Making consultations run smoothly: An analysis of doctors' skilful use of time inspired by science and technology studies

Introduction

In these words, Bent Bjerre, a retired Danish doctor, reflects on the difficulties that were very prominent in the beginning of his career and he gives voice to the ever-present challenge of managing time in consultation work. As a young doctor, Bjerre opened a practice in a small rural town in Denmark in 1963. It was an overwhelming experience. He recalls that the phone often rang in the middle of consultations, that there were too many patients in the waiting room and that urgent patients ruined the timing and made the working day stressful. He quickly realized that things had to change. He first tried to put up a take-a-number roll, similar to the one his patients would know from the local bakery. Unfortunately, people drew several numbers, passed them on to others, went for errands and forgot to come back. He then tried to put up a board with hooks, and signs with time intervals written on them. But this system also ended in chaos. Finally, he managed to install the practice that people would have to phone and arrange a time before they arrived. It was difficult to persuade people that they would have to phone first, and it took quite a while before both Bjerre and his patients had adjusted to the new regime. Bjerre had to learn to manage the phone consultation time carefully, and to fit everything into a protocol. The patients had to learn to distinguish between urgent and non-urgent problems, and they had to accept that a visit to the doctor was a two-step process: first, the making of an appointment over the phone; and, second, the visit to the doctor at the agreed time.

The purpose of this article is to explore the kinds of time challenges that Bjerre gradually managed to organize. Our topic is the skilful use of time in general practice consultations, and we have chosen to begin this article with the trials and tribulations of Bjerre for two reasons. First of all, the story indicates the somewhat obvious, but nevertheless crucial, importance of handling time in a skilful manner; had Bjerre and his patients not worked out a functioning arrangement, they would have experienced a great deal more stress, frustration and chaos. Second, we find it particularly interesting that the story calls attention to the messiness of time. Time is not just at distant variable ticking away like a clock on the wall. Time is an intricate and troublesome affair, which involves practical tools such as number rolls and telephones, the habits and actions of both patients and doctors in and around the consultation room, and the continual negotiation of contested issues such as respect for telephone hours and the nature of urgency.

If we take the handling of these practical circumstances to be our empirical substance – if we believe that the devil of consultation work is in precisely these kinds of details – then it follows that not all perspectives from the literature on medical practice are equally well-suited to explore the process of time use. In the first part of this article, we will consider three well-established strands of literature on medical practice. All of these have contributed substantially to the understanding of medical practice, but in relation to the question of time use, we find them wanting because they are either too aggregated, too prescriptive or too language-oriented.

Second, we will turn to the interdisciplinary field of science and technology studies (STS). From this field, we select a number of key ideas, which we suggest might contribute to an exploration of the skilful use of time in medical practice. To put it very briefly, we will argue that ideas from STS will allow us to engage in a more direct manner with time itself – the unruly beast that the young Bjerre struggles to tame – and we will argue that STS allows us to better grasp the significance of the material ‘stuff’ involved in the skilful use of consultation time, such as Bjerre’s number rolls, board with hooks and telephone.

Having presented our analytical perspective, we will continue with an exploration of how a number of Danish general practitioners (GPs) manage time before, during and after consultations: how patients achieve an appointment with the doctor; how time is handled during the consultations; and how doctors manage future times and appointments. This part of the article is based on an extensive field study conducted by one of the authors.

Finally, we will summarize our depiction of skilful time use, and we will suggest how this STS-inspired approach might open up a wider discussion about time as a complex resource and challenge in general practice.

Some established perspectives on medical practice

The literature on the sociology of professions (Abbott, 1988; Freidson, 1970) offers fascinating historical accounts of the emergence and establishment of professions, their professional associations, their authority and their privileges. It would be no exaggeration to say that the sociology of professions provides indispensable background knowledge for any sociology of medicine. However, it is also clear that these analyses operate with units of analysis that are far removed from the practical details of manoeuvring through the daily list of patients. Therefore, the analysis of practical time use in the sociology of professions tends to be on a highly aggregated and external level, such as the arguments that time pressures have increased throughout the century, and that ‘dehumanization’ is likely to follow from governmental attempts to further increase ‘efficiency’ by establishing measures of control and quality (Freidson, 1988: 391). For this reason, the analysis of professions and professionalization is not directly applicable to an investigation of the specific time issues in daily consultation work.

The attention to the handling of minute, practical details, which is rarely found in the sociology of professions, seems to take centre stage in some of the writings that originate within the medical profession itself. We are alluding here to the countless medical textbooks that contain highly elaborate descriptions of checklists, methods and procedures (e.g. Bentzen et al., 1997). Through the careful reading of these books, and through their training in medical schools, medical students learn to follow a large number of procedures, and they come to value them as the necessary means to reach optimum results. Most procedures are concerned with specific examinations or treatments, but a similar procedural perspective and corpus of knowledge has been developed around the ‘art’ or the ‘craft’ of handling a consultation. In this literature, the consultation is described as a sequence of tasks such as preparation, listening to the patient, examination, defining the problem, planning a course of action and follow-up (Pendleton et al., 2003). On the issue of time, this consultation literature notes that time usually comes in the form of units, for example, 5, 10 or 15 minutes, depending on the social security system in question. But the same authors also seem well aware that time per se tends to slip out of the focus defined by the procedural approach. In the words of Pendleton, who allegedly is a key figure within consultation research and consultation teaching: ‘little is known about the skillful use of time’ (Pendleton et al., 2003: 60). In our interpretation, this lack of knowledge is an effect of the prescriptive or normative project, which is inherent to the procedural literature. Its ambition is to define all the things that should be done during a consultation, not to explore how doctors in practice manage to squeeze some or all of these activities into the limited time available. For this reason, the procedural literature is useful as a tool for medical practitioners, but since the procedure is not the practice, the procedural literature is of little use for an exploration of how the skilful usage of time unfolds in the intricate relations between doctors, patients and material circumstances.

The strand of literature on medical practice that devotes most attention to these situated and somewhat unpredictable interactions is studies of patient–physician relationships and the discourse of clinical encounters (Mattingly, 1998; Mattingly and Garro, 2000; Mishler, 1984). These studies build on close observations and systematic description of the verbal exchanges between doctors and patients. They investigate differences in perspective, for example, between the technical-scientific concerns of the doctor and life-world concerns of the patient. Furthermore, they explore how the participants in clinical encounters occasionally resolve their differences and create mutual understandings, coordinated actions and shared narratives. The distinct quality of these interpretive, social constructivist authors is their attention to the interactive and somewhat unpredictable nature of medical encounters. This attention is driven by a keen interest in discourse, such as question–answer formats, narratives and plots. But this discourse orientation also constitutes a limitation: since the skilful use of time is not merely the product of verbal exchanges, but also of exchanges with appointment schedules, with instruments used for medical examinations and with various other artefacts in the richly equipped consultation rooms, one could argue that a broader notion of interaction is needed (Berg and Mol, 1998; Mol, 2002). The field of STS, which we will turn to next, has made exactly this kind of argument. Some STS authors, for example, anthropologist of science Bruno Latour, have argued that social constructivist, or language-oriented, conceptions of interaction are entirely inadequate, since everything changes once we take the role of materiality into account (Latour, 1996, 1999). Other authors take a more forthcoming position, arguing that an important family resemblance exists between various interactionist traditions (Bowker and Star, 2000; Law, 1994). Our own position leans towards the forthcoming side. But, for the sake of clarity, we will emphasize in the following a set of ideas that clearly sets STS apart from the traditions previously mentioned. Through this we hope to elucidate how STS may contribute new ideas and perspectives to studies of consultations and time.

Theoretical resources from the field of science and technology studies

The point of departure for many authors in STS is the assumption that everything is relationally defined (Blok and Elgaard Jensen, 2011; Latour, 1988; Law, 2008). This means not only that there are important mutually constitutive relations between science, technology and society at all levels. It also means that every conceivable entity is taken to be defined by its relations; the field of STS, or at least substantial parts of it, thus builds on an entirely relational ontology (Law, 1999). Consequently, STS is rich in cases of how the arrangement of particular material, technical, social, discursive relations have brought about recognizable ‘entities’ such a scientific facts (Latour and Woolgar, 1979/1986), empirical methods (Shapin and Schaffer, 1985), technological artefacts (Callon, 1986; Law, 2002), illnesses (Mol, 2002), markets (Callon, 1998) or any other of the distinct configurations that populate our contemporary world. As we shall see, time might be added to this list.

The relational ontology of STS gives rise to a number of methodological challenges. Most significantly, one might ask how the researchers should prioritize their attention, since networks and relations extend everywhere. One possible, and rather pragmatic, solution to this problem is that researchers should pick their analytical points of departure very carefully. In a seminal book on how to study scientific practice, Bruno Latour (1987) thus argues that the best point of entry is what he calls science in the making. At a certain moment, things are unsettled, uncertain, contested. No one knows if this machine, which keeps breaking down, will ever work. No one knows if this elusive effect, which can only be registered intermittently by complicated laboratory equipment, will ever be established as a scientific fact. This phase, according to Latour, is the right moment to start exploring the unruly sets of relations, which may, in the course of events, evolve into what he calls ready-made-science; the smooth-running, trustworthy, predictable and efficient outcomes that sometimes follow. The implication of this approach – of following ‘entities’ as they become increasingly ready made – is that no underlying essence is assumed. Latour never assumes that scientific facts are lying out there in nature, waiting to be discovered. Instead, he follows the work of constructing facts, which again means that full attention is given to the material, practical, social, discursive circumstances of scientific work.

Our contention is that a similar approach may be taken to time. To study time, we do not need to assume that time is an essential entity, which is somehow given. Instead, we may turn our attention to the intricate work through which participants construct time in their arrangement of relations. Our vignette story of Bent Bjerre is indicative of this process. In the beginning, Bjerre is faced with time in the making; there is no established and predictable order to the flow of events. The implicated actors have different ideas about when to do things, when to interrupt and what to expect. And the artefacts, for example, the number role and the board with hooks, are insufficient to stabilize the situation. A few years later, time in and around Bjerre’s consulting room seems to have come into a more ready made form. The regular phone hour, the habits and expectations of patients, and Bjerre’s work with his appointment schedule form a set of relations that have turned time into a much more stable, predictable and smooth-running entity, not entirely without frictions, but far more orderly than the chaotic days in the beginning.

The assumption of a variable ontology – that time is defined by a changing set of relations – is one key idea that we take from STS. The next idea we want to consider is the so-called multiplicity of time. The argument is developed by the French philosopher Michel Serres, who opposes the ordinary (historicist) view of time that we are moving through a successive series of time periods or epochs, leaving one behind as we continue to the next. As a radical alternative, Serres suggests that every historical and contemporary event or object should be understood as a composition of a multitude of times. To illustrate his notion of time, he takes the example of a late-model car, which we would normally pin down in the present by describing it as a ‘contemporary thing’. Serres, however, raises the question of what such ‘a contemporary thing’ really is. The late-model car, he argues:

is a disparate aggregate of scientific and technical solutions dating from different periods. One can date it component by component: this part was invented at the turn of the century, another ten years ago, and Carnot’s cycle is almost two hundred years old. Not to mention that the wheel dates back to Neolithic times. The ensemble is only contemporary by assemblage, by its design, its finish, sometimes only by the slickness of the advertising surrounding it (Serres and Latour, 1995: 45).

Serres’s compositionist view of events and objects leads him to explore some time-metaphors that are radically different from the common metaphor of time as a linear sequence. In particular, he is fond of comparing time to fluids and fluid movements. In this vein, he talks about time as an extraordinarily complicated mixture (Serres and Latour, 1995: 57). He suggests that time makes folded, turbulent patterns (Serres and Latour, 1995: 59). He compares the movement of time to seeping: a fluid can move in one direction in a leaking pipe, while it seeps in other directions simultaneously (Serres and Latour, 1995: 58). Serres’s fluid metaphors may be difficult to comprehend entirely, but his general argument is clear: we must imagine a present/contemporary time as a multiplicity of times, and we must imagine that these times move in complicated, folded ways that generate contacts between points that were previously distant, seen from a linear perspective. Like the case of a brand new car, we might think of every consultation as a composition of multiple times, and we can therefore explore the bundle of times that makes up a particular consultation.

A third and final idea that we take from STS is the question of otherness. In reading certain STS analyses, one might get the impression that the construction of stable entities is a matter of bringing together a large number of well-ordered relations at one location. According to the STS scholar John Law, this is not the whole truth. Drawing on feminist and symbolic interactionist literatures (Haraway, 1991; Star, 1991), Law argues that important constitutive relations rest in matters that are made absent, in the sense of being kept away, and in matters that are ‘othered’, in the sense of being made impossible to relate to. One interesting empirical example of such processes that Law mentions is Charis Thompson’s study of fertility treatment (Thompson, 2005). Fertility treatment is sometimes taken to be a prime case of how technology invades human life. To critics, nothing is more symbolic of this transgression than the situation, where an undressed woman is placed on her back, legs spread and some instrument is inserted into her body. Thompson, however, argues that such objectifying moments must be seen as moments in a particular trail of activity. Subsequent moments may be intensely subjectifying, such as when a woman can walk out of the room, proud, pregnant and strengthened as a subject. By turning the attention to the trails of activity – the various trajectories through fertility treatment – Thompson suggests that a particular ontological choreography is being performed. In a particular moment, certain things are pushed aside, such as the woman’s family situation, her anxieties, her hopes and her motivation for entering treatment. But these aspects of her subjectivity are only pushed aside under the premise that they will re-enter the picture later. The object-like thus depends on the temporary rejection of the subject-like, and vice versa. In broader terms, the implication is that the relational definition of everything in STS should include relations of absence or otherness. If the skilful use of time is our entity, then it is also worth exploring how doctors and patients in consultation practices manage to define certain ‘other’ matters as irrelevant, as beside the point or as untimely. This handling of otherness-relations may be relatively carefully planned and ‘choreographed’, as in the case of fertility treatments, but ‘disturbing’ matters may also enter in a more unruly and unexpected way (Law and Singleton, 2000). In the second part of this article, we shall see examples of both kinds.

To sum up very briefly, we propose to supplement the well-established sociological, procedural and discursive-interactional perspectives on consultation practice with a perspective inspired by STS. This latter perspective investigates time as an ‘entity’ defined by a broad variety of relations (material, technological, social, discursive, etc.). It assumes: that time may have a variable ontology (from time in the making to ready made time); that any situation may be seen as a composition of multiple times; and, finally, that relations of otherness may contribute to the skilful use of time.

Methods and data

In the following, we will turn our attention to the consultation practices of GPs. Our analysis is based on an ethnographic fieldwork, which was carried out in 2004 by one of the authors with four GPs in four different parts of Denmark (Jespersen, 2007). The general approach to the fieldwork was inspired by the literature on multi-sited ethnography (Coleman and Collins, 2006; Gupta and Ferguson, 1997; Marcus, 1998): these ethnographers do not view the field as a naturally bounded entity, but, rather, as a distributed, performed event, which includes a heterogeneous collection of materials.

The key part of the empirical material for the Danish ethnographic study of GPs consists of observation notes from roughly 250 consultations, which were observed directly at the four different locations during a six-month period. The observation notes include anything from descriptions of the physical space, instruments and participants, to notes on the unfolding of conversations, arguments and coordinated actions. In addition to these heterogeneous observations, the ethnographic observer engaged in informal conversations with the GPs before and after the consultations, which, in many cases, provided an occasion for the GPs to explain and make sense of the events. Additional field notes were written to register the content of these conversations. As a further attempt to adhere to the good practice of basing case studies on multiple sources of evidence (Yin, 1998), the ethnographer conducted subsequent in-dept interviews with all four GPs, and she reviewed a range of literatures related to GP consultations (e.g. medical handbooks, medical journals and health policy papers). For this article, we have chosen a number of field note excerpts that are particularly illustrative of the daily challenges of managing time in consultation work. In the following we will examine, first, how patients achieve an appointment with the doctor. Second, we will analyse a couple of examples of how time is handled during the consultations. Third, we will describe how doctors manage future times and appointments. In the conclusion, we will summarize the different forms of relational construction of time that we have encountered, and we will discuss the possible contribution of this STS-inspired approach to the study of time practice.

Making appointments: On the daily organization of tasks, patients and time

The GPs’ agreement with the national health insurance system lays down certain minimum requirements on the structuring of time: GPs must make themselves available for phone consultations with the patients at some point every day; and the GPs are required to offer any patient a time for (physical) consultation no later than five working days after the initial phone contact. But aside from these formal requirements, the GPs have a fairly wide range of options in how they structure the booking of consultations. In the following, we will examine three GP practices in more detail. (The fourth GP fieldwork is omitted here because she was largely similar to the first). We will describe the organization and distribution of the daily time slots, and we will discuss how these time-related decisions relate to other aspects of the GPs’ practices. OPEN IN VIEWER

Practice 1 is a single-GP practice in a major city. The office facilities and service staff are shared with two other GPs. This GP has allotted 15 minutes for each consultation. In an interview, the GP explains that he prefers this arrangement because it produces a relatively peaceful working day. He does, of course, realize that it influences his earnings negatively, but he feels that he earns enough, and he therefore considers the extra time a luxury that he can afford. In this GP practice, the mornings begin with phone consultations directly to the GP between 8 a.m. and 9 a.m. At 9 a.m., the secretaries meet and take over the phone. During the phone consultations, the GP sits by the computer with the schedule of the daily work in front of him. In those of the 15-minute slots that are already booked, he can read the patients’ names, their social security numbers and some brief notes on their complaints. The first observation day in this practice turns out to be very quiet. The GP has time to eat breakfast, go through the mail and study the files of the patients that will arrive later. He explains that he cannot predict in advance whether a day will be quiet or busy.

Practice 2 is located in a suburb. It is a single-GP practice, but she collaborates with another GP, with whom she also shares office facilities and a secretary. This GP has allotted only 10 minutes for each consultation. The GP holds phone consultations between 8 a.m. and 9 a.m. From 9–9.30 a.m. there is an open consultation, where the patients can come without previous booking. The first patients show up at 9 a.m., at the same time as the secretary. A glimpse on the computer screen reveals that this GP manages not one, but two, columns. Column 1 divides the day into 10-minute slots and contains all the appointments. Column 2 is for acute or unplanned patients, who call and ask for an appointment on the very same day. If the GP accepts their request, she looks at Column 1 to find the time of the day where the pressure is smallest. Although the GP seems to manage this merging of Column 2 into Column 1, it sometimes means that she is left with only five minutes to do a consultation. In a follow-up interview, the GP explains that she can easily handle the increased pressure. She also states that, in her opinion, this form of ‘extended’ availability is the best way to approach the patients.

Practice 3 is located in a medium-sized town. The GP works in partnership with two other GPs. The three GPs have divided the work into three columns:

Column 1: planned consultations, interspersed with unplanned patients if possible.

The doctors shift from one column to the next every day. In this practice, there are also phone consultations between 8 a.m. and 9 a.m. The phone system relays the patients to the first available GP. The GPs can book patients for each other, and during the morning phone consultations, it is particularly Column 3 which is filled out. However, the house calls in Column 2 are also often booked during the morning. According to the GP who was interviewed, the benefit of this system is that the GPs’ work becomes varied and flexible. The system also creates a good symmetry between the GPs. The downside is that those patients who only want one particular GP will sometimes have to wait for quite a while. In the experiences of these patients, the system is inflexible.

In the practices we have described, time is organized in significantly different ways. In Practice 1, the GP allows himself relatively plenty of time, with 15-minute consultations. In Practice 2, the GP only uses 10 minutes per consultation, and she even manages to squeeze in unplanned appointments in between. In Practice 3, the GPs have arranged a form of job rotation, which allows them to solve particular types of tasks for one day at a time.

In all three practices, however, time is given the form of a time-slot. Time is a unit that can be allocated at the beginning of the day, when the GPs sit in front of their computers, with their booking software open and with the patients on the phone. This arrangement is a significant obligatory passage point (cf. Callon, 1986) that the GPs attempt to establish between an always unpredictable patient population and the ordered planning of the day’s work. Another common feature among the three practices is that no one can predict the number of patient contacts in the morning or during any other time of the day.

Our description of the three practices indicates that significant pros and cons are involved with the choice of any particular organization of time. In Practice 1, the GP realized that 15-minute consultations give him more tranquillity, but less income. In Practice 2, the GP emphasizes that 10-minute consultations combined with the frequent addition of unplanned patients make her more available – it is always easy and quick to get a time with her – but this, of course, comes with less tranquillity, and possibly more stress. In Practice 3, the GPs obtain job variation and the benefit that one GP is always available for unplanned patients. On the other hand, the patients who want one particular GP must be prepared to wait longer.

As appears from the preceding sketch of pros and cons, the organization of time is related to a number of significant issues: the patients’ experiences of continuity, tranquillity and accessibility; and the GPs’ opportunities for earning, job variation and sufficient time to do the job. The apparently simple decision – to allocate the time for a day’s work – is thus profoundly entangled with many aspects of the practice. Time, as we have depicted it here, is not a distant and abstract yardstick; it is a materialized and intensely related part of practice, even before the first patient enters the door. From the outset, the GPs attempt to deal in ready made time units and they constantly try to make their work plan and time allocation smooth-running and predictable. At the same time, however, the GPs must constantly manage interruptions and reopenings in the form of problems and patients that define themselves as emergencies that are unable to wait. For that reason, ready made time plans may at any point revert into time plans in the making.

In conclusion, the dilemmas and entanglements around the issue of time-planning gives us a first glimpse into the multiple ways in which time is relationally defined in practice.

How much time does it take to get a urine sample?

In the following, we will move inside a consultation – a 15-minute consultation – to see what times come into play and how they are handled. The following example is an excerpt from field notes:

The patient is a man in the beginning of his thirties. He is somewhat pale and feverish. The GP asks what the problem is – on the screen, a note indicates something about blood in the urine. The note is correct – during urination that patient has noticed blood. The GP enquired into other symptoms, and the patient reported fever, pain during urination as well as more frequent urination. It has been going on for about a week. The GP then asks, very specifically, at which time during urination the blood appears. The GP states that he suspects that the patient might have a kidney stone.

For a normal, healthy man, urination takes 10–20 seconds. So the GP’s question is about where in this sequence the patient notices the blood. The patient answers, very precisely, that it is at the end. In fact, it is after the urine that drops of blood appear. This description of the sequence clarifies many things for the GP – he is now close to a diagnosis, or rather a partial diagnosis. The fact that the blood comes in the end indicates that the bleeding is in the bladder, in the back part of the bladder, and this may indicate a bladder stone. However, a bladder stone is only a partial diagnosis because the patient has a fever, which indicates that there is also an infection.

Since the patient is a relatively young man in the sexually active age, the GP ask about his sexual relations. The patient reports that ‘the last time’ was on a trip to Thailand – he did protect himself, he adds. This information shifts the focus of the consultation. It is now not merely about a bladder stone, but also about sexually transmitted diseases – in spite of protection and distance in time. The GP asks if the patient has been to other exotic destinations previously, such as Africa. He hasn’t. The illnesses that now enter the picture are, of course, sexually transmitted diseases, but also parasites. The GP asks the patient to submit a urine sample. He is sent to the toilet with a white plastic cup in his hand. While the patient is in the toilet, the GP plans the diagnosing process: he attempts to set up the most rational sequence with respect to different possible diagnoses and possible treatments.

The patient returns and sits down. Shortly after, the secretary arrives with the preliminary result from the urine sample. ‘There is everything’, she says. This means that the sample has contained blood, bacteria and white blood cells. The GP asks the secretary to save a bit of the urine for further examination.

The preliminary conclusion is that an infection in the urinary tract is indicated. Possibly, there is also a bladder stone. The patient is sent to a urologist and he and the GP agree that he should phone the following day. The patient goes to the secretary, who will draw a blood sample, which will reveal venereal diseases and/or parasites. In the afternoon, the blood sample will be sent to a central laboratory, and the result will arrive in about a week.

The consultation is over, for now. The diagnosis has been made, tentatively. The treatment has not begun, yet. And everything has been kept within the time span of 15 minutes.

What can we learn about time from the example above? What times emerge, and how are they handled? First of all, it is evident that we are dealing here with a hotchpotch of times: 15 minutes for the consultation, 15 seconds to urinate and 15 months since the patient had sex in Thailand. There are also several other important times: the time of the patient’s appointment with the urologist; the day it will take the GP to cultivate the urine sample; and the week that will pass before the blood sample results will return from the central laboratory. It appears that the handling of times as well as the launching of times is a crucial feature of the diagnosis, the treatment and ‘the craft’ of consultation.

Furthermore, it is evident that a variety of times emerge in the situation. Based on the note of ‘blood in the urine’ in the booking system, the GP could hardly predict that he and the patient would have to think 15 months into the past or one week into the future. Finally, it is interesting to note that the consultation creates novel links between different times. Drawing on Serres, one could say that the consultation folds times and make contacts between points that were previously distant (Serres and Latour, 1995). The consultation constructs a new form of contemporariness. The course of urination is linked to the examination of a blood sample, which is linked to a trip to Thailand, which again is linked with the booking system in the urologist’s office and so on. In sum, the example shows, quite simply, that a lot happens – and that many ‘times’ emerge – in the course of the 15 allotted minutes. The 15 minutes is a circumscribed unit, but this circumscription seems to stimulate rather than prevent the traffic of times in many directions. Drawing again on Serres, one could describe the consultation time as a semi-permeable pipe; it directs time to a certain extent, yet it also allows time to leak in various directions.

Conversation time and examination time

The following example is an excerpt from field notes:

A young woman has a problem with one of her knees. She takes a seat in the ‘patient chair’ next to the GP’s desk, and he asks her what is wrong. He has read on his screen that she has reported a problem with her knee, and now he wants her to tell him about it. She is a very active gymnast, but her knee hurts during rotations. The GP asks if she has experienced pain at other times. She says that she can feel the knee all the time, but the pain is most evident when she does gymnastics. At those times, she also feels a loss of control over the knee.

The GP wants to examine the knee. They go to the adjacent examination room. She takes off her pants [trousers] and lies down on the examination chair. The GP examines the knee while they talk about the shows and competitions, which she loves, but which she now fears that her knee will not allow her to take part in. The GP comments on the knee and the leg while he examines it. The woman has very muscular legs, which according to the GP, is extremely helpful, because her kneecap is loose. They discuss two different kinds of surgery while she gets dressed. The GP warns against surgery because it will influence the gymnastics a lot. Instead, he recommends that she trains her muscles and ligaments around the knees by means of a balance board. He also says that she must come back if it doesn’t help.

This consultation takes place in two different material set-ups and at two different paces. First, at the GP’s desk, the GP and patient are positioned face-to-face. This set-up arranges a conversational situation. The patient’s story and GP’s listening is in focus. Through this interaction, it becomes clear to the GP that he needs to examine the leg physically. This leads to the second material set-up, which is established in the adjacent examination room. Here, we find the examination chair on which the woman lies down after taking off her pants [trousers]. It is noteworthy that the conversation does not stop at this point. Rather, time is condensed by the performance of several things at once. The GP and the patient continue their conversation, although the GP now talks more than her. As he examines her, he explains what he does and what he concludes. As she puts her pants [trousers] back on, they discuss the pros and cons of surgery and the idea of using a balancing board. In this consultation, then, there is first a slower, conversational set-up, and later a set-up that allows a condensation of time through the partially overlapping activities of conversation, examination, conclusion and the making of further agreements.

This passage from conversation time to conversation-and-examination time is similar to the trails of activity through objectification and subjectification that Thompson describes. Precisely because the patient is first treated in a subject-like manner, it later becomes possible, and legitimate, to treat her as an object – while conversing with her. This case (like the previous one) therefore illustrates that the consultation is an occasion to link different times and processes. The objectification of the patient a few minutes into the consultation is possible because its ‘other’, the face-to-face conversational relation, has had its time, and has now been gently pushed into the background. In this way, there is a productive ontological choreography between conversational time and observation time.

Future times: Postponements, check-ups and planned courses

In the previous examples, we have analysed how different matters can be ordered, folded and handled before and during a consultation. In the following two examples, we will examine how a present situation can be linked with future times.

The following example is an excerpt from field notes:

Male – needs blood samples. Found sugar and cholesterol. The GP brings out the blood sample analyser and processes the samples. The man points to a small birthmark by his nose. He wants it removed. It is a small operation. The GP is able to do it himself, but it requires more time than they have right now. They make a new appointment.

An examination of a five-year old boy. A double-time (20 minutes) has been booked. The boy’s mother begins by saying that she has a long list. The GP begins with the physical examination. The boy is weighed, his height is measured and his motor function and coordination is examined. The GP looks at the boy’s feet, which are flat. Everything looks fine. While doing this, the GP talks with the mother, who begins on her list.

He wets his bed – the GP says that it will probably pass with age, and may be caused by an immature bladder.

He has a rather large birthmark – GP: must be removed later.

His foreskin is too tight – GP: needs to be treated with hormone lotion.

The boy’s language is rather ugly (swear words), and he has a very bad temper, which can be difficult to handle – GP: requires hard work and consistency in the upbringing.

This was the last annual examination at the family GP for this boy. He will soon go to school, where a school doctor will perform the health checks. Finally, the boy is vaccinated.

The two examples from the field notes indicate several dimensions of the handling of time. First of all, they demonstrate the entirely mundane and ubiquitous act of postponement. All sorts of matters that cannot be handled there and then are put off. There appears to be two forms of postponement. Certain matters are postponed to a specific time in the future where it will be handled (the birthmark will be removed at the next consultation). Other matters are put in a wait-and-see position (e.g. bedwetting). In both cases, the GP and the patients construct a relation between one event in their present situation and a (possible) future event. In John Law’s terms, one could say that the present is handled and constituted through its relation to that which is absent or ‘other’ (Law, 2002, 2004).

But the field note excerpts also indicate that the time of the consultation can be related to larger and more planned courses of events, similar to Thompson’s trails of activity. These trails may take the form of a ladder, such as the prescribed sequence of examinations of children at particular ages. A trail can also look like stepping down: people who phase out of their blood pressure medication visit the GP at regular intervals to have their blood pressure checked. Finally, a trail can be a recurrent activity: patients at risk of diabetes have their blood checked at regular intervals.

Speaking in more general terms, these examples demonstrate that the handling of time in a present consultation is constituted in a process that involves absent times. The consultation becomes doable because it can push surplus problems elsewhere, and because it can limit itself to a smaller contribution in a larger course of events. Absent times thus influence the consultation, and they are a part of what the consultation produces. The consultation is thus moving between situations where trails of activity can be established, and situations where the present matters overflow the available time and space, or where matters become troubled by their relations to that which is absent. When the mother of a five-year old boy brings a long list of problems that exceeds the GP’s capacity, and when she introduces problems related to ‘swear words’ that seem to relate to upbringing rather than medicine, then it is clear that matters must be postponed, rejected, re-categorized or put on hold if the consultation is to work at all.

Complexity and the risk of being overwhelmed are never far away. The GP quoted in the introduction of this article, who worked in a small town in the 1960s, could also speak for his present-day colleagues when he states that: ‘An outsider could hardly imagine just how difficult it is to demand that telephone hours are respected, to make consultations run relatively smoothly, and to insist on not working when you are off – without insulting the patients’ (Bjerre, 1999: 17). In this article, we have explored some of the materialized practices through which present-day GPs manage these challenges. We have described how GPs attempt to manage their booking systems in order to turn a daily influx of patient calls into an ordered allocation of time slots. ‘Inside’ the consultation, we have examined the handling and folding of multiple times, and the establishment of trails between conversation time and examination time. Finally, we have explored how links to future times, in the form of postponements, rejections and the establishment of trails and sequences, help to make the present consultation possible.

Conclusion

The field of STS offers a series of ideas or analytical resources, some of which we have attempted to deploy in this study of time. First of all, we have followed STS in its completely relational definition of things: the nature of time is not given in the order of things, it is an effect of specific material and semiotic networks, which may render time in many (more or less ready made) forms. For this reason, we have attended closely to events and practices in the consultation room, and to a variety of mundane materialities, such as booking systems, examination tables and handwritten notes.

Second, we have based our analysis on Serres’s idea that every situation, event or object can be described as a composition of multiple times. Third, and finally, we have drawn on the idea that the relational definition of time may include important relations to that which is absent or ‘other’.

The package of ideas from STS leads us, we believe, to a distinct analytical style. It is clear from the outset that we make no attempt to directly define what time is. The relational definition of time in effect brackets the question of an ostensive definition or, perhaps more precisely, it shifts the analytical interest to the networks of relations that involve and perform time-related activities. As a consequence, time in our analysis is not depicted as a noun or a particular thing; rather, it is a process, an activity or a verb. It could be said that our analysis is about timing, rather than time per se. We would suggest that this analytical strategy – treating the analytical object as a verb – is similar to the one deployed by other process-oriented ethnographers and sociologists. One classical example might be Arjun Appadurai’s essay on the social life of things (Appadurai, 1986). In his analysis, he describes how ‘the same’ object (an heirloom) can achieve completely different functions over time. The object may follow a trajectory leading from a personal belonging, to a gift, to a commodity, and all the way back.

What image of time, then, emerges from this deployment of ideas from STS and this verb-like conception of time? Our most general assertion is that time is an important and complex resource for the doctors. Time is not merely an external yardstick with given units; time flows and folds into medical practice in a variety of ways, and the doctor’s handling of time becomes an opportunity to influence other important issues. In the first part of the analysis, we noted that time is entangled with income, stress, availability and the division of labour among colleagues. Because of these intricate relations, even a relatively modest difference in the structures and routines of time-booking – such as the difference between 10- and 15-minute consultations – will have a relatively large impact on the entire functioning of the practice. Intuitively, one might think that more time (‘better time’) is an unequivocal good that one should always strive for. But when the entanglements of time are taken into consideration, it becomes clear that the handling of time is rife with dilemmas. A shorter consultation time generates more income for the doctor, but also more stress. Shorter consultations make it more difficult to manage everything within each consultation, but it also increases the patients’ chance of getting to their doctor quickly.

When focusing on individual consultations, more aspects were added to the description of consultation time. Each consultation, in our view, works as a form of folding machine (cf. Serres and Latour, 1995): it connects points that were previously distant in time and space. This linking of times takes place with varying degrees of predictability. Some consultations follow a relatively steady path: time flows from conversation time supported by one particular material set-up to conversation-and-examination time supported by a different material set-up. Other consultations are far more unpredictable. A host of different, potentially relevant times find their ways into the consultation through the interaction between doctor and patient, handwritten lists of complaints, test results, examinations and so on.

In the final part of the analysis, we have traced some of the ongoing work of making and maintaining relations between a present consultation and other consultations. We have suggested that some consultations become manageable only by pushing matters elsewhere. Problems are relayed to later consultations, it is decided to ‘wait and see’, or issues are simply deemed irrelevant. In addition, consultations sometimes seem to work by means of their embedding in a series of other consultations. This is the case with routine controls and child examinations at certain ages. In sum, the processes we have indicated here suggest that the handling of time is, thus, not merely a process of folding distant times into a particular consultation; it is also a process of making and unfolding timely relations to other consultations.

In this article, we have attempted to develop our sensitivity to the flows, the multiplicity and the folding of times in consultations. By attending to these situated materializations of time, we hope to have suggested a wider discussion on ‘the skilful use of time’. The analyses of consultation practices indicate that time, practice and materiality are thoroughly intertwined, and that competent practitioners must handle the entire spectrum of times – at the same time.

In public and private debates on medical practice, doctors and patients often argue, with more than a little exasperation, that there is not enough time. We agree, there never is, and precisely for this reason, we need to enhance our understanding of the complexities of time and timing. Ideas from STS – we hope to have demonstrated – might contribute towards this end.