Temporal dynamics in the daily lives of health practitioners

Abstract

The working days of health practitioners are long and often hectic. This paper examines the minutiae of how health practitioners, particularly physicians and nurses, organize their time throughout the day. Through in-depth interviews of attending physicians, medical residents, and nursing staff at a major urban teaching hospital in California, I explore the daily dynamics of temporality within the lives of health practitioners, from the point of view of health practitioners, and consider the structures of power that are evident, and I do this through the lens of time and temporality. My studies have found that, whereas individuals may be able to control the time of other individuals who are lower on the hierarchy than themselves, institutional obligations and ritualized cultural practices that colonize individual time, and indeed, normalize certain temporal rhythms and expectations often trump these individual dynamics. While the specific site of this study was focused on the health care field, the broader themes of how social and organizational power manifests through the negotiation of time are relevant to many other sites of inquiry, particularly within monochronic societies which perceive time as a commodity.

Keywords

Health Care practitioners critical/cultural social power temporal organization qualitative

The alarm clock goes off at 6:00 am, and Martha, a second-year ophthalmology resident at University Medical Center,¹ 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. 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 4:00 pm every day, it is now 6:30 pm, 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 8:30 pm, 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 the fast food she picked up. She falls into bed and immediately dozes off around 10 pm, wanting to get as much sleep as possible before possibly being woken up by her pager, which she keeps on her nightstand right next to her bed. She receives a call at 3:00 am 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.

The working days of health practitioners—physicians and nurses in particular—are long and often hectic. This research project examines the minutiae of how health practitioners organize their time throughout the day, drawing from my previous work (Wang, 2013) around temporal capital, which is a framework by which to think about time as an exchangeable commodity, and how the ability to exchange time for other forms of capital (economic, social, cultural) depends on one’s position within the relevant social stratum. Through in-depth interviews of attending physicians, medical residents, and nursing staff at a major teaching hospital in Southern California (which will be referred to as “University Medical Center”), I explore the daily dynamics of temporality within the lives of health practitioners, from the point of view of health practitioners, and consider the evident structures of power through the lens of time and temporality. This research shows that whereas individuals may be able to control the time of other individuals who are lower on the hierarchy than themselves, the institutional co-option of individual time often trumps these individual dynamics. This paper is situated in broader conversations which explore 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.

While health professionals are popularly perceived as infallible, authoritative figures, they face many challenges, both work related and personal. Physicians and medical students have high depression suicide completion rates—1.4–2.3 times that of the general population (Andrew, 2014), while the nursing field recognizes a need for better work–life balance, given the long shifts and the emotional exhaustion of the job. For example, Susan Simmons (2012) wrote about this in American Journal of Nursing, a study of over 95,000 nurses by McHugh et al. (2011) found that nurses who care directly for patients have high rates of dissatisfaction, which can lead to risks for patients, and the Royal College of Nursing has an entire booklet on the subject (Spinning plates, 2008). Health practitioners 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 pressure to see more patients under the Affordable Care Act. While there are some studies that explore how medical students choose their specialties based on the potential for a life outside of work (Patel et al., 2010), few studies focus on affective experiences and challenges health practitioners face. Studies tend to focus either on patient experience, or on how changes in system procedures and processes might improve efficiency, like Eugene Litvak and Maureen Bisognano’s work (2011) which proposes that, rather than increasing resources and staff, hospitals think of ways to increase “throughput,” or the number of patients served given a fixed amount of time. Their suggestion is to increase bed occupancy to as close to bed capacity as possible. Studies like these presume an objective rationality of practitioners, without understanding the potential, often temporal, limitations. This is not unrelated to patient care. On the contrary, the well-being of health professionals ultimately has an impact on the quality of patient care. As time is an “omniscient dimension of the world” (Zerubavel, 1979), the implications of temporal structures and patterns both of the health system and of the lives of the individual actors within it are crucial to consider.

This work is framed in theories of how time is perceived, valued, and used, including how control of time is used as an indication of social power (Harvey, 1989). The categorization of time into work, leisure, and free/discretionary time is used by many scholars to understand the social aspect of temporality (Robinson and Godbey, 1997; Rybczynski, 1991; Stebbins, 2012; Veblen, 1899). These discourses separate time into predetermined boxes depending on the activity conducted (or not) during a given increment of the day. Power dynamics are also implicated within these categories of time, especially with respect to the relationship between time and labor (Marx, 1887) in which at times, the biological rhythms of workers are colonized by the clock (Linder and Nygaard, 1998). While autonomous time is perceived as a measure of freedom (Goodin et al., 2008), work itself, while often positioned within an organizational hierarchy and prone to alienating a worker from his or her labor (Marx, 1959), does not have to be undesirable or devoid of meaning, depending on if an individual is drawn to labor or leisure activities (Claassen, 2012). The proliferation of communication technologies has complicated the traditional notions of social relations within temporal categorization, with the blurring of work and nonwork time in an increasingly accelerating world (Castells, 1996; Eriksen, 2001; Hassan and Purser, 2007; Mitchell, 1996, 1999; Wajcman, 2015), opening space up for different social relationships and interactions to take place. Finally, I have done work on the idea of temporal capital, which is defined as the amount of time individuals or groups have under their control, but is necessarily differentiated given one’s position within the relevant hierarchy (Wang, 2013).

Often, the position of the practitioner and their placement in the hierarchy of training or institutional structure is often 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 ritualized 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 (i.e. to administer medication every 6 hours), and this temporal rigidity, and therefore decreased temporal autonomy, is imposed upon by the physician who ordered the medications. Similarly, rounding schedules are often set by the attending, who dictates what time rounding will start each morning.

In this paper, I examine the temporal power tensions that exist throughout the day between different groups of practitioners and how these individual interactions are negotiated with institutional demands and ritualized cultural norms. In particular, I look at the differences between attendings and residents within the same department, between physicians and nurses, and between practitioners in different department who consult with each other on patient cases. I 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. Finally, I explore the breakdowns in procedures during attempts to be efficient.

In a single day, 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 and duties performed for a certain patient, such as nurse intake of patient, medication and test ordering, and documenting and closing a patient file, 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 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 outpatients (patients who goes home the same day), the patient encounter temporally fragments throughout the day. For inpatients (patients who stay in the hospital for more than one day), this fragmentation of the patient-encounter timeline can take place over the course of multiple days.

Finally, the practitioner’s timeline also interacts with other practitioners’ timelines. For example, the relationship between attendings and residents, residents must interact and wait for attendings during some parts of their day, especially when it comes to staffing patients. The attendings’ times, though, are also tugged on by yet other factors—by other practitioners or other patient encounters. These interweaving, overlapping timelines make for a complex system of temporal dynamics that impact the temporal capital of the practitioner at any given moment of the day.

Methods

In order to interrogate these issues and delve into the affective aspects of how health professionals perceive their temporal autonomy, a qualitative, critical approach was taken. The data that I used were taken from a larger project, so for purposes of space and brevity, I will discuss the methods used to collect and analyze the data relevant to this paper’s conceptual focus. Thirty-five health professionals from a major teaching hospital in California (which will be referred to as “University Medical Center” throughout) were interviewed between Fall 2014 and Spring 2016. These health care professionals were recruited primarily from my personal networks. I would then get referrals from participants for colleagues of theirs who would be willing to speak with me. The vast majority of interviews took place in public locations, such as cafes or restaurants. A handful (2–3) took place in the homes of the participants, and one (the nursing director) took place in the participant’s office. Out of the 26 physicians, 10 of them were attendings, three were fellows, 12 were residents, and one was a medical student. Physicians interviewed also included 18 women and eight men. At the time of the interview, all of the attendings were in their 30s and early 40s. Most of the residents interviewed were in their late 20s and early 30s, except for one (male) resident, who was in his 40s. Interviews, which were semistructured in-depth conversations with open-ended questions done with participant consent, were recorded, then transcribed by the author. The interviews ran between 45 minutes and 2 hours, depending on the individual. Some participants were interviewed more than once on different dates. Participant names are anonymized throughout this paper to ensure confidentiality. This project received IRB exemption.

During the interview, participants were to describe what they did throughout the day and how their day was organized, starting from the time they arrived at the hospital, their tasks throughout the day, their breaks (if they had any), and what sorts of organizational responsibilities and duties were expected of them from the health care institution, their colleagues, and their patients. Because of the open nature of the interview, probing questions were asked as appropriate to excavate more complex and nuanced dynamics of the temporal organization of the interviewed health practitioners.

The analysis of the interview data is based on critical cultural perspectives, which are deeply rooted in examining and deconstructing power dynamics within social relations and cultural practices. I used a critical rhetoric approach (McKerrow, 1989) to consider how the discourse both contained in the interview as well as the actions taken as related in the interviews function within a framework of power, ideologies, and institutional norms. The interview data were organized into major themes, which include activities that are done (staffing/rounding/documentation) and with whom the informant interacts (patients, superiors/subordinates, other health practitioners). These themes were organized into conceptual frameworks around power and temporality, with consideration as to from where the power is imposed—either from individuals, or from institutional practices and norms—as well as how much temporal autonomy a practitioner feels like they have in certain contexts, in order to tie empirical information to theory. I have selected quotes from the participants which best exemplified the themes that emerged from the data.

Attendings versus fellows versus 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. 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. They know their position and have interpellated themselves as subjects (Althusser, 1971) into the organizational power hierarchy of the medical field. The differences in responsibility and investment of time are not only cultural, but institutionalized, as will be demonstrated. Furthermore, there are many hierarchal nuances within these three groups as well. Residents are split up by cohort, 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. While residents are often the ones that directly interact with patients,² they must “staff” patients with attendings, ensuring that an attending reviews the proposed management of care for the patient. 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 nonsurgical both inpatient and outpatient services is as follows:

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

Prescribing medications

Answering questions

Schedule next patient visit or follow-up (for an outpatient clinic)

5. Postencounter tasks

Write note, document

Enter orders

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 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].” 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, 18 September 2014).

Part of the reason why predetermined additional minutes are 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, when a resident needs to staff a patient, they end 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, 18 September 2014)

There are a few interesting things happening here with 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 are not temporally located within the day (i.e. he does not have to write the note at 3:20 pm, he just needs to write the note before he leaves the hospital in the evening). Hence, he enjoys a modicum of temporal autonomy in the writing of the note during this waiting period, so that the waiting time becomes productive time for nontemporally 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, 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 time in an attempt to follow the preordained 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 second-year emergency department (ED) resident, also points at the rupturing of the “rules” of staffing:

There’s a patient I see, like, this kid’s getting admitted, it’s like, a peds congenital something kid, it’s like, the pediatric hospital is already seen the patient before, I’ll staff it often. I’ll put in the admit before I staff it. I’ll be like, hey, FYI, I have a kid with XYZ who’s getting admitted to the PICU, and the attending’s like, ok. And like, whereas if there’s a patient, cuz like, it’s actually easier sometimes to, with sicker patients because you know they’re gonna be admitted, so you’re not in as much of a rush to get the approval, get them moving, get them out, and usually sicker patients have, you don’t have, you can be more liberal with ordering tests and, it’s generally are able, at least by this point in the year, you’re like, ok, I feel comfortable initiating the workup and treatment by myself for like, a pretty significant period. (“Donna,” personal interview, 1 October 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 acquired as one gains more experience allows for the flexibility to do things out of 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, 22 September 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 particularly stressful brand of the Socratic method, asks pop-quiz-like questions in relation to the patient’s condition to test the resident’s understanding of medicine, such as specific diseases, conditions, treatments, or medications. 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 staffing needs and the temporal limitations on the staffing process also differ according to how advanced in training a resident is and the type of patient 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, 22 September 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 the seniority of the resident. 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 seemingly contradictory things—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 hierarchal system. (“Amy,” personal interview, 22 September 2014)

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 was 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 may be staffing another yet patient.

The changing landscape of health care, especially from an institutional level, greatly affects the temporal organization of attending physicians. According to Danny, a hospital administrator, physicians are now required to see more and more patients as compared with two or three decades ago (“Danny,” personal interview, 17 November 2014). One of my participants, Sarah Jane, mentions that the number of patients seen in the clinic and the number of operations performed determine the compensation of the physician, even in a teaching institution (“Sarah Jane,” personal interview, 17 February 2015). 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, such as seeing more patients, respecting a patient’s time by speeding up patient encounters, teaching, researching, and managing and teaching residents. These obligations, both legal and cultural, cut 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.

Rounding

Rounding happens every morning on inpatient units, during which physicians in a patient’s 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, which is a shift from traditional practices, where nurses round with physicians (“Alaya,” personal interview, 27 October 2014).

The schedule of rounding is usually up to the individual in power. Zerubavel (1979: 51), 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.” Indeed, in rounding, this pattern is seen 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.

Outsourcing work

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 chain, the more they are able to delegate tasks to subordinates. As we saw before, the temporal requirements for staffing change as one moves up the ladder, with those higher up on the hierarchy wielding more temporal flexibility. Residents who have more years of experience are able to staff patients within a wider temporal range than new residents. Attendings often 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.

This pattern of temporal flexibility as correlated with position in hierarchy is evident in the call schedules and call etiquette of ophthalmology residents. The following procedures were taken from my interviews with the 15 participants in the ophthalmology department. 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 backup call. If the first year, for whatever reason, needs assistance, advice, or support, they call the second-year backup, 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 nonwork 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 resident is needed, the second-year resident can tell the first-year resident over the phone to prep the patient while he or she drives over to the hospital. After examining the patient, the first-year resident 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 resident spends less time overall in the work sphere during nonwork hours by outsourcing the patient care duties that either first or second year can perform onto the first year.

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 University Medical Center checks patients, while the nurses ask intake 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 one of the University Medical Center ophthalmology outpatient clinics, 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 preassigned to physicians and nurses. The clinic staff will look in the electronic medical record (EMR) system and see which patient has been waiting the longest. They will then take that patient next. The specific patient, nurse, or doctor does not matter (“Vera,” personal interview, 18 February 2015).

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 years 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 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.

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, 12 October 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 the 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 without hand-holding from a superior. In case of an emergency, however, Rose can easily step back into the OR and take over as needed, thanks to the off-site monitoring capabilities of the EMR system.

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. Signing off 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 stereotype of the stoic, coldly rational physician.

A different dynamic happens in the ED. According to Donna, the second-year ED resident, every physician who is a third-year resident or higher working in the ED is assigned a scribe—an additional person who follows the physician around and documents for the physician in the EMR system (“Donna,” personal interview, 1 October 2014). 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 without pausing to document. This also is 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 ED (Morganti et al., 2013). While a scribe in the particular case of the ED seems necessary, the differentiation of who gets a scribe and who does not implies differing values of time for those positioned differently on this hierarchy. The time 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, where patients that stay in the hospital for extended periods of time, 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, the director for a medical/surgical unit, 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, 27 October 2014)

Doctors give orders through the use of communication technology, thus working in a different temporal sphere as the nurse, using the EMR system as the mediator to bridge the two spheres.

The power relationship between doctors and nurses is apparent in the temporal dynamics between the two, as Clara, a geriatrics nurse, illustrates:

And that is true too with like the time constraints, cuz, yea, like, the way you said, 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. (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, 20 October 2014).

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, as mentioned earlier, the physician themself may not actually have that much temporal flexibility. Physicians rarely see patients at their leisure—they see them under pressure, because of the increasing number of patients they must see to maintain in good standing at University Medical Center.

The relationship between doctors and nurses in an outpatient setting, where patients show up for a couple hours for an appointment, can be a bit different. In this section, an ophthalmology outpatient clinic is used as an example to examine the temporal dynamics of nurses and doctors in an outpatient clinic (“Vera,” personal interview, 18 February 2015). Outpatient clinics generally have a set daytime schedule. In this case, the ophthalmology clinic is set to open at 8 am every day and close at 4:30 pm. Vera is a licensed vocational nurse (LVN) 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 RNs and the four LVNs to duties throughout the day. Vera arrives at the clinic before it opens. There are 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, physicians 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, according to Vera, 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.

Relationship between physicians and patients

The question of who has the temporal power between physicians and patients is one that is complex and complicated. This section explores the difference in this relationship between clinics and inpatient services, which are two common situations during which patient and physician paths cross.

Clinics

When a patient goes to a medical clinic to see a doctor, they often find themself waiting past their appointment time before any actual interaction 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 to determine the extent to which a patient can see. The patient then waits for the doctor’s examination. 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. Patients are often overbooked in the system, and unexpected walk-ins further delay seeing patients. Physicians themselves feel they have very little control over their time and little control over when to see patients. While Danny, a hospital administrator, 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, 17 November 2014), the reality 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. 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.

Inpatients

My brother was recently admitted to a hospital in New York in 2014 for a surgical procedure. His hospital stay was mostly characterized by waiting. His cardiothoracic surgeon, like most of his colleagues, would run up to the unit to see patients between surgery cases, often resulting in family members and patients waiting to talk to physicians. There is the sense of not wanting to leave the bedside, since the physician might be there any minute. Doctors usually do not stay long by the bedside—usually a minute or two, 5 minutes at the very most. “Catch ’em now! Or they’re gone,” as the nurse Clara put it earlier. In an effort to not miss talking to the surgeon, I felt compelled to stay at my brother’s bedside, which drastically decreased my temporal autonomy. Physicians, then, implicitly control the time of not only the patients and the nurses who wish to participate in that conversation, but also that of family members. Family members hence exist and function within the confines of the physician’s temporal patterns, flexibilities, and limitations of the day.

During my brother’s stay, 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 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. However, no one knew when the surgery case would finish, as surgical procedures are rife with temporal uncertainty. Because of this, I was wary of leaving his bedside to even pop out to get a snack and waited several hours until the surgeon was available. My time 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. 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 times. 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. The physician itself, while many people wait on him or her, often is tugged in multiple directions by other forces beyond his or her control that demand time.

Donna and others talk about trying to respect patient’s time as well, which becomes tied to the temporal patterns of staffing, as discussed earlier.

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, 1 October 2014)

There are two things that are happening. The urgency to staff, on the one hand, points to trying to respect the patient’s time. On the other hand, discharging the patient will “keep things moving,” relenting to the pressures of the institution, and pressure of the normative hectic rhythm of the ED to keep beds free to be able to see more patients.

There is a misunderstanding of perspectives both from the patient and the physician’s side, mostly with patients not understanding physicians 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, 18 September 2014)

Here, Mickey is trying to see the patient’s perspective, and understands it, while trying to negotiate his own stressors from the day, a balancing act many physicians mentioned. Ultimately, Mickey demonstrates that, while it may seem from the patient’s perspective that physicians wield more temporal autonomy, which he acknowledges is a popular perspective, patients often inadvertently co-opt a physician’s time, decreasing that physician’s temporal capital, and delaying the rest of that physician’s day.

Flexibility of time at work

Flexibility of time on the unit often depends on the position of the practitioner. 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, 1 October 2014)

The lack of temporal capital often manifests as an inability to take care of oneself, and one’s bodily needs call to mind Foucault and Sheridan’s work (1975) on biopower and the institutional imposition in disciplining bodies, which is evident at times in the daily routines of physicians, especially when it comes to intaking and excreting, or to put it more crassly, eating/drinking and urinating/defecating. Marc Linder and Ingrid Nygaard (1998) discuss in detail the Taylor-esque ways in which factory workers’ bodily functions are tightly controlled by the clock. The time they have to void is both temporally located (i.e. they may use the restroom at a certain time during their shift) and temporally restricted (i.e. 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, 20 September 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 (2008) 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. As Toshiko (personal interview, 20 September 2018) states,

You just don’t remember. It’s like you forget to drink water. I think everyone is permanently dehydrated because you just, you bring, like I used to bring in like, um, you know water bottles, but it just sits there. You just forget to drink it. After a while you don’t feel thirsty, like, 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].

While the temporal inflexibilities of residents may sound dire, this does not mean the labor they perform is necessarily alienating. Many practitioners, both nurse and doctors, gesture at greater meaning behind their time expenditure and use different methods to take charge of their time. 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’ days can be 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, with which they identify. This process of identification has implications around temporal capital, in that increased temporal capital indicates one’s agency to control one’s time in a way that is meaningful and self-actualizing. While understanding the long-term implications of meaning and temporal autonomy is outside the scope of this particular project, it is a good springboard for future research.

Conclusion

The daily temporal dynamics of health practitioners are varied and complex. In this paper, I illustrated only a segment of the various complexities and factors that affect the daily organization of a health practitioner’s time. There is much future work that can be done in this area, such as examining the long-term temporal investment that health professionals put into their education and training, and explore questions around the meaning of and identification with their work, especially given the temporal investment both in years, and in the temporal inflexibilities of their day-to-day lives. There are also questions around work–life balance to be explored. Finally, in the larger scope of this project, I interrogated the ways in which communication technologies—particularly the EMR system and personal mobile devices—impact the organization of time for health professionals both at and away from work. While this section concentrates on the daily schedules of doctors and nurses at work, questions of how work time and nonwork time intertwine, and the subsequent negotiation of social relationships and power in which these individuals engage, have great implications on temporal capital, and ultimately the quality of life for health care practitioners.

There are several limitations to this research, as the scope of the project had to be somewhat feasible. My interview participants were all from the same teaching hospital. Therefore, generalizability of these findings is limited. While we can extrapolate roughly how organizational power dynamics in US health care organizations interrelate to temporal dynamics given the national training hierarchy (resident < fellow < attending) set out by the American Council for Graduate Medical Education, it is difficult to relate the findings here to international or transnational understandings of temporal capital in health care. As the scope of this project is limited, future studies could also extend this project into international health care organizations and health care institutions in other countries. This particular project is limited in scope to the US, given the training and organizational hierarchy that is used specifically in the US.

Additionally, each department within the hospital functions differently. This project looked at practitioners from a variety of different departments, and it would be helpful to do a study that more deliberately takes into account the practitioner’s department and compares, for example, internal medicine with surgical specialties or other categorizations. What are the variations in temporal negotiation between different departments and specialties? Are there departments or specialties that have a process in place that other departments may learn from? Similarly, there is much potential to conduct applied research to this field as well, implementing experimental policies and procedures to target some of the challenges addressed in this paper to see if certain practices may ameliorate the co-optation practitioner’s temporal capital.

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 of stress from the implementation of the Affordable Care Act, and the looming shortage of nurses (Rosseter, 2014) and primary care physicians (Petterson et al., 2012), there is a push to make health care more efficient. Equally as important, within the last couple years, there has been increased interest and concern around the mental well-being of health professionals, with individuals like Pamela Wible (2018) working to bring this issue to light. While this paper does not necessarily provide many operationalized solutions moving forward (which is ostensibly outside of the scope of this project), understanding individualized temporal factors within the reality of practicing medicine potentially may lead to solutions to ameliorate the intense stress and temporal strain that many practitioners feel. Similarly, understanding the institutional and systemic factors that impose a temporal rhythm on the bodies of individual practitioners can potentially lead to reform in health care procedures, policies, and legislation on a broader level, which in turn may result in more efficient and higher quality patient care.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

References

Althusser

(1971) Ideology and ideological state apparatuses (notes towards an investigation). In: Lenin and Philosophy and Other Essays. New York: Monthly Review Press, pp.142–147, 166–176.

Andrew

(2014) Physician suicide. Available at: http://emedicine.medscape.com/article/806779-overview (accessed 15 January 2015).

Castells

(1996) The Rise of the Network Society: The Information Age: Economy, Society, and Culture. Vol.1. Oxford: Wiley-Blackwell.

Claassen

(2012) Temporal autonomy in a laboring society. Inquiry 55(5): 543–562.

Csikszentmihalyi

(2008) Flow: The Psychology of Optimal Experience. New York, NY: HarperCollins e-books.

De Grazia

(1962) Of Time, Work and Leisure. New York: Vintage Books.

Eriksen

(2001) Tyranny of the Moment: Fast and Slow Time in the Information Age. London: Pluto Press.

Foucault

and

Sheridan

(trans) (1975) Discipline and Punish: The Birth of the Prison. New York: Vintage Books.

Goodin

Rice

Parpo

, et al. (2008) Discretionary Time: A New Measure of Freedom. Cambridge: Cambridge University Press.

10.

Harvey

(1989) The Condition of Postmodernity: An Enquiry into the Origins of Cultural Change. Cambridge, MA: Blackwell.

11.

Hassan

Purser

(eds) (2007) 24/7: Time and Temporality in the Network Society. Stanford, CA: Stanford University Press.

12.

Linder

Nygaard

(1998) Void Where Prohibited: Rest Breaks and the Right to Urinate on Company Time. Ithaca, NY: Cornell University Press.

13.

Litvak

Bisognano

(2011) More patients, less payment: Increasing hospital efficiency in the aftermath of health reform. Health Affairs 30(1): 76–80.

14.

McHugh

Kutney-Lee

Cimiotti

, et al. (2011) Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs (Project Hope) 30(2): 202–210.

15.

McKerrow

(1989) Mckerrow_Critical_Rhetoric.pdf. Communication Monographs 56: 91–111.

16.

Marx

(1887) Das Kapital. Moscow: Progress Publishers.

17.

Marx

(1959) Economic & Philosophic Manuscripts of 1844. Moscow: Progress Publishers.

18.

Mitchell

(1996) City of Bits: Space, Place, and the Infobahn. Cambridge: The MIT Press.

19.

Mitchell

(1999) E-topia: “Urban Life, Jim – But Not as We Know It.” Cambridge: The MIT Press.

20.

Morganti

Bauhoff

Blanchard

, et al. (2013) The Evolving Role of Emergency Departments in the United States. Santa Monica, CA: RAND Health.

21.

Patel

Katz

Volpp

(2010) Match rates into higher-income, controllable lifestyle specialties for students from highly ranked, research-based medical schools compared with other applicants. Journal of Graduate Medical Education 2(3): 360–365.

22.

Petterson

Liaw

Phillips

, et al. (2012) Projecting US primary care physician workforce needs: 2010–2025. Annals of Family Medicine 10(6): 503–509.

23.

Robinson

Godbey

(1997) Time for Life: The Surprising Ways Americans Use Their Time. 2nd ed. University Park: The Pennsylvania State University Press.

24.

Rosseter

(2014) Nursing shortage fact sheet. Available at: http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage (accessed 15 January 2015).

25.

Rybczynski

(1991) Waiting for the Weekend. New York: Viking Penguin.

26.

Simmons

(2012) Striving for work-life balance. American Journal of Nursing 112(1): 25–26.

27.

Spinning plates: Establishing a work-life balance (2008). London: Royal College of Nursing.

28.

Stebbins

(2012) The Idea of Leisure: First Principles. New Brunswick, NJ: Transaction Publishers.

29.

Veblen

(1899) The Theory of the Leisure Class. Oxford: Oxford University Press.

30.

Wang C (2013) A slice of time: An exploration of temporal capital and its relationships to economics, culture, and society in a technological and digital age. Gnovis: Georgetown University’s Journal of Communication, Culture & Technology 13(2). Available at: http://gnovisjournal.org/2013/04/26/a-slice-of-time-an-exploration-of-temporal-capital-and-its-relationships-to-economics-culture-and-society-in-a-technological-and-digital-age/#fnref-6941-20 (accessed 13 July 2018.

31.

Wajcman

(2015) Pressed for Time: The Acceleration of Life in Digital Capitalism. Chicago, IL: University of Chicago Press.

32.

Wible

(2018) What I’ve learned from 757 doctor suicides. The Washington Post, 13 January. Available at: https://www.washingtonpost.com/national/health-science/what-ive-learned-from-my-tally-of-757-doctor-suicides/2018/01/12/b0ea9126-eb50-11e7-9f92-10a2203f6c8d_story.html?utm_term=.50b38775b303 (accessed 13 January 2018).

33.

Zerubavel

(1979) Patterns of Time in Hospital Life. Chicago, IL: University of Chicago Press.