own outside of work is still evident, and physicians often must negotiate their
precious limited time with non-work obligations.
Physicians, especially residents, tend to be very protective of their time away from work.
My partner often counts down the number of free hours she has before she has to be at work
again, and will often prioritize things that she herself wants to do over familial or relationship
obligations, since her allotted non-work time is so limited. Familial or relationship obligations are
often carried out with a tinge of reluctance, if not outright refused. Likewise, Owen,
ophthalmology resident, has this to say about managing his relationship with his (ex)girlfriend:
Yeah, [she] like CSI type shows, and it was just like, "God, I don't want to
fucking watch this shit." But she's my girlfriend and that's what she
wanted. It's like, okay fine, that's cool we'll watch it, or we'll do these other
things that you want to do that perhaps would not be my first choice of
things to do, and that's okay. After a while it just gets to the point where it's
like, you're at work, as a resident, especially a first and second year
ophthalmology resident, you're in clinic the whole day. Just churning
through it, seeing a bunch of patients. It's a lot of repetition, which is good,
but it's just taxing, and it's not super fun. When I get home I want to do the
things that I want to do. After having kind of sacrificed, and perhaps done
things that I didn't enjoy tremendously all day at work, to then come home
and do more stuff that I was lukewarm about....I find myself doing these
things to humor someone else and it's fine, that's life, but... It would be one
thing if we both had tons of time, and if you have a ton of time then fine it
doesn't matter if I sacrifice, or I compromise for a half hour if we have 8
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other hours to hang out, [but] you only have two or three hours when
you're not sleeping or at work (“Owen”, personal interview, June 20,
2015).
Part of Owen's frustration comes from the fact that his temporal capital is zapped when he is at
work, and it is further co-opted in service of relationship maintenance while he is at home. For
him, even though he spends time with his girlfriend, this is not a balance, since he feels he has
little choice in how to spend his time away from work. Here, it is useful to separate out work-life
balance and temporal capital, as the two are clearly different. While Owen may have work-life
balance in a quantifiable sense, he does not have high levels of temporal capital, ample time to do
the activities that he wants to do. In this way, temporal capital qualifiably determines the level of
work-life balance achieved, and also determines general satisfaction with said work-life balance.
The negotiation happens between prioritizing activities that oneself wants to do (higher temporal
capital, lower relationships maintenance) and prioritizing activities that others want to do (lower
temporal capital, higher relationship maintenance). In a similar vein, Mickey, internal medicine
resident, gets frustrated when he makes an effort to spend time with his boyfriend, and his
boyfriend fails to match his enthusiasm:
I would say it was one of the biggest tensions in the relationship to begin
with. I think that I had a certain amount of righteous anger toward a lot of
stuff, like what [my boyfriend] would do. I have so little control of my time
all the time, and like, then I take what little I have and I give to you...I just
got off of a 30 hour call at work, like, I was required to be at work, and if
there wasn't time to sleep, I didn't get to, so I only slept one hour in the last
30 hours, and then I came and I try to be chipper and hang out with you
and you're saying you're tired? How dare you say that? Like (laughs), like,
how DARE you (“Mickey”, personal interview, September 18, 2014).
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Mickey very much perceives of his time as a commodity here, and his frustration at offering his
boyfriend what he perceives to be a precious commodity, and his boyfriend not valuing it is
palpable. Hence, in trying to balance the demands of the job with the demands of a partner, or
friends, or a social life, physicians often find themselves torn between the two, watching their
dwindling hours of freedom drip away, relegating the time spent maintaining social capital and
social relations outside of work into the realm of reluctant, non-agentic labor time.
While the previous research, as we have seen, spells doom and gloom at every turn when
it comes to the work-life balance and mental wellness for health practitioners, especially those
still trudging through residency, the following sections attempt to make some sense through
looking at the differences between individuals that may explain the nuances of negotiating work-
life balance and temporality in their lives. Those with more temporal capital (and more relative
power given the relevant social hierarchy) are often better able to negotiate a more satisfactory
work-life balance. In the case of health practitioners, attendings of certain specialties tend to have
the best work-life balance, particularly those belonging to specialties on the E-ROAD to
Happiness – Emergency, Radiology, Ophthalmology, Anesthesiology, Dermatology – which
combines better work hours and good monetary compensation. Hence, specialties seem to
strongly determine long-term macrolevel temporal capital for practitioners, as discussed earlier in
the chapter.
Simon, junior radiology attending, explicitly states that he chose radiology as a specialty
because of the work-life balance. Radiologists essentially work an 8-5 schedule and can work at
their own pace. Because of the nature of radiological work, Simon's time is relatively flexible,
both on an hour to hour basis, but also on a macro-temporal level. He finds that he is able to
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coordinate his vacations with his girlfriend's, to enable them to go on vacations together
(“Simon”, personal interview, March 11, 2015). His girlfriend, a resident, conversely has very
little control over her schedule and her vacation time, but because of his temporal capital on a
macro level, thanks both to his status as an attending and his choice of specialty, they are able to
make their vacation times intersect. This is a good example not only of a case where the
differences in temporal capital and temporal autonomy between attendings and residents are seen
across specialties outside of a direct line of hierarchy, but also demonstrates the advantage of
having a specialty that allows for more temporal flexibility leading to ways in which time can be
manipulated to allow a space for relationship maintenance work. Ironically, this means that
Simon, with higher levels of temporal capital, uses that to negotiates his time with his girlfriend,
ultimately subjugating his temporal autonomy to the constraints of his girlfriend's schedule.
However, it is the radiology specialty that allows for the flexibility that liberates him from work
constraints in order to put more energy toward and cede control of his time to a more inflexible
resident schedule.
While Simon is on the ROAD to Happiness, with a specialty that has high amounts of both
economic and temporal capital, others prioritize temporal autonomy over monetary compensation.
Rory, the internal medicine attending, speaks to his decision to choose time over money:
I think given the option of working my butt off and earning a lot of money
and never spending personal time versus a lower activity job where I'm
spending less hours, making less money it would be a non issue for me. I
would pick time over money (“Rory”, personal interview, May 29, 2015).
For Rory, the tradeoff for more personal time and some semblance of work-life balance is enough
for him to sacrifice the potential economic gains of another career path. In another example of
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how practitioners consider both economic and temporal factors in their career, Amy, psychiatry
resident, discusses her choice to go into psychiatry, taking into consideration the income and the
schedule the specialty allows:
The biggest driving force for why I went into psychiatry was the ability to
have flexibility in my schedule, um. Psychiatry has fewer hours, and you
get paid more...But for me, spending the time with [my daughter] and [my
husband is important], at least in the future. Right now, it's the same for
everybody. None of us have any time right now. But looking longitudinally,
looking at, you know, when I'm an attending, you know, I will definitely
have more time and better pay as a psychiatrist than as a you know, in
another field. And that's probably the biggest driving force as to why I
went into (“Amy”, personal interview, September 22, 2014).
The choice of temporal autonomy over monetary compensation is the general consensus amongst
my attending subjects. Not a single interviewed attending stated that they would choose money
over time. However, they do point to compensation as a motivation for being a physician, more
than the residents do, who have not yet reaped the monetary benefits of their career path. I will
later discuss the differences in attitude between residents and attendings toward the temporal
tradeoffs and temporal investments they put into being a physician – the most notable being that
residents are more future-looking in their aspirations for personal growth through their career. In
the same future-facing sense, residents were more likely to point out that they put in the time
because they need the money in order to pay off student loans.
Gendered Temporalities
It would be amiss to not at least make a mention of the gendered differences of negotiating
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temporality between male and female practitioners,
92
especially as gendered temporality is a much
discussed topic. The fact that women spend more time on unpaid domestic labor and childcare is
no surprise, with mothers spending two to three times as much time with their children than
fathers (Craig & Powell, 2012). Arlie Russell Hochschild's (2003) research notes that there are
increasingly more dual-earning households in which the women's job is not an option, but rather a
necessity, given certain economic realities. She references work done by Alexander Szalai in the
mid-1960s, which found that “working women averaged three hours a day on housework while
men averaged 17 minutes; women spent fifty minutes a day of time exclusively with their
children; men spent 12 minutes” (3). Her book examines how men and women feel about women
undergoing a “second shift” of work after the normal workday on unpaid domestic labor and
found that women were “far more deeply torn between the demands of work and family than were
their husbands” (7). This statement gestures at a sociocultural norm that places expectations of
responsibility for unpaid domestic, familial labor squarely on the shoulders of women.
Similarly, Wajcman (2015) references Fraser in talking about how the significant
difference in time is with leisure time, with more women doing unpaid labor during times of
“leisure”. Interestingly, in terms of the quantifiable amount of work – either paid or unpaid,
Wajcman states that the differential between women and men is not substantial, and seeks to
“reconcile the apparent gender equity in the objective quantity of leisure with the subjective
92 Female physicians, in particular, are often frustrated at being mistaken for a nurse (Lemay, 2013) or even, as
Tara, a junior ear-nose-throat attending recalls, a janitor (personal communication, April 3, 2016). They are also
often mistaken for the resident or the student, Rose, junior anesthesiology attending, hilariously recalls a patient
encounter she conducted with her resident, who is male. The patient looked up at them, gestured at the male
resident, and asked “So, he is doing my surgery, right?” Rose shrugged and nonchalantly responded, “Sure. He's
my student, but he can do your surgery if you want him to...” The patient quickly backpedaled. Tara has similar
experiences where patients mistake her for the student or the resident, and her male resident as the attending. Her
approach is to let her resident take the lead in communicating with the patient (since they need the practice
anyway), understanding that the patient may feel more comfortable with a more...normative (not to mention
patriarchal)...perspective of the situation.
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impression of increased time pressure among women [by considering the] density of quality of
leisure time available, and not simply the quantity” (Chapter 3, sec. “Temporal Density”, para. 6)
And in the same vein, Craig & Powell (2012) found that while dual-earning couples will either
outsource child care or use other methods to maintain a career and kids, women will tend to adopt
different non-standard work hours or work from home in order to make taking care of the family
easier, thereby prioritizing familial obligations over career obligations to a greater degree than
men do. In another study, the same researchers, Craig & Powell (2011), found that for men
working non-standard hours (7pm-7am), women's schedules changed the most to accommodate,
and women would spend more time doing household chores. Conversely, when the mother works
non-standard hours, she is more able to schedule her work hours around family obligations and
vice versa. In a way, while women help men expand their temporal capital, they (women) expand
their temporal capital themselves, without the help of men, and yet their temporal capital is
constrained and limited by familial obligations to a greater degree than that of men.
Female physicians face similar challenges while trying to juggle a demanding career with
family commitments, both in the training process, and in the duration of their career. The demands
of medical school and residency, as well as the predictable patterns in the variation of the intensity
of training force aspiring physicians, particularly women, to shoehorn their biological rhythms
into institutional temporal rhythms. Marriage and pregnancy must be carefully considered within
the constraints of medical school and residency – a process that lasts at least eight years. And as
much as it is illegal to ask questions about marriage and pregnancy during residency interviews,
many applicants will eradicate any indication that they have a family or a life outside of medicine,
removing engagement or wedding rings while on the interview trail. In a 2012 blog post about to-
be physicians, to-be physician Marianne DiNapoli expresses her palpable frustration as she
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considers whether or not to wear her wedding ring, expressing her disbelief that this is something
she needs to think about in this day and age (DiNapoli, 2012). What is striking is that the
comments swing heavily on the side of her NOT wearing her wedding ring, including one
commenter, “Gail”, who states, “Yes, unfortunately you still need to worry about this. I'm on
faculty at a med school...don't interview with the ring on. Sorry it's the way it (still) is...” The
simple fact that this issue is up for discussion and would likely not come up in the event of a male
residency applicant highlights the societal expectation that women will sacrifice career over
family, which in turn exemplifies the long-term temporal considerations that women, more than
men, must navigate in the balance between career and perceived child-bearing and family
responsibilities. And, although the institution itself will not blatantly admit that it does not want
residents who might become pregnant and will have to take time off, burdening the rest of her
residency cohort, the unspoken, subliminal judgments made during the interview may hold
stronger than official admission policies. In this way, female physicians, particularly younger
ones, must often dance a treacherous temporal ballet between her career, her biological capacity
to bear children, and societal prejudices based on gendered expectations which her future
employers may hold.
The long-term plans for pregnancy and motherhood often must take into consideration
how it affects the day to day. One anonymous physician on KevinMD.com, a blog site that
highlights physicians' perspectives, points out that, while they (physicians) are the ones
advocating for breastfeeding, “practice administrators dictate whether or not physicians can build
15-minute pumping breaks into their schedules” (“Maternity leave for physicians is a disgrace.
It’s time to fix that,” 2015). Then there are simply certain windows of time during medical school
and residency when it is more ideal to raise a child. Rose, Melody, and Zoe, three junior
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anesthesiology attendings, all planned their pregnancies for their last year of residency, because
work was relatively easier, and they had junior residents who did most of the front-line patient
care and other tasks. Not only did they have to consider when to be pregnant, but they also had to
plan out the best time to be on maternity leave in conjunction with the pregnancy. And oftentimes,
maternity leave is not kind to new mothers, especially upon returning to the practice. As we saw
in Chapter 4, Rose had experienced a somewhat unexplained upward tick in the number of days
she found herself on call soon after returning to work.
Female doctors find themselves juggling a lot of different balls. Being a mother and a
doctor further complicates the way that their time is divided up both within a day and within a
lifetime, given the high demand on time spent on one's career as a physician. This forces many
physicians who are also mothers to make concessions and negotiations between their temporal
capital and economic capital. Between the long hours during the day and the unpredictability of
being on call, both for medicine and surgery specialties, many female doctors who have children
opt for nannies, like Rose and Melody, especially if their husbands work. Pei-Chia Lan, in her
(2006) book, Global Cinderellas, explores this dynamic of outsourcing of domestic labor to non-
familial members of the family in the context of Filipino and Indonesian domestic workers and in-
home caregivers in Taiwan and found that “[m]any Taiwanese dual-career couples...have turned to
migrant women for the assistance in childcare” (96). In fact, only dual-income couples are able to
hire a domestic worker in Taiwan, solidifying a direct relationship between the economic means
to hire a nanny and time that both parents will spend outside of the house, ostensibly earning
economic capital to pay for said nanny. Having a nanny is to say that the time put into the
mother's career (in this case, as a physician) is important enough to be exchanged for the cost of a
nanny, displacing the unpaid domestic labor that the mother otherwise would be expected to do
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onto the body of a nanny, transforming that unpaid labor into paid labor. This process is mediated
by the value placed upon not necessarily the time a woman puts toward her career, but the
perceived value of that career to individual and to society.
Rose, Melody, and Zoe are all female anesthesiology junior attendings with two children,
and all three have husbands who work. Melody's husband is an emergency physician at another
hospital, while Rose and Zoe's husbands are both computer programmers. All three employ (or
employed) nannies to take care of their respective children during the day. Rose employs her
nanny for her two sons during working hours, while Melody has a live-in nanny. The difference
between having a working hours nanny and a live-in nanny may be due to the husband's job, and
husband's ability to pick up the slack. Rose's husband, a computer programmer, works fairly
standard hours. In contrast, Melody has stated,
It's necessary...for her to be live-in, because you know, my husband's [an
emergency medicine physician], so he works a lot of nights. And I'm on
call a lot of the time, so, especially since I do a lot of [obstetric surgeries],
[so I'll] just [be] gone and then, if it coincides with when he's gone, then
you know, no one would be home (“Melody”, personal interview, October
17, 2014).
The fact that Melody's husband also has non-standard hours necessitates the live-in nanny, as their
time over the course of months is unpredictable, with many nights when they could potentially
both be gone. In this way, hiring someone else to take care of the domestic aspects of life becomes
a way to enable and reconfigure a work-life balance for Melody and her husband. The outsourcing
of domestic labor to allow for higher degrees of temporal capital, as well as enables this particular
configuration of family – dual-earning, career-intensive couple - exemplifies our tendency to
solve our temporal dilemmas, and our familiar obligations – through economic means, and it is
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only those with economic means who are able to displace domestic duties to pursue what
presumptuously is a meaningful career. To put it simply, economic power reinforces temporal
capital in that it allows practitioners like Melody to use the time they have to seek out meaningful
activities to fill said time, which then loops back to reinforce economic power by giving them
high monetary compensation.
Zoe's situation is a bit different. Her husband works from home, and while they had a
nanny when their two children were very young, they do not have a nanny now, and her husband
does the lion's share of looking after the children, in addition to cooking and other household
chores (“Zoe”, personal interview, October 14, 2015). What we see here is a necessary inversion
of traditional gender roles when one partner, regardless of gender, has more temporal capital
throughout the day than the other. Because of Zoe's husband's high levels of temporal capital,
which is now being exchanged to do domestic chores and childcare duties, the family saves on the
economic capital that would otherwise be spent on a nanny. However, a similar reification of the
structures of power as realized through temporal and economic capital are seen in this situation as
well, in a slightly different way. Zoe is able to take advantage of her husband's high levels of
temporal flexibility, by pursuing her career, which she finds quite meaningful, outside the home.
Meaning and Identity
When asked, most practitioners say they go into medicine or nursing because it is a
meaningful career, as opposed to a job they do just for the money. In 2007, Keeton et al found that
it was not work-life balance, predicated on schedule and work hours, but rather personal
accomplishment and emotional resilience that are predictors of career satisfaction (Keeton et al.,
2007). Health care, particularly clinical practice, where one has direct contact with patients,
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arguably is a profession that carries with it meaning beyond a simple economic transaction for
one's time. Given the years of training, the grueling days spent in the hospital without a social life
during residency, and the financial hole out of which one has to dig oneself after said training, the
temporal sacrifices put into this career path, which, it is important to remember, was made by a
choice that is more accessible to those in the higher echelons of socioeconomic statuses, must be
worth something that eludes quantification. In a way, this is the essence of temporal capital – the
choice, the agency to exchange one's time – whether it is for a few minutes, or for several years –
for something that one finds meaningful and worthwhile. And the endgame, the answer to the
“why do this?” question, the worth of this temporal investment, often differs depending on who is
asked.
Residents, as we have seen throughout this project, are often those with the lowest levels
of temporal capital on a micro-temporal level, as they are beholden to fellows and attendings, as
well as the obligations of their education and the health care institution itself. Interestingly,
attendings tend to have less empathy than expected for residents, despite, or perhaps because of,
the fact that they themselves have been there a mere few years earlier. Junior attendings are
uniquely positioned to remember their residency while currently experiencing the payoff to that
temporal investment, and the attendings that I spoke with all unequivocally say that the have more
control over their time and their lives after residency. When hearing about residents' complaints
about work-life balance, many of them roll their eyes in an “I've been there” sort of way. Rory,
junior internal medicine attending, who had completed residency not too long ago, reflected on
what the payoff for the temporal investment he put into training by comparing the lives of
attendings to residents:
The thing is, if you had asked me the same question two years ago when I
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was a resident, I may have given you a completely different answer. I think
as a resident your perspective is skewed. You're working 80 hour work
weeks, you're putting a lot of time and commitment into your professional
life. I think as a resident it's a tough road. Don't get me wrong okay, I'm not
trying to underplay exactly what residents have to go through because I
went through exactly all of that, but there's light at the end of the tunnel.
There's an end point to it. Life does get better after residency. I've gotten to
experience that. Going through residency made me appreciate what I'm
doing even more, right now (“Rory”, personal interview, May 29, 2015).
Zoe, junior anesthesiology attending who did her residency at University Medical Center,
similarly states unequivocally that being an attending allows for more temporal flexibility and
autonomy, especially in her current practice, which is not an academic position (she does not
work with residents, nor does she teach) (“Zoe”, personal interview, October 14, 2015). However,
there is a tradeoff. An attending has more responsibilities than residents, as they have no
institutionalized process to ask for help – ie: they do not have a senior or a supervisor who is
checking their work. Some attendings, including junior attendings, comment on how entitled
residents these days are. Simon, junior radiology attending, has this to say about residents
complaining about their work hours and their lack of personal time:
They don't realize that, I think, their chances of making an impact is high—
much greater if they become an attending, if they become doctor and you
know, reach out to people in whatever way that they can, whether it's
seeing a lot of patients, whether it's teaching a lot of doctors, whether it's
writing a lot of impacted articles on how we manage health care and
approach it. I think they just don't realize that they have a lot of potential
when they do become doctors. Sure, as just a numbers game and a time
thing, oh yea, if my goal was just to live a decent upper middle class life,
then yea, being a technologist will, you know, give me a $90,000 salary,
and that's for two years of post-high school schooling and then some
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maybe additional internship. Wow, that's huge. You know, not that much
paid into tuition, and not that much time spent studying for all these tests
and so on. So if that's your goal, then that's fine. But maybe you shouldn't
have thought of medicine in the first place, right, so I think for a lot of
people, you have to think of what your goal is. If your goal is just to have a
decent living, you can do that a lot of ways - just go be a pharmacist, or go
become a [physician's assistant], but why do you want to do that? That's
not a very interesting job. You're not going to have that much personal
growth, cuz in medicine, just, you become an attending, and you get paid
an attending salary, and that's all good. But um, and some people may find
that to be the pinnacle of their careers, in which case, well, maybe they
should have, maybe you could have a little more ambition, right? Those
who are, who make a difference in medicine constantly think of how they
could make their specialty better and how they could learn more about their
specialty to try to make a greater impact on their patients. So it really
depends on their motivation (“Simon”, personal interview, March 11,
2015).
In addition to commenting on the difference in the quality of life between residents and
attendings, this passage also reveals Simon's biased perspective that doctors' jobs have more
meaning and are relatively more impactful than other specialties. His talk of personal growth
echoes other physicians' perspectives of their own career trajectories. This is a fairly extreme, but
not altogether uncommon perspective on the role of physicians in society – one that reinforces the
superiority of physicians over other health professionals. It is as if this particular individual is
trying a little bit too hard to justify his decision to be a doctor. In this section, he seems to be
constantly defending being a doctor: “But I think [residents] claim that [going into medicine may
not be worth it] because they think that, well, maybe the whole numbers thing doesn't work out as
handsomely as they hoped it would be. First of all, that's not necessarily true. They haven't
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become an attending yet. Attendings do get paid really well, and they just don't see that yet”
(“Simon”, personal interview, March 11, 2015). Whatever the motivation for emphasizing the
glories of being a physician, Simon does have a point in that as hard residency is, it does pay off,
literally and figuratively, reinforcing the ongoing theme that the higher up one is on the hierarchy
ladder, the more temporal capital is available.
Indeed, the lower levels of extrinsic rewards play a role in an individual's intrinsic
motivation, particularly in terms of compensation. Social psychologists found that higher extrinsic
awards like higher levels of monetary compensation “tend to have a substantially negative effect
on intrinsic motivation” (Deci, Koestner, & Ryan, 1999, p. 659). Compensation, as many doctors
know, while good, is drastically delayed in comparison to their peers who do not choose to enter
the medical field, with lost earnings while undergoing training while accruing immense debt, then
only making a paltry resident's salary the first few years as a physician-in-training out of medical
school. For individuals still undergoing residency, the intrinsic motivation is compounded with a
future-facing perspective – the hope of what life will be like when they are attendings.
Hence, the ways in which residents, attendings, and nurses talk about the worthwhileness
of their professions differ. Physicians in general, when asked why they do what they do, while
mentioning that they like to help people, tend to phrase things in a more internalized way – for
example, “What I did saved that person's life” (“Donna”, personal interview, October 1, 2014),
placing oneself in the place of the active subject, the agent, the one that makes something happen
that causes an effect. Residents in comparison to attendings, have a future-facing rhetoric when
talking about why they spend the time they do – to be a better physician, to invest in “knowledge,
skills, expertise...all the things necessary to practice,” as Nicholas, ophthalmology resident, puts it
(“Nicholas”, personal interview, October 9, 2014). Toshiko, another ophthalmology resident, talks
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about the time she invests into her profession outside of actual work hours:
If you have a surgery coming up, [and you're not] really good with cataract
surgery, might want to go in to practice doing stuff in the lab or on the
computer to feel more comfortable, and that's on your own time. You
know, now all of us are trying to do research, and that's definitely on your
own time. I think most of us also try to read a little as well. As a first year,
you have to read a lot because you don't know anything, but even now, you
realize, you still don't know a lot of stuff, cuz it's only one year out. So you
have to spend time reading, otherwise you just won't get good. It's kind of
like, the things that you do outside of clinic are things that make you a
better doctor (“Toshiko”, personal interview, September 20, 2014).
Toshiko's sentiment is common amongst residents. Her payoff for spending the time she does both
at and outside of work is for her to become a “better doctor,” indicating her willingness to
exchange temporal capital for a personal endeavor, a journey, an identity, that is meaningful. She
gestures at the labor toward personal growth, which is clearly an important trajectory for her,
through reading and research.
For both residents and attendings, being a physician is an identity. As Craig,
ophthalmology fellow, states, “I do get annoyed if [people] don't call me Dr. So-and-So, if they
call me by my first name, I don't like that” (“Craig”, personal interview, February 9, 2015).
Indeed, Zerubavel points to the strong sense of identification of a physician's occupation and
duties with the self, stating, "Medicine is among the few professions which still adhere, at least
ideologically, to the traditional conception of the 'professional' as inseparable from his
occupational role" (Zerubavel, 1979, p. 53). This sense of doctor-as-identity, and an underlying
pride in being a physician, is often felt a bit more strongly with residents, which can loosely be
interpreted as over-justifying their choice to go into medicine when they temporarily have very
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low levels of temporal capital. Nicholas, ophthalmology resident, states that being a physician is
an identity that he will have for the rest of his life, even if he stops practicing:
I think being a doctor is one of those few professions in which kinda stays
with you. It's kind of like, who you are now. My mom's a programmer, my
dad's an engineer. When they retire 30 years from now, they won't be
identified as a programmer [or engineer], but we'll always think of
ourselves as a doctor or ophthalmologist, whatever it is. It's just, it's kind of
embedded as part of your identity. You know how people graduate from
different degrees and might go on to do different things? Doctors
invariably will always practice medicine...It's just something that's woven
as part of your identity (“Nicholas”, personal interview, October 9, 2014).
In here, he speaks about doctors as “one of the few professions,” which reveals his belief that
doctors have a stronger sense of identity than most professions. His use of the words “who you
are now” indicates that he thinks of being a doctor as a part of his identity, and that the lack of
temporal autonomy on a day to day basis and the temporal investment he puts in over the long
term is part of his personal growth that transcends a simple transaction of time for money.
It makes sense that many residents see their time in residency as temporary, as an
investment, since residency is a finite amount of time – a rigidly structured program of training
whose process, responsibilities, and expectations vary little from cohort to cohort. It is easy, then
to see residency as a temporal investment put toward their future career, toward themselves, for
them to be a good doctor. As can be seen in Donna, emergency medicine resident's statement, the
temporary state of residency is something that justifies the long hours and the lack of temporal
autonomy, leading to that future-facing, career-focused, hopeful “it gets better” perspective:
Everyone wants to be a good doctor. That's first and foremost. I'm
investing in my career. I don't want to come out of residency and be a
crappy doctor (laughs). And you also have the light at the end of the tunnel.
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After residency, the schedule gets a lot better. I mean, regardless of where,
you can work as much or as little as you want after residency. You can
support yourself pretty well with a part-time job. And some people will just
work part time, some people work multiple part time jobs, some people
will try to get somewhere full time...Most full time jobs are 10-16 shifts a
month, depending upon what other responsibilities you have...[and our
academic] program director, he works eleven 9-hour shifts a month
(“Donna”, personal interview, October 1, 2014).
That sounds pretty good. As Donna describes, there is a lot of room for temporal flexibility once
one becomes an attending, with multiple variations of work structure. The way she talks about her
current situation is with an understanding that it is temporary. She points to those higher up on the
physician hierarchy as examples of where she expects herself to be, and what she expects the
payoff to be – a flexible, self-made schedule that is well compensated. To be expected, her
perspective here is future-facing, and her current state is seen as an investment in her career,
which she ties to her identity as a doctor...of the good variety.
In contrast, attendings' states of being are not temporary. They have, in a sense, arrived,
and their motivations are a bit different. Sarah Jane, junior ophthalmology attending, describes her
experiences:
When I keep going, I'm going towards an overall goal of what my career is,
is to be a physician, to be a good clinician, so I don't mind being busy in
clinic, as long as it doesn't completely overwork me, and I'm exhausted.
Last year [as a fellow], there were times I didn't have lunch because I just
had to keep going. This year, if I want to just stop in the middle of my
clinic and go get something to eat, I could. I would just make people wait. I
don't do it. (laughs) But [it's nice] knowing that I have the option of being
like, I'm just going to take half an hour and just go eat something really
quickly (“Sarah Jane”, personal interview, February 17, 2015).
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While Sarah Jane makes a comparison between her experiences as a resident and fellow, and her
experience as an attending, pointing out that being an attending grants an individual more control
over one's time throughout the day (a recurring theme throughout this dissertation), it is
interesting to note that Sarah Jane's motivation during the day, similar to the residents, comes
from her identity as a physician and her drive to excel in the practice of medicine, which is
expressed as an identity - “to be a physician, to be a good clinician.” And while Melody,
anesthesiology attending, says that being a physician is not necessarily a part of her identity, since
most of her friends nowadays are physicians, she acknowledges the fact that being a physician is
something that is held sacred by some people,
I don't think people see me quite different, but I think a lot of people who
are physicians, they like people looking at them differently, like they are
physicians. So some people like attention, and they, you know, make the
distinction, and stuff like that. This one guy I know, they ask him a
question, he'll speak in this crazy medical jargon he knows no one
understands, and I'm just like, no one understands you but you just want to
feel like you're smart or something, you know? So, I think some people
really like it (“Melody”, personal interview, October 17, 2014).
As we can see, there are a few differences between the way that residents and attendings talk
about why they do what they do. Residents in particular are more apt to state that they are putting
in this temporal investment for their future, to become a better doctor. Attendings, on the other
hand, while mentioning the impact that they wish to make on patients' lives, will talk about being
compensated satisfactorily and, within the scope of my research, are much more likely to talk
about compensation than residents or nurses. Residents, unsurprisingly, do not see compensation
as a motivation to do well. While this fits into how extrinsic rewards like monetary compensation
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do not always align with internal motivation, and especially in the case of residents, certainly do
not align with the amount of temporal investment and the lack of temporal capital experienced,
there is also institutionally imposed pressure to not fail – for their attendings to like them and
think highly of them. There are also higher stakes for residents to excel. After all, they need to get
a job after residency, or be a competitive applicant for subspecialty fellowship positions, which
requires letters of recommendation from their superiors.
While physicians do talk about the difference they make in the lives of patients, nurses
tend to focus on their jobs as being in service to patients. Nurses are more likely to say that they
invest the time they put in every day to do well by the patients. This is not to say that doctors do
not have the patients' best interest at heart, but that their temporal investment, especially in
residency, is seen as personally meaningful as it contributes to their individual development in
their career in addition to patients' welfare. We saw earlier in Kaylee's testimony that she enjoys
specializing in oncology as a nurse because it affords her to provide long-term care to her patients
and make connections with them that transcend the simple clinical or medical care that defines
her job as a nurse (“Kaylee”, personal interview, July 3, 2015). Similarly, take this statement from
Alaya, nursing unit director, when asked why she became a nurse:
I know exactly why I come here on a daily basis, it's because of our
patients! I know what I'm here for, and I know exactly why I wake up in
the morning, and come into work excited. Probably most people don't
believe [me] (laughs), but I am, and it's because of our patients. I love the
idea, cuz like I said, I'm accustomed of coming into work and making the
rounds to the patients because even just one patient at a time I can touch
their lives, that's what I'm waking up for (“Alaya”, personal interview,
October 27, 2014).
Alaya's perspective is common amongst nurses. Nurses use a more patient-centered rhetoric when
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talking about the meaning and worthiness of their profession. While there is a sense of identity, it
is not quite like those of physicians, and particularly physicians-in-training, to which they cling
desperately in order to justify their demanding schedules, substantial temporal and financial
investment, and stressful environment. Instead, the focus is on their connection with the patient.
While both for nurses and for physicians, the motivation to enter into and continue on in their
profession goes beyond the simple economic exchange of timed labor for money, the motivations
themselves are driven by internal versus external motivations. For physicians, perhaps because of
the long years of investment and personal sacrifice, the motivation is personal investment, while
for nurses, with a less insular and shorter, albeit more uncertain, training process with incremental
stages at which to stop and start work, the motivation is more external.
Conclusion
My partner came home one day in high spirits, and she told me that one of her patients
that day was a former soldier who was also a boxer, for whom she performed cataract surgery.
During his followup of the successful surgery, he gave her a big hug and wished her the best in
her future endeavors. As she was telling the story, her face lit up with delight at the memory, and
it was clear that her job goes beyond the simple economic capitalistic exchange of labor (J. Chen,
personal communication, March 5, 2016). For my partner, the gratefulness of her patients makes
her happy, and makes her feel like her job is meaningful, beyond any potential monetary
compensation that she may reap from the work she does. For many practitioners, the journey to
become a health care professional, while long and arduous is worth the struggle. For those who
are still inside the period of struggling (ie: the medical residents), the light at the end of the tunnel
provides hope that their long-term temporal (and financial) investments pay off. For many, this
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means a path that allows for temporal autonomy, flexibility, substantive compensation, and a good
work-life balance. The ability to enact temporal capital over the long term to exchange years of
temporal investment into a meaningful and economically beneficial end is helped greatly if an
individual has resources before embarking upon this career. Time to study and access to academic
help during medical school in order to make one the most attractive candidate to one's residency
of choice notwithstanding,
93
individuals from more privileged backgrounds have a wider range of
career choice within the field of medicine, due to not being burdened with mountains of medical
student loan debt.
Even in the long term, there are institutional impositions that come to bear upon temporal
capital. The institutionalized process of training, the actions that need to be done at each stage, not
to mention the varying temporal autonomy allowed for individuals at different stage as they
advance in the training hierarchy, lock individuals into predictable actions and behaviors over
years. The negotiation of individual temporal capital happens on the individual level in terms of
the resources one can ostensibly put into play with time – economic capital to exchange for the
privilege of choosing a lower-paying specialty with a better lifestyle, for example, as we have
seen. The good news is that for the most part, for physicians, the training process is temporary,
and for the most part, once they reach the level of attendings, they are better able to control their
time – granted, some types of practitioners better than others, but the sacrifice ultimately, at some
point, pays off. Moreover, the meaning generated from the time spent, in a way, provides a crucial
theoretical way in how practitioners, unknowingly for the most part, counteract a totalizing
neoliberal subjectivity within a strictly capitalist logic. The humanism of personal growth or
93 There is much that can be said about not having to work to put oneself through medical school or nursing school,
freeing up time to study in order to get higher scores and get into a good residency program in a choice specialty.
But that is a bit out of the scope of this chapter.
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service to others, the reflection of time spent on labor as meaningful and worthwhile, subverts, or
at the very least resists, the idea that the temporal capital invested into training merely yields a
quantifiable ROI.
The importance of understanding not just the temporal navigation and investment of
practitioner training, but how the economic and educational systems collude to create situations
that force aspiring practitioners to make certain career decisions that have wide-reaching
implications not just for individual practitioners, but for the health care system in general. As
individual practitioners make decisions based on the economic trends of student debt, higher
specialty compensations, and rising costs of health care, a gap in primary care is seen that
ultimately affects patient care and the overall health of our society.
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Conclusion
I am a big fan of Doctor Who, the beloved
94
long-running BBC series. The Doctor is an
alien Time Lord from the planet Gallifrey, who travels through time and space. His human (and
sometimes non-human) companions, traveling with him in his TARDIS (Time and Relative
Dimensions in Space), a time machine/spaceship type of vehicle, often defy chronological time,
traveling into the past and the future with as much ease as, say, scrambling some eggs. As a
student of temporality studies, among other disciplines, this narrative seemed particularly apt.
Unfortunately, for most of us human mortals, time moves linearly and ever forward. Once it has
passed, we generally cannot get it back. It is unrecoupable.
Time is a constraint on society that acts upon us in often invisible ways. Through our
treatment of time as a resource, time communicates and reifies social power structures without us
knowing, and we subconsciously discipline our bodies and our behaviors to its strict logic.
Because of the invisibility of the influence and power of temporality, temporal capital is a useful
framework by which to differentiate levels of societal power between individuals, and within
individuals' relationship with institutional structures through the reality of a society entrenched in
capitalist values. Since everyone's time is differently used and differently constrained, even an
abstract measure of the amount of time people have in their control provides a way to think about
the differentiations of power that individuals have in particular situations. Moreover, temporal
capital is a measurement of temporal autonomy, which is associated with positive attributes in an
individual's life like well-being and life satisfaction. Being as we are in a capitalist society, many
of us are beholden to the strictures of capitalism in the structuring of our time and our lives.
94 And problematic. But we won't get into that.
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Temporal autonomy is co-opted by the institution, and through the organizational hierarchy that
differentiates power between individuals. However, this co-optation is counterbalanced by the
investment of time into meaningful endeavor, to which all practitioners in this study alluded. Such
a perspective – the high levels of temporal capital coming not from the amount of autonomous
time necessarily, but from the exchange of time into a meaningful goal - denies the Marxist
reduction of worker to the constraints of capital through labor time and the alienation of labor. A
medical resident does not work 80 hours a week for the monetary exchange of a measly resident
salary
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while simultaneously being saddled with mountains of debt from medical school, but the
temporal investment is an investment in personal self growth, potential future earnings, and a
reputable identity as a physician, not to mention the gratitude and appreciation of their patients.
This dissertation project topic intrigued me because I saw my own temporal flexibility as a
graduate student juxtaposed with my partner's constrained temporal rhythms, and saw firsthand
the impact that the stress of time can potentially place on the bodies of individuals. Health care in
the US is undergoing a long transition process to comply with stipulations in new legislation and
policy that come to bear on the everyday practices of practitioners, and potentially exacerbates
some of the pre-existing issues around burnout, mental health, work-life balance, and overall
career satisfaction. With so much of health care and health care/medical research focused on
patient experience and outcomes, there is, reasonably, fewer studies done on the quality of life for
practitioners. This should not be a zero sum game. While patient-focused research is imperative,
the needs, perspectives, and experiences of the individuals actually providing patient care should
be more a part of the conversation, as it undoubtedly impacts the quality of care. And while there
has been fantastic research previously done on the experience of practitioners, this research has
95 In 2015, the average resident salary was $55,400 (Chesanow, 2015).
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focused on the quantitative methods, correlating burnout and others with certain aspects of work,
but very few if any have attempted to bring a critical cultural perspective that addresses issues of
power, social norms, ritualistically constructed cultural practices, and other qualitative questions.
This dissertation is an entry into that conversation, to try to dig deeper into the reasons why the
correlations found in these other studies exist between different variables, to bridge the gap
between the quantitative social science methods used in medical research and qualitative,
interpretive research used in critical cultural studies, and to present a nuanced and complex
perspective from the practitioner side that starts to examine and illuminate how power structures
and social dynamics impact the lived experiences of practitioners through an understanding of the
role of time and temporality.
In the health care field in particular, time is ever present from the macro-levels to the
micro-levels of temporality, from regulating and normalizing training times in physician training
to the obligations to various colleagues and institutional rules that govern a practitioner's actions
on a minute-by-minute basis. This dissertation looked at the entire spectrum of temporality, from
the minutes and hours of daily patient encounters, surgeries, charting, and navigating family life
and leisure, to the years and decades of education and training in which earlier decisions impact
future temporal rhythms. The research also considered the differences in temporal capital
according to an individual's position within the organization or within the training hierarchy, as
well as how the institution imposes control over individual time, and found, simply, that the
power an individual has within an organization is correlated with the amount of potential temporal
capital wielded by that individual.
The colonization of time is enacted in two ways – one is on the individual level, where
one individual has control over another person's time. We see this most clearly with the delegation
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of tasks between attendings and residents, where the interchangeability of set tasks make such
expansion of temporal capital for the individual in the higher position of power possible.
Ultimately, though, these individual interactions of temporal exchange and expansion are framed
within an institutional culture of time and temporality. From my research, almost universally in all
cases, the temporal constraints came from the institution itself, whether it is the health care system
with recent changes in legislation that results in increased burdens on practitioners, the policies
and regulations imposed by hospital administration, or simply the ritualistic cultural and social
norms of the practice of health care that manifest into certain expectations from colleagues and
superiors. Through it all, the impetus to reproduce the cycle of capitalism is ever-present – by
seeing more patients, by using electronic medical records to make patient encounter processes and
the sharing of patient information more efficient, by bypassing institutionally-sanctioned but
laborious and tedious processes through the use of personal mobile devices in order to accelerate
the sharing of information, the normative cultural practices in healthcare thereby discipline the
physical bodies and spaces within the lives of health practitioners to conform to logics of
capitalistic productivity. And we have to remember that this is not necessarily confined to the
health care field. Logics of productivity, making sure that time is not wasted, comes from the
mentality of treating time as capital, as temporal capital, exchangeable for other forms of capital.
However, within this framework of institutional imposition of temporality, individuals use
their own temporal capital to navigate and negotiate their autonomy, resulting in those with more
circumstantial power able to do so the best. Attendings are able to recoup time that has been
colonized by the institution by offsetting tasks to residents. Practitioners who are proficient with
technology can fully unlock the potential of the EMR system while others who are not as
technologically literate fall behind, experiencing delays, and are sometimes cut out of the system
264
altogether. Colleagues who communicate primarily through the use of personal devices are able to
do so more efficiently than the institutionally-sanctioned process of paging, which is used by
those who do not have the privilege of knowing a certain person's number. And while all
physicians need to go through a set process for training and residency, some physicians are able to
graduate from medical school with no debt due to a supportive and privileged background,
making choices about specialties and future career paths based purely on interest, while others
take into account a mountain of student loans in a decision to specialize. On the other end of the
process, institutional impositions on different specialties are also varied, and decisions to go into
certain specialties because of the temporal autonomy it affords is common, making certain
specialties (the E-ROAD to Happiness) highly desirable.
While this project did not tackle quality of life directly as a variable, temporal autonomy is
an important aspect of a happy life – a point that was both implicit and explicit throughout this
research. The more temporal capital and temporal autonomy one has, the more content they seem.
Attendings tend to be happier than residents, with more control over their time, and more
compensation. Their temporal capital over the long term has been exchanged for what they see as
a meaningful career that is handsomely rewarded monetary-wise. Moreover, on a day to day or
hour by hour basis, they have more control over their time in their ability to delegate work to their
residents. They look upon their own residencies as temporary trial-by-fire experiences with an “it
gets better” attitude. In most cases, practitioners find their work highly meaningful and worth the
temporal investment and the sacrifice of time. As such, even though on the micro-temporal level
certain practitioners may have seemingly low levels of temporal capital due to low temporal
flexibility, with their time at the whim of others, they willingly subject themselves to a situation
with temporal constraints for the value they feel in their work. Like my consultant friend who has
265
said that health care is difficult think about in purely economic terms because putting a monetary
value on the life of a person is grossly reductive and impossible, their time, as capital, is being
exchanged for something that far exceeds the mere economic gains of their labor. It makes sense,
then, that practitioners feel that their job is a noble calling of sorts, and well worth the time.
To focus on time is admittedly, a limited perspective, albeit an important one, on factors
that affects the well-being of practitioners, and particularly physicians. There are other factors,
many of them necessitating the discussion of emotions and affect – things that do not fit neatly
into the usually rationalized and quantified discussions found in medical journals or the broader
ethos of medicine. As such, there are only a limited number of studies out there that address
practitioners' experiences and feelings. And yet, these issues of burnout, mental wellness,
depression, and the overall challenges of navigating the rigid hierarchical system of health care
personnel and practitioners have been present for a very long time, with little to no amelioration
of it – indeed, it has been getting worse. The vast majority of the research that I have found were
studies about doctors done by doctors. As such, their methods do not normally use methods that
recognize and interrogate institutional and interpersonal dynamics of power. One of my junior
attending subjects, Rose, is also an administrator for the anesthesiology residency program, and
tells me that although they have a seminar on mental wellness and put into place initiatives that
encourage medical students and residents to seek out help – particularly emotional help, they are
not very effective. No one takes advantage of them because they do not want to appear weak to
their colleagues and their superiors. This is not a matter of inserting a simple intervention of an
hour-long seminar about the importance of mental health and work-life balance that residents may
or may not attend. What is needed is an upheaval of the very culture of medical training and the
266
normalization of the rigid hierarchies that promote harsh methods that oppress, belittle, abuse, and
take advantage of those on the lower rungs.
And yet, there is a concern that the hardness necessary to practice medicine if the training
and the supervision along the hierarchy is too soft. Stakes in medicine are very high. Practitioners
fall into the strange category of people for whom a routine day is someone's emergency or outlier.
If my lung collapses
96
and I need to go to the emergency department, then be admitted into the
hospital, that is a very bad day for me, but a very normal day for the chest surgeon who performs
my pleurodesis procedure. The emotional toll taken on practitioners is not very often talked about,
and only discussed as anecdotal for the most part. There is also a necessary hardening and
desensitization on the part of the physician so they are not so emotionally paralyzed as to not be
able to effectively do their job. But then, how much is too much? The concern is a population of
practitioners who are coddled and entitled (a sentiment that is already seen in some of the
attendings as they talk about their residents) who will not be able to handle the really tough cases,
and that is not a population of practitioners that we want either. The stakes are too high.
As with most things, the answer does not lie on either extreme – of extreme malignant
training where what does not kill the practitioner makes them stronger, or extreme empathy where
egregious mistakes go only lightly punished. The broader issue is that the public discourse does
not empathize with practitioners. We sometimes forget that they are people, rather than these
infallible, indomitable authority figures that know everything and can fix everything. We expect
that of them. And in doing so, we make them less than human. Or more than human. But we
forget that they are, in fact, human. This is not all doom and gloom though. Digital media and the
Internet have enabled a plethora of voices and allowed for many avenues of expression previously
96 As it does sometimes.
267
unavailable. Blogs like KevinMD and communities like Physician Moms (which boasts over
50,000 members) for practitioners have sprung up and become popular through social media. The
anxiety of Match Day can now be expressed through a Fiddler on the Roof parody called
“Matchmaker Matchmaker”,
97
created by a group of talented singing and dancing medical
students from University of Chicago's Pritzker School of Medicine. The Internet and social media
has been a wonderful outlet for practitioners to share their stories not just with each other, but
potentially with the public.
This project is not meant to be interventionalist or prescriptive, nor does it claim
generalizability for these findings beyond reasonable extrapolation. Rather, it sought to uncover
potential underlying systemic and cultural factors surrounding uneven uses of time, and hence
uneven potential for autonomy, self-actualization, and well-being by using temporality as a
barometer for power. This is not to say that such research cannot be somehow used in practice. It
would be logical to use this research to find ways to shift and rethink legislation or institutional
policies that govern the temporalized labor of practitioners. But more often than not, a top-down
approach may not be the most effective. The biggest issue I feel can be reasonably tackled is that
of giving practitioners voice and finding ways for the public to understand their experiences, as
the overrationalized figure of the practitioner, caught up in a rigid temporal framework dictated by
various forces around them, has proven to be, if not detrimental, then certainly not inspiring, to
the practice of medicine. This dissertation itself gave my practitioner informants a place to share
their experiences, express their frustrations, and reflect on their own lives, which I hope is a step
toward more conscientious practitioner-facing research that can start addressing the challenges
raised in this piece.
97 Found here: https://www.youtube.com/watch?v=eYVZyGpWAco
268
This dissertation at times feels like #firstworldproblems, a Twitter-born commentary form
used on social media to criticize someone else for complaining about how hard their privileged
life is when there are, for instance, children starving in the Third World. At the end of the day,
health practitioners, and especially physicians, are not considered a disenfranchised group. They
are privileged in terms of economic status, social status, and for the most part, upbringing.
However, we disregard the experiences and challenges that health practitioners face at our own
peril, and there is a social imperative to examine the ways in which the system falls short or fails.
The challenges of temporality are most felt at sites that serve the most disenfranchised of our
society, at public medical centers, it is crucial to address them in order to ensure access and
quality health care for those who are socially disenfranchised. Moreover, happy, healthy
practitioners do their job to their fullest potential. And their ability to deliver high quality of care
affects everyone.
269
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Asset Metadata

Creator Wang, Cynthia (author)

Core Title Temporal dynamics in the lives of health practitioners

School Annenberg School for Communication

Degree Doctor of Philosophy

Degree Program Communication

Publication Date 07/05/2018

Defense Date 04/27/2016

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag critical theory,cultural studies,health care,OAI-PMH Harvest,practitioners,temporality,time

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Gross, Larry P. (committee chair), Ananny, Mike (committee member), Castells, Manuel (committee member)

Creator Email cyndaminthia@gmail.com,wangcynt@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-263942

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Legacy Identifier etd-WangCynthi-4514.pdf

Dmrecord 263942

Document Type Dissertation

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Type texts

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