 All right, we're going to go ahead and get started so that our speaker, Dr. Callender, has plenty of time. It's a pleasure to introduce Dr. Brian Callender. I think most people know him, but for those who don't, Dr. Callender is an adult hospitalist in the section of hospital medicine and an associate professor of medicine. He is a graduate of Pritzker School of Medicine, went on to do internal medicine residency here at the University of Chicago, and also completed a fellowship in clinical medical ethics at the McLean Center. Dr. Callender is an academic hospitalist. He's interested in how health humanities can improve the patient experience, patient provider relationships, and our understanding of the illness experience and the practice of medicine. As a result of these interests, he has developed a number of really fascinating courses about the phenomenology of illness and the visual culture of medicine, including, and I won't read them all, but really fascinating, the body in medicine and the performing arts, narratives and aesthetics of contagion, knowledge formation, the COVID-19 pandemic, graphic medicine, comics creation as knowledge formation, the art of healing, medical aesthetics in Russia and the US, and death panels exploring death and dying through comics. So really amazing body of work. Brian is also the medical director for the Advanced Practice Service Short Stay Unit and a senior medical director for inpatient clinical operations. So pleasure for me to welcome Dr. Callender. All right. Thanks everyone for being here. Let me just... Can everybody hear me okay? I know the acoustics in here can sometimes be challenging. So at any point, they become difficult just let me know and do some sort of signal or gesture. So for those of you collecting CME credit, there it is. What's going on? Okay. Yeah, so the title of my talk is called Tick Tock Goes to the Hospital Clock, Temporal Considerations of Clinical Ethics. There are no actual tick tocks in here. My wife said, oh, you got to insert a tick tock. That will be funny. And so there are no actual tick tocks from that sort of social media platform. So I do not have any financial disclosures to declare. I'm not even wearing a watch that I could sort of reference while here. But I want to get... As Peter mentioned a little bit of my personal background that really informs where I'm coming from in terms of this talk. I'm an adult hospitalist and so a lot of this sort of pertains to the hospital setting, like the acute care setting. But there's a... I'm less familiar with the outpatient, the emergency department and OR settings, many of which have their own sort of temporal considerations that could certainly inform this talk and later discussion or even the sort of the clinical areas that you all work in. I am a medical director for the short stay service, which just has time built into its title in terms of expected length of stay. Also a senior medical director for inpatient services in which I work closely with colleagues in care coordination to help with throughput for complex cases, including one we sort of talked about in case conference a couple of weeks ago. And so that really sort of informs thoughts from an institutional perspective about how we utilize time. Also an ethicist and then I consider myself a humanist who really sort of attends to the phenomenological dimensions of illness and patient care when I provide clinical care. And so all of this sort of informs how I think about time within the hospital and clinical care. Now there are particular challenges with time. And this is sort of a newer topic for me that I'm really diving into. But there's this pervasiveness of time that sort of renders it both obvious, but also oblivious. And so these various aspects of time, we have this sort of reflexivity that we're constantly adjusting to it. So it almost sort of occurs in the background, such that we tend to neglect many of the temporal aspects of our daily lives just because it is so pervasive. And it also sort of affords us to make assumptions about time and temporality, right? Like how we may experience time as an individual, we may project that or make assumptions about how others use time or perceive time. There's also, especially within medicine, an important role for the sort of socialization and professionalism that relates to time and sort of the temporal structures of the institutions that we work for, right? Whether that's inpatient, whether that's outpatient. But there's sort of work, we're kind of socialized to these various aspects of time within the hospital setting. The thing about sort of putting together a lecture like this that focuses on time, in part because of this pervasiveness, is that everything seems to become about time. I'm putting this together, like how many slides am I going to go over time, am I going to go under time, like how much time should I spend? Like everything really became about time. But then I started thinking, but is it truly about time, or is it something else? And that becomes important when thinking about sort of the ethical implications of how we perceive and view time. And a lot of this actually ended up raising more questions that are kind of challenging for me to answer. So a lot of the questions that I pose in this talk, I really don't have clear answers and it'd be great to hear from the audience, especially those that sort of work in different areas in healthcare, how they view this topic. So the objectives for today's talk is one to just sort of learn some of the basic concepts of time and temporality as they relate to illness and clinical practice. The second point is that you understand differences in the perception of time within clinical interactions and settings. And then lastly, that you appreciate how conflicting perceptions of time lead to ethical dilemmas. But I want to sort of start with a case study, and this is actually a case study from Dr. Angelos's talk a couple weeks ago, right? Just to recall that case, it was the case of a 22-year-old male who was involved in a high-speed motor vehicle collision. And he suffered a devastating traumatic brain injury and was on a ventilator. The parents were the surrogate decision-makers and testing had confirmed death by neurologic criteria. Like that wasn't even in question. And so the clinical team wanted to discontinue the ventilator. The parents, however, did not want withdrawal of the ventilator, right? And this is something we see on a regular basis here in this hospital as well, right? And so the trauma service, the way they approached it was that the trauma service offered a period of three days prior to disconnecting the ventilator, okay? In these three days, it was time for the family to grieve and come to terms. It was time to educate and build trust and help the family sort of define the narrative of their son, okay? And Peter sort of made the argument that this was all within the scope of clinical ethics and sort of made the point that all they needed was time. And he mentioned that waiting three days had value, okay? And what I hope then is to sort of really explore it. And it says, well, what does that mean? What is sort of the value in time? What does that equate to? What does time mean in the context like this? And so I really hope to explore the temporal aspects of clinical care, particularly within the hospital setting and how they intersect with clinical ethics, okay? And to do this, I'm going to take a phenomenological approach to illness and time rather than a sociologic analysis. And I'll get to what that actually means, but that's sort of the foundation upon which I'm building this discussion. So let's think a little bit about time in medicine and clinical care. And I think you all recognize that much of what we do in medicine is time-based, okay? That the hospital is a fast-paced environment, right? There is this sense of urgency inherent to a range of clinical activities and settings, okay? Because quite literally some of you are involved with maybe even what's going on right now. People are taking part in life-saving interventions in which sort of there's an acuity to it and then urgency or emergency to it, right? And there's also this sort of continuous demands for our services that we provide, right? Our hospital is open 24-7. We have an emergency department. Patient care is ongoing all the time, right? That this is not sort of nine to five jobs when we think about populations, individuals that need healthcare, okay? And within this sort of broader context, like we all have expectations, you know, including patients, clinicians, healthcare workers, staff leaders, administrators, right? We all have expectations about how time is used within this setting. And I think we all have different interpretations of what time means in these settings as well. And part of that in terms of how that gets framed are the role of temporal structures in our day-to-day work. And again, I'll get to sort of what that looks like a little bit, okay? But if you think about what we do in medicine, right? The language of time and clinical care is pretty pervasive, right? We hear about time as tissue and a sort of stroke code or, you know, running an ACS code. Door to balloon time. My wife said, courted me sort of decision to incision or skin to uterus when it comes to sort of the urgency of a C-section. Some of our spaces are even defined by time, right? We have an emergency room, emergency department, urgent care. We have rapid response teams. We talk about length of stay, discharge before noon, turnaround times, right? There's just this pervasive sense of sort of time within the work that we do here in the hospital, right? Just another funny cartoon. Do you mean like stat or stat-stat, right? A lot of the terminology is time-based. What I'm interested in thinking about as sort of one of the first questions is how is time perceived within the patient experience of illness? And this is where I turn to sort of phenomenology and sort of thinking about a phenomenological foundation. We're thinking about time and just sort of for background. So phenomenology and I'm no philosopher, so correct me if I'm wrong from the philosopher up there. Phenomenology is really just the study of a phenomena, right? And it's a philosophical method for studying the lived experience. And this could be the lived experience of anything. This could be the lived experience of riding roller coasters. It can be the lived experience of fine dining, right? But in this case, we're going to be thinking about the lived experience of illness, okay? And when we think about phenomenology, that there's a centrality of the body and embodiment to experience, okay? This idea or concept of the lived body, right? Which you are all inhabiting right now, right? That body that experiences space and time through interactive processes. So our senses, our emotions, our movements is how we sort of engage with and interact with space and time. And we create a sense of self and embodied normalcy. You probably are going to make the assumption that a lot of you sort of went about your normal day really without thinking about it, right? And you sort of had your habits and you went about, you know, you woke up, you ate breakfast, came to work, you're sitting here now. That's all part of your sort of embodied normalcy maybe for Wednesday, right? And so when we think about sort of the lived body in illness, an individual experiences disease as a lived body, not as a strict biological entity, okay? And here I'm making the distinction between a disease as sort of being a biological thing and illness being the effect a disease has on a lived body, okay? Because you could have a acute coronary syndrome in two different people and they might experience it completely different, right? And so when we think about the lived body and illness, we think about the somatic and sort of psychological manifestations that we often call symptoms, okay? And it's important here to note that illness disrupts one's embodied normalcy and leads to a reorganization of the self and one's world, including the experience and perception of time, okay? And we'll get into this a little bit more, right? And two important concepts to think about when it comes to the lived body is the idea of lived spatiality, okay? That our physical world, the auditorium that we're sitting in at this very moment, for example, is a functional space in which we direct our bodies, right? Our world is sort of a space of possibilities, okay? But illness alters lived spatiality, right? That the lived world becomes more confined and constricted, okay? And that functional space becomes problematic and presents challenges and obstacles that previously did not exist, right? Just for example, like, I woke up today, I walked across campus, I came to work, I walked down these stairs. Now say for instance, I tweak my knee, tweak my ankle right here and now this previously functional space for me might become problematic in terms of how I navigate it, okay? And may sort of limit and constrict my lived spatiality, okay? And if you think about many of our patients and you think about their chronic illnesses or how they become sort of debilitated from a particular condition, think about how they become more and more confined based on the severity of their condition. And this is sort of lived spatiality. And if you think about the spaces that they tend to start to inhabit, like more clinical spaces or beyond the clinical space, do they go home, do they go to a nursing facility, what becomes their sort of lived spatiality? And that too becomes important later in the discussion. But I really want to focus on sort of lived temporality, okay? And that's this idea that embodiment is dynamic, that we all have this sort of moment to moment unfolding towards what is to come, right? And that we have these expectations about the temporal flows and rhythms of our actions and our biological processes, right? We have our circadian rhythms. We sort of expect that this talk is probably going to last maybe an hour and then afterwards you're going to go on with your day, right? You have expectations about how time is going to flow through your day on a fairly regular basis. And some of that probably becomes habitual in some sort of way or part of your sort of embodied normalcy, okay? But here again, illness alters lived temporality, right? It affects how we perceive time. It introduces new relationships to time. It disrupts our more habitual routines and expectations. Going back to the example of if I twisted my ankle, walking back to the chair, the one minute that it would normally take me to get up those stairs now might take me three to five minutes. I might have to rethink and renegotiate sort of the time that I spend doing common activities, okay? And this sort of alteration and lived temporality certainly changes and varies depending on the nature of a condition. Something that's more acute versus something that's progressive versus something that might be permanent like a stroke, okay? And so those are just sort of important things to understand about lived temporality. And so a lot of that sort of based on work done by one of my favorite philosophers, SK Tumes, in that paper sort of cited there, one of the sort of I think the most foundational papers for me in terms of how I viewed sort of patient care from a phenomenological standpoint. So I encourage anybody to sort of read that. But she goes on to sort of write another paper about the temporality of the illness. And in it sort of defines what is known as objective or outer or public time, which is measured by clocks and calendars, okay? Then there's also subjective or inner and private time, which is our individual perceptions of time, including pace, duration, sequence, okay? And this perception of time considers the contextual aspects of an experience, okay? That's the sort of notion that time flies when you're having fun versus, you know, someone who may leave here and say, that lecture lasted forever, right? I know that's going to be you. But this sort of time is elastic, okay? It's modifiable based on the context and interactions, and that becomes important to note. So she goes on to sort of talk about this transformation that happens in the temporal dimensions of illness as one becomes ill and sort of recognizes their illness. They go to the, you know, seek clinical care and they get a diagnosis, right? This transformation in which an illness that is experienced in terms of dynamic subjective time ends up being conceptualized through the diagnosis of like a disease, it's conceptualized in objective terms or objective time, okay? We do this all the time with our patients, right? That we construct a history of their illness that's very much sort of more objective time-based. And we give them timelines of diagnosis, treatments and prognosis that again tend to be more about objective time rather than subjective time. So there's this perception that goes more from subjectivity of their feeling of their illness to more objectivity of time around their disease, okay? And this is sometimes why we have challenges, reconciling these two different temporalities, right? We might say someone is a poor historian when they can't really construct a good objective timeline of their condition but that may be because they really live more subjectively with their illness, okay? And I mean, we've probably all, anybody who's taken a history area has probably experienced this where they're like, well, how long ago was that? I don't know, two to three weeks and you're like, well, can you be specific? And they really can't be specific because they're not living their illness in objective time. They're living it in subjective time, okay? And, you know, so that's sort of an overview kind of of the phenomenology of illness and thinking about lived temporality and how we might conceive of time within the illness experience. Now, I want to turn some attention to thinking a bit more about time in terms of how we might define it. And I'm basing this in sort of work by Jauzy who looked at time and chronic illness and did a narrative review of like 40 papers and then identified four key interconnected types of time or what she calls temporal structures that inform people's illness experience, okay? And these are calendar and clocked time. These are biographical time, past, present, future time, and then lastly inner time and rhythms and I'll go over each of those briefly, right? But the orientations to and experience of these times are dynamic, interrelated and complex. Again, kind of depending on the setting, depending on who you might be talking to, one might be more dominant than the other, but they're definitely related, okay? And so just to think about calendar and clock time, right? That this is our sort of shared temporal structure, okay? That it's used to measure how long activities and procedures will take and it has social meaning, okay? Like, right? We're here for an hour, hour and a half. Like, we've defined that, you know, that's our sort of our clocked time. And it allows for this standardization and uniformity, okay? And we could assign a value to these lengths of time and we do this a lot in medicine, right? We are forced to sort of document that I spent X number of minutes with a patient, right? Because there's a sort of shared meaning to that and we assign a value. In part, we know this time very well because it is the dominant temporal structure within clinical practice, right? I think all of our lives are when we're working clinically are kind of ruled by this, whether it's how many, like, your appointment time for Mindy when you're out in the outpatient, how much surgical time for Peter, right? Like, we're all living within these sort of temporal structures of sort of calendar or clock time when we're here in the hospital. But now if we think about biographical time, this is the sort of time that is our summative period of time allotted to an individual during the course of their life, right? This might be childhood, adolescence, adulthood, old age, right? And here it's important to know when we think about our biographical time, right? Like, that's sort of a bit, it's relevant to our individual narrative, but that there's something considered called biographical disruption that's caused by illness, okay? And we'll get into this a little bit later as well, right? But the idea, and I'm sure anybody who's worked with patients will tell them that it's thrown their story into chaos in some sort of way, and they have to sort of re-navigate and renegotiate what their story is, okay? But there's also this idea of biographical reinforcement. And this is the sort of one thing to consider is the role of risk factors and behaviors within a biography and how that may inform a diagnosis, right? So if you take an individual who is diagnosed with lung cancer and they have a long smoking history, their biography may change, right, when they reflect back on that. The relationship to their past and their past behaviors as they engaged in these risk factors now may be completely different how they sort of view that, okay? And this is where these relationships of past and future are somewhat fluid and dynamic, okay? That some of them may seem more remote for a patient that has a significant disability that past where they were more able might seem really far away, okay? Or they may collapse, right? Again, that sort of cancer diagnosis where you're kind of living in the immediacy of the diagnosis but you're reflecting on your past and now you're thinking about how your future is going to change and what that means. And again, so there's this kind of collapse of your past, present, present and future. And again, these are all relative to the individual narrative when we think about biographical time. Past, present and future time is just sort of the longitudinal orientation that is sort of more discreetly demarcated, okay? I'm not going to say much about this other than it's also informed by biographical and intertemporal structures. And that's kind of what we ask patients to do, what happened next, right? And then lastly to think about inner time and rhythms, right? That there are multiple temporalities that are coordinated within a functioning lived body, okay? That we have our physiologic paces, okay? And we actually, these are vital signs, right? Respiratory rate, heart rate, we have our circadian rhythms. We have certain expectations about how our physiology is going to work in terms of when we might go to the bathroom, when we need to sleep, when we need to eat, right? That's all part of these sort of coordinated, sort of biologic or physiologic temporalities within our body. And these too, again, might be disrupted. You know, these temporal expectations that we have of our own bodies might be disrupted by illness, okay? They might sort of play into sort of our expectations about how long it's going to take us to recover. And again, each of these might be different from one patient to the next, right? And all of this sort of informs the individual experience and perception of time when we think about these inner rhythms, inner time and rhythms. So now I want to sort of turn and really think about, okay, we've talked about the sort of phenomenology of illness and perceptions of time. We've talked a little bit about sort of defining what some of those different times may be that people may experience. But again, as a hospitalist, when I was sort of first starting out, I really started becoming interested in what's going on with our patients. Like, how are they experiencing their time within the hospital? And really sort of started with the question of what happens to patient perceptions of time within the hospital when you sort of think about these different temporalities that are going on and how they might all have different paces that are competing and conflicting, okay? But let me take a moment to sort of talk a little bit about hospital time, okay? There we were sort of more focused on patient time. But you put a patient in a hospital, what does hospital time sort of look like to a patient, right? Because time in the hospital is dominated by temporal structures that are marked by objective calendar and clock time, okay? This is how we organize and regulate activities that support organizational goals, right? Like patient care, okay? These are schedules. These are expectations that we may have around length of stay. This is a lot of times and bookings, right? That we're working really on clock time. How many appointments are you allowed in your clinic? You have 15 or 20 minutes. If it's a new patient, you get 45 minutes, right? There are various ways in which the temporal structures exist within the hospital that really are dominated by clocked or calendar time, right? That objective time. But this does allow us to establish expectations, okay? That when your OR time is scheduled at 1 p.m., you know, okay, 1 p.m., I should be going to the OR, right? And so it's important. This is not to sort of say that clock time is not, you know, or to be cynical about clock time. It is really important, okay? But this also exists within the broad context of dynamic and at times conflicting temporalities, okay? And this requires sort of prioritization of activities and time allocation. I'll come to that again, right? Like the different paces within the hospital can even sort of be at the sort of level of the different paces of clinical care for an individual patient who might be having a rapid response or having a sort of acute chest pain, right? And that forces a reorientation and a reallocation of time throughout an individual's day, right? And also if you think about hospital time, right, that many of our outcomes are often improved by speed. I went back to sort of time is time is tissue. But I imagine in the OR you're not lollygagging for any reason because that, you know, the pace at which you do it at quicker pace may lead to a better outcome. Then also many of our metrics are measured by speed, okay? When you think about turnaround times, whether it's for an OR or a room or length of stay, right? All sort of these time-based metrics that we look at. And this sort of also comes back to sort of just how we sort of live and exist in this environment and how we're sort of socialized to it. And it's also just part of our profession, okay? And this may impede or impair our awareness of these various time structures and temporalities, right? That they just sort of become invisible because it's just the way it is, okay? And if we sort of tease some of those temporalities out, there are a lot that are going on, okay? We have the temporalities or the paces and temporal expectations of patients. They're family members who might have to adhere to visitor restrictions or visitor hours of restriction. We have loved ones as well. But then think about just everyone working in patient care from clinicians to nurses to care coordinators to staff, right? They're all running, not literally, but sort of running at various different paces that often are dynamic throughout the course of the day, okay? And then if you think too about sort of the temporalities of the hospital itself as an institution or what is sort of administration expects of us, both internally, you know, going back to sort of the schedules and expectations around, you know, how many patients IR should be seeing in a day or what the turnaround time for an OR is, right? And we go back to sort of thinking about some of those time-based metrics that are some of the temporal structures that put pressure on us within clinical care. But we should also think about what are some of the external sort of pressures that might be put on us, right? When working with payers who say, well, they're not going to pay anymore because this patient's ready to go, right? And so might put a pressure for a discharge. I think about facilities that say, well, we're not taking patients on the weekend, so they'll have to wait until Monday. Think about regulatory agencies which come up with some of these time-based metrics that we're looking at, right? So when you think about all the different temporalities within the hospital, it's just kind of really chaotic, very, very, very dynamic. And many of these temporalities are sort of competing or conflicted, okay? And I like this as sort of a framework. This is for nursing time, but it's sort of, I won't get into the details, but if you think about whatever sort of clinical area that you're working in and thinking about, well, what might be sort of the physical time aspects of your job? What might be, again, some of those more psychological or inner time aspects? And then what might be some of those times that are sort of competing and conflicting? But it's sort of a nice framework to sort of think about your own sort of temporalities in the type of work that you do, all within, again, that broader context of what might be some of those sort of internal pressures, as well as external pressures or time structures or temporal structures that sort of inform how you practice, okay? And I just like to sort of also point out that one of the more historical contexts is thinking about sort of a broad theme of medical history. Is that of increasing diagnostic, therapeutic and prognostic efficiency and specificity, okay? That there's been this sort of acceleration in a lot of the work that we do, okay? And we can think about these accelerations in clinical practice when it comes to the role of technology. Again, whether that's imaging technology that I think is increasing going to be like AI, whether that's the electronic medical record and our ability to sort of share and access information that previously it might take two days to get medical records from somewhere else, but now we have care everywhere and we could access it, you know, in real time. Also affects our sort of communication with each other in terms of moving from just beyond just pagers, but secure chat, epic chat, right? Texting, right? So these multiple accelerations that have put sort of time crushers on us, right? And this is also within the sort of broader sort of pressures for increased efficiency in healthcare delivery, okay? And anybody who's practiced long enough probably feels this, like, got it, you know, throughput, throughput. And then I sort of wonder too about what are the patient expectations, okay? In terms of leading to some of this acceleration, okay? Because they too have expanded access to information and providers, okay? There's often advertising or messaging out there about, we'll see you quick, right? Urgent care always, always open, right? So I think patients too have, you know, in many ways benefited from these accelerations in clinical care, but at the same time it creates expectations, okay? And I think anybody who does sort of outpatient care and they have to worry about their inbox because a patient checked record, you know, checked their lab work and we're busy during your day and they're like, why haven't you responded to these labs, right? That previously, without patients having access to that, you controlled sort of that timeline more, okay? And like Peter, I'm a fan of sort of medical history and this is from the precursor to the New England Journal from 1841. And this is sort of a pretty typical case study and I think it's sort of fascinating from a sort of time perspective, okay? Because you look, the patient was admitted, well, first off, they give the real name, you know, so there's issues with that maybe, but, you know, admitted May 23rd. This is somebody who had like a sub-maxillary tumor and they did a tracheotomy, right? And it sort of just goes through kind of what happened this day, what happened that day, but they do pay attention to, you know, time, right? The surgery was done at 2 p.m. You can see that there's four o'clock, you know, 3 p.m., right? They're really attentive to sort of time and the passage of time, right? And then you get to sort of October 2nd when the patient died, right? So nearly five months in the hospital and this sort of gets boiled down to sort of this timeline. And it's sort of crazy for us to think about what would this patient look like coming in now, right? And how long would their hospitalization be, right? At this point, they'd probably be well through their treatment at five months. And so there's this sort of acceleration that's happened. And if we sort of look at this as sort of another way of looking at that, right? That we've created, you know, we being sort of the biomedical, big biomedical, you know, reductions in sort of the preclinical phase and the clinical phase, right? We've compressed these time periods through sort of science, technology, and medical discoveries. And then I think sort of changes our expectations, but it also changes patient expectations in some ways and sometimes leads to conflicts. And that's what I'll sort of get to. Okay, any questions I think at that point? I actually don't have a watch, but how am I doing on time? But I do want to sort of turn, what? Okay, I want to sort of turn attention to sort of what is time actually equate to or mean, right? We sort of define how it might be perceived, how, you know, some definitions of it, how it might may exist in the hospital. But I'm interested then in the question now, what does it actually equate to or mean, okay? Right, for a patient, you know, I tried to boil this sort of down this time probably equals care, okay? That I am in the hospital and people are caring, right? But then if we think about clinicians, right, what does time for them mean? Okay, or what does time mean for me when I'm on clinical service, right? It's the provision of care, right? This is the practice of medicine, nursing or surgery or whatever sort of your profession is. That's what time means to you in the hospital, right? It's your job, it's what you've been trained to do. I also think that we might consider time for the patient to also be potential harm, okay? That the longer a patient stays, the longer they stay because there's the potential for harm, okay? And then lastly, if we think about hospitals, clinics, institutions and systems, time maybe sort of meant or equated to resource allocation and revenue generation, okay? And I don't say that cynically. I say that because I think that's sort of the reality, right? That we need to allocate and utilize resources and we need to make money, right? And so time might have different meanings for each of these different entities, okay? And I want to sort of focus in a little bit more on the sort of patient aspect of that in terms of maybe concerns and expectations that they may have when they're in the hospital, okay? Right? That's sort of a weighted time to being care. We can expand this sort of thinking about compassion and hopefully recovery in a safe environment, right? That's probably, you know, again, summing that up in terms of what patient, how patients might consider their time in the hospital, okay? But I do think patients also have an expectation of efficiency, okay? Like, why can't it be done today? Why can't it be done over the weekend? What's taking so long for these results? I think, again, anybody that sort of cared for patients have probably had these questions about why aren't things working more efficiently. But then there's also the important aspect of loss of control, okay? That patients come in here into the hospital kind of with their lived temporality and expectations and how they go about their day, okay? But then they're here in the hospital and their schedule is dictated by the temporal structures of the hospital, okay? This is sort of this imposition of hospital time on patient time, which is in many ways an assertion of power and control over them, you know? And that becomes problematic. Again, we've probably all heard patients like, you know, why does it have to be 2 p.m.? Why do I have to be in NPO, right? So the schedule that's dictated to them, they often have no control over. Or why are you rounding at 5 a.m. to make your 6 o'clock O.R. time? Why do I have to be woken up, okay? But I think patients too often, you know, do have that expectation of shared decision-making in the hospital. Now, I think one of the questions we could ask is, does that extend to their ability to sort of negotiate with us or make decisions about how time is used in the hospital, okay? Do I need to be woken up at that time? Do I have to take my medications at 7? I normally take them at 8 when I'm at home. And so that too can raise, you know, tensions in how schedules are managed within the hospital when we think of what patients' expectations are within the broader context of the sort of temporal structures of the hospital. And thinking more broadly and kind of coming back to sort of a biographical time and sort of the disruptions that may exist, right? That a patient in the hospital often has to revise their life story and relationship to their self, okay? And I think this is more stark when a patient is suffering from a really debilitating or significant condition, right? But as I mentioned, right, like their time in the hospital might also be time for them to sort of reinterpret their past, their present, their future. It changes their relationship to their body and their conditions when they're in the hospital. There's this whole idea sort of in the philosophy of medicine as well, is that how one's body becomes alien to oneself because it's sort of, because it's sick or it's ill, it has disease. And so one's relationship to their own body can become fractured and forces people to sort of reinterpret that. And then as I sort of previously mentioned, there is this reinterpretation of lived spatiality, okay? Now they exist within this clinical space maybe sort of acutely, but then there's the question of how do they navigate the space once they're outside of here? What spaces do they go to? And then coming back to the idea of biographical disruption, on the short term, right, time in the hospital is time away from life outside of the hospital in terms of what they do, how they live, their friends and family that they engage with. And then if we think long term, how illness or trauma alters one's life trajectory, right? That sort of terminal diagnosis in which people don't always say, I just want to make it to my grandchild's wedding or graduation, right? This alteration, this long term alteration that happens as well. And the patients are doing this as we're sort of caring for them in the hospital. So now I finally want to turn sort of the attention to how should clinical ethics attend to time. Okay. And so I think about, you know, these competing temporalities that I sort of just just discussed. And yeah, I just learned that Google Slides allows you to easily insert gifts and so I play, I tried to sort of limit myself, but nonetheless. So I think about sort of some of these competing temporalities and try to sort of layer on to it, you know, what sort of principles of bioethics may be there, right? On one hand, you have the patient and their temporalities while they're here in the hospital and all these different aspects that they have to consider when we think about lived temporality, lived spatiality, just in general how they perceive time within the context of illness, right? And thinking about autonomy and their ability to sort of control their decision-making and control their destiny. Then we think about providers, right? And the sort of myriad ways in which they're running around the hospital doing things, their way their day-to-day flow is disrupted by various aspects of patient care or the temporal structures of the institution. But when we come to sort of think too about what, you know, the meaning of time in the hospital is sort of beneficence and maleficence, right? To do good and not to do harm when caring for our patients and the provision of care. And then institutions, I think sort of zooming out a little bit, thinking about that justice aspect, right? That time in the hospital is resource utilization and allocation and thinking about how do we do that, right? So these things are sort of triangulated and often sort of competing. But you also may have institutions and providers on the same page, but there's tension with the patient that they're not ready to be discharged. But the institutions, yeah, discharge them and the providers like you're medically ready to go, but they don't want to leave. And we see that all the time, right? So when we think about the ethical considerations of time, I do sort of ask, does time have ethical significance? And should time be treated as a resource that we allocate through ethical principles? Or is time different? And this is sort of something I struggled with in sort of putting this together and really thinking about it. That is it really just a proxy for something else, right? The time might be often equated to resource utilization. Is it really just the way we allocate resources, right? And so is it just a proxy for something else? Maybe that could be for part of the discussion afterwards, right? Because I do think there is a significant challenge of separating out resource utilization from more purely temporal aspects, right? Like what would a more purely sort of time as a resource look like? And not necessarily from a sort of philosophical standpoint, but really from a like, how do we make decisions about time utilization within the hospital and what that means? And then sort of thinking too about, well, how much time is enough, right? If we're going to be thinking about allocating it with all these sort of different temporalities and maybe even coming back to sort of the case study a little bit, like how much time is enough time? Not too much, not too little, right? And so a few have sort of tried to look at this. And I'm not convinced that it sort of really gets to sort of the ethical issues of sort of time as clinical ethics. So this paper by Braddock and Snyder, you know, they sort of assert that time has ethical significance with specific implications for the patient-physician relationship or respect to patient autonomy or promotion of well-being for maintenance of fidelity and for preserving justice, okay? They contend that sort of quote-unquote inadequate time is sort of the term they use leads clinicians to limit or forego activities integral to the patient-provider relationship in clinical ethics, okay? So that's sort of how they sort of looked at it. Another paper sort of time is ethics by Mark McCurrio. You know, he sort of states that most often, and this is more just a thought piece, but he states that most often when I have fallen short of ethical ideals that I hold and teach, it has been for want of time, okay? That when the right thing to do is not clear, the best course is to think, read, discuss, consult, debate, and yes, take some time, okay? And so here is sort of really truly equating that time, yes, is ethics. But I think we could ask, we're just saying, like, this is how we should practice clinical method, practice clinically. So is this really about ethics, right? Because I think in sort of looking at these papers, you know, they note that sort of quality care and establishing a trusting and therapeutic relationship with patients takes time. I think we all know that, right? Often to do good clinical work and whatever that may be, it takes time, okay? And so, you know, is it fair to sort of say that the ethical significance of time is equated with having adequate time to provide ethically sound levels of care, okay? And the flip side of that then is, does inadequate time equal unethical care, okay? I think we've probably all gone through our days where we felt we haven't had enough time, okay? The time was inadequate for the amount of work that we had to do. Does that mean that you provided unethical care, right? Because I do think that we could look at this sort of at a macro level. But I think on a micro level, that this is a very real challenge in everyday practice, okay? That anybody who's sort of on clinical service now, you know, or within the, you know, recently, right? Is that all you need is sort of one patient to spend a lot of time with. Maybe doing informed consent. Maybe trying to build this trusting relationship with the family. Maybe they're crashing, right? And they're decompensating. But you have to spend more time with them in a way that because your sort of day is temporarily sort of bound by sort of your schedule to reallocate how you spend your time and prioritize other patient care, okay? And we do this all the time, right? And so, you know, is that sort of a version of microethics? Is that sort of this idea that time is ethics? And if so, what do we do about that, okay? But I want to sort of think about this other idea of ethics as either a decelerator or accelerator of clinical time, okay? Kind of coming back to the paper by Mercurio where it was like things kind of slowed down or this idea that good clinical care, good ethical care takes time is right? Does the sort of deliberative or sort of consultative process of ethics permit a slow clinical practice, okay? That it sort of permits the sort of establishing of adequate time, okay? But then when I was thinking about that and sort of raising this question, but is this any different than a diagnostic or kind of therapeutic deliberation or consultation, okay? That I might consult pulmonology to sort of be part of that deliberative process, right? And that might also be a decelerator of time, you know, or clinical care. And this we could again come back to the question of how much time is too much time. But then I think the flip side may be, you know, ethics can serve as an accelerator. And I think it was mentioned in a previous talk about how ethics consoles can actually reduce the length of stay in various clinical settings, okay? That sort of recommendations or ethics recommendations can permit progression of a terror case, right? And so I think it's interesting to sort of think about, you know, ethics as either being a decelerator at times when we need more adequate time. But when is it also an accelerator that allows us just to keep, you know, to progress, progress clinical care, okay? And a little bit of attention to sort of time reconciliation, right? Because I sort of talked about sort of these temporalities of the patient illness and how they sort of experience time. But that to me sort of raised the question of, you know, as clinicians, as sort of healthcare providers that should we attend to the temporalities of a patient's illness, or maintain sort of that focus on more objective time, right? Using our data, sort of using the natural progression of disease, looking at studies, right? And when we think about in terms of diagnosis and prognosis, based more on biological understandings of disease and standard practices of clinical care, the part that's probably just easier for us, right? To sort of assert a more biomedical timeline than it is to sort of really consider the temporalities of a patient's illness, right? Because I do think it's, you know, tricky to really think about how do we sort of recognize and sort of reconcile the lived experience of uncertainty and waiting, okay? That when you think about patients who, you know, in the scan, there's a small mass, it could be cancerous. We're not quite sure, but the recommendation is sort of a repeat scan in three months, okay? And to sort of think, what is that three months, that sort of lived experience of that three months waiting for that repeat scan, or whatever sort of follow-up appointment may be, or a biopsy was done, and it was done on a Friday, so there's the weekend effect, and you're not going to get it back until, you know, a few more days, right? But that's probably excruciating time, right? That the duration of that time just sort of seems to just sort of expand, okay? And I think some of this sort of leads into, you know, this sort of reconciliation, leads into the case study again, it's sort of thinking about narrative responsibility, right? And the sort of idea of sort of biographical time, right? That we all use narrative as a form of meaning-making, okay? And, you know, do we then have a responsibility to our patients who are responsible, you know, whether it's patients, family members, loved ones, of shaping their stories, or their stories of their loved ones, okay? And we think about the sort of interpreted within the context of illness or trauma, right? That there's a sort of attempt to sort of reclaim from a focus on illness, maybe to sort of, that's what this person really believed in. That's what they were sort of living for, right? We certainly see this in obituaries, obituaries are sort of a way to sort of reclaim someone's narrative. And I think as sort of providers who do oftentimes control this time, that what is our responsibility to shaping a patient's narrative? Again, I think in Peter's case, right, he quoted that the father saying, you are killing him, okay? That what responsibility might an institution have or providers have or say, no, we're going to withdraw the ventilator. I'm sorry, that's just what we're doing. That patient's narrative ends with the hospital killed them. And so, you know, there's this idea of sort of narrative by after genesis, like what do we owe as sort of institutions and providers that do control time? How much time should we provide to allow loved ones, family members, a patient to sort of reinterpret that their narrative? Okay. And I think that's an important question. And when I think about time to, and this is sort of getting a little bit away from ethics, but I think you can question whether they're, you know, what are the ethics of manipulating time in the hospital? Okay. Right. There's a big difference between what goes on in the Peds Hospital and what happens in the adult hospital when it comes to how time is passed. Okay. That the patient experience of clinical practice is often marked by acute periods of activity and prolonged periods of waiting. Okay. And that too can be sort of excruciating for patients. Okay. But how can we maybe think about promoting socialization? Diversional therapies like pet therapy or bring in the clowns, entertainment or enhanced patient control of time. Okay. We do that with the electronic medical record. I think it's also important to think about how we actually communicate time. Okay. Because that impacts perceptions of time, whether that's wait times or prognosis right that are we using objective terms instead of subjective terms right that you tell a patient, oh, you'll be out of the hospital in a little bit. Our little bit might be one or two days. They're a little bit based on previous hospitalizations or expectations. Previous experiences with loved ones, family members might be, oh, that's going to be three to four days. Okay. Right. And so we sort of have a little bit of an onus on us to be responsible how we communicate time. So to sort of mitigate any misinterpretations of what that may be because I've made that mistake. You'll be leaving soon. Next day. Wait, you said I'll be leaving soon. I thought that was two to three days. I'm not ready yet. Right. And so how do we sort of think about how we actually communicate time. Right. And there are other studies out there too that show that I think ED waiting times that it when you actually communicate. How long it's going to take to get lab work back, how long it's going to take to get sort of scans interpreted. You set expectations. Right. So they feel like they're not waiting as long because you're building in those sort of temporal structures. And I want to quickly come back to sort of the idea of space. Right. That they acute care hospital. So thinking about that as sort of live spatially out of what our patients sort of how they're sort of receiving care versus other places of care for recovery and rehabilitation. Okay. So when a patient is ill, they likely have certain expectations about the type of spaces in which they receive care and recover. For them that might not be going to a facility or an acute rehab or a sub acute rehab that might be I stay here until I'm ready to go until I'm back back to normal. Right. And so I think that's interesting to sort of think about what are the ethical dimensions of differing spatial expectations. Right. Just as we sort of can think about the ethical dimensions of differing temporal expectations. Right. And I sort of go back to this sort of natural progression of disease that like I think historically patients would often stay in an acute care setting longer than they had to. Right. And we've had this sort of compression of from symptom to diagnosis to initiation of treatment. We don't do we, you know, have to wait for them to recover an acute care setting. Or are there other settings that they can and should go to. Okay. And, you know, if the patient says no, but we have an appropriate place to send them how do we sort of then navigate those sort of differences and sort of where they feel that the space in which in which they should recover. So just kind of just sort of and things want to return to that case study right that, you know, when all they needed was time that that waiting three days had value. I think really part of that value in that decision was one negotiating and reconciling the competing temporalities. Right. You could, you know, was three days enough. It seems like it was what a week been too long probably would we're giving you 24 hours. I mean too short right so so there was some negotiation of sort of the timeline there, but it really did allow from the way Peter told it for the family to really attend to the narrative their narrative responsibility. Right. And it also sort of mitigated the potential harm of the institution of, you know, the of the narrative being that they killed him. Okay. It allows for the processing of grief and loss. It's set temporal limits on resource allocation right so if you think about the good institutions and providers that were concerned about resource allocation of of an ICU bed. It's set temporal limits on that. And then it mitigated moral distress and burnout from team members that on a day to day to day basis, had to care for care care for this patient right. So, in summary, I hopefully you sort of understand that the experience and perception of time are multi dimensional, and that illness disrupts and alters this live temporality. And when we think about sort of clinical settings and practices that they are time complex time intense and complex with their own hierarchical overlapping and competing temporalities, which often conflict with those temporalities of patients. And that tensions between these temporalities do give rise to ethical dilemmas. And so I would argue that attending to the sort of phenomenological aspects of these tensions has value and assist with achieving resolution. And so with that, I just want to sort of acknowledge to that and sort of thinking about about this and working with colleagues across the institution. Right. You know, quite thankful and we just want to acknowledge all the work that you regularly do striving to provide how high quality care in a very challenging health care situation that often puts these significant time pressures on you. So, so, so thank you. And with that, I'll take questions and comments. And I know it's past time. Or it's what time. We're not too bad. All right, thanks everyone. Any other questions. Competitor was reduced. This station for three days have value in the ICU. What if these patients waiting to get into the ICU. This is just word that the value for this station. One time the ICU is devalued for somebody else to visit again. No, I mean, I think, yes, I didn't pay attention to, I guess I was focusing on sort of what we do here in the acute care setting and less on everybody else's time outside of the hospital. But I think that that is like one of the trade offs that happened. I mean, when we talk about that, you know, is that a time issue. You know, this is where I sort of struggle when you say, well, this patient sitting here, this patient is not do we are we devaluing that patient's time or devaluing that illness or devaluing the experience that they're undergoing because it probably is excruciating. Right. Where a patient may be to be sitting at a community hospital waiting to be transferred. And they're like, when is this transfer going to happen. It took three days to get this get get get get this transfer in. And so I guess, is that a, and again, this is where I struggle is that a, you know, allocation of time or is that an allocation of resource or are they one in the same right is time really just the proxy for resource allocation. And I had a really hard time the sort of separating that out. Yeah. Yeah. I mean, again, I think some of that's more of a systems problem. And who raises questions about who defines what is adequate or inadequate time. I think there was a study by one of our colleagues who actually looked at how much time it would take to do everything that one is supposed to do. And it was just sort of remarkable how much time it actually took and how much time one is actually given. I think it does raise questions to when we sort of think about time allocation is, is that, are we optimizing our scope of practice in from a time perspective. Right, like, you know, I know, I know Dr. Runke hates doing prior offs right should he be spending his time doing prior offs when he should be at the bedside or everything else that needs to be done. Right. And I guess the question that you know that the concern or the sort of issue that that raises are what are those external pressures. Like why why why are outpatient I mean appointments like 15 or 20 minutes, but like who who negotiated that who is who established that I'm similar on the sort of length of care length of stay side when when a payer says, you know, we you know, the average length of where a patient coming in with pneumonia is is what I don't know, you know, I'm just making this up as two days, and we'll pay for two days but anything beyond that. If the patient's medically ready they should they should go even though the patient might be saying how about one more day. And so I don't know I think there are those sort of external sort of temporal structures that are put on us that are really one they're unfortunate because it doesn't allow us to sort of be more dynamic with the sort of the work that we do. Oh, yeah. Oh, oh, I'm here. And then there, like $1500. Yeah, administration, the administrators, like the same priority prioritizing my patients. And I usually just err on the side of the priority. I think that for patients and my dynamic relationship with them and sort of saying screw it to the administrator to a degree, you know, through the balance you sort of I would be promoted and let me have one for the unit and then maybe I had my own question that it's, you know, your association but but you know I think that we are the clinicians on the front line of the 11 and we are born between freshers upon us from the other direction. I mean, I think if you go back to those two papers that were sort of looking at ethics and time, I think they would make the argument that like, you know, you know, it's an ethical choice to provide adequate time to do the work that you need to do as a clinician. Right. And so, you know, what is that? No, I and I think that comes back to that sort of micro ethics where, yes, you just spent your morning with, you know, transferring a patient to the intensive care unit, you're behind behind on rounds. Your discussions are going to be be be be be quicker. And I don't know if there's, I mean, unfortunately, I think this is sort of the environment in which we work. And we have to sort of struggle with these and hopefully at the end of the day, you know, I allocated my time in a way that provided the best care I could within those limit limitations. Recognizing that sometimes that doesn't suffice. And it might not suffice for you personally, but it also might not suffice for the institution says well, okay, I asked for that discharge at 4pm because they had a bed and you put it off to the next day. It's like, well, yeah, I was just so far, so far behind. I think for me in terms of, I think about the idea of sort of manipulating time for patients in some sense, and how I communicate that. And, you know, do you err on the side of communicating them a quicker recovery. Yeah, almost as sort of a placebo. You know, most patients with this condition that they'll be out of here probably in one and a half, two days. And do you sort of prime them to kind of go one and I'll good I'll be out of here in one in one or half two days again and sort of staying away from language of, you know, yeah, you know, we'll get you out of here in a couple of days. Right. You may think that's two days, but again, what's couple versus several versus a few. You know, like, you know, there are interpretations of that are that are different. And so, I don't know that's sort of I think about like, how do I sort of frame my communication and ways that prime them to get better and prepare for for discharge. I mean, I don't know if that's ethical or unethical in terms of thinking about manipulating patients time and their interpretations of time. Right. Yeah, and I think that, you know, when talking about sort of how does, you know, this is all great and fine and theory, but how does this work in practice. The one way is it does it make sense or should we do a better job as well of not just sort of communicating time with with the patient with regards to themselves, but communicating actually how we spend our time. Right. Like, if say you spent three hours transferring that patient, and you're like, I'm sorry, I'm getting around late. And there is a paper that I include here that talks about how you sort of mitigate some of the harms of like waiting is to sort of be clear and sometimes explain why patient probably understands like, you know, I'm sorry, I'm just getting to you late. I'm rounding late. I'm probably going to have to spend a little less time with you because I spent three hours with the patient that wasn't doing well. And I had to transfer them to the ICU. Right. Like, I mean, hopefully patients were, oh, okay. Like, oh, you're really busy like, and they then may sort of alter their expectations about the time that they have for you at, you know, at that moment or in that day. Other questions. So I thought this was really great. And it really makes me think a lot about how we talk about things. And I didn't think that there are ways that we can affect patient subject experience time. And part of that is, you know, sitting down to talk to them and all the things we learn from communication. Partly, I think it's also low expectations. And so, you know, setting reasonable expectations. I also think that there are just some things that we cannot offer, which you mentioned, and I'm struck by, I have always thought that a good, sort of good quality care and surgery involves spending time with patients. So they trust us, let us operate on them. And, you know, I've written about this, I've lectured about it. I was giving a talk in China a number of years ago, and a surgeon said, this all sounds great and theory, but he said, I have a four hour office hours. And I have a line of 100 feet. And so I can spend approximately two and a half minutes for patients. And so all the things that you talked about sound great. But they're not real. And so I do think that I mean, I think that all the things that you raised are amazing and make us think about it. But I just wonder about sort of that, you know, the cultural reality, perhaps the logistics that allow us to do things that other places. Yeah. And then there's stuff that is written about in terms of like the culture of an institution as it relates to time and the pace. And for some reason, there's a lot of literature from like the UK around sort of how time is spent. But looked at, you know, perception like staff and provider perceptions of like the pace of their hospital and, you know, there are a good number of sort of negative outcomes from that. Right. The faster things were people had negative perceptions higher, higher, higher rates of burnout. And I do think that sort of then raises a sort of larger sort of macro kind of ethics question of like, well, what is it? Why is our culture this way? Why do we have these temporal structures that create these pressures or create inadequate time for us? And I mean, that's a sort of systems based issue. And maybe that's why, you know, how staff are unionizing like, you know, I mean, they unionize for duty hours or not. But, you know, fought for different for duty hours. And that's a whole nother sort of thing in terms of thinking about the structures of trainees, like temporal structures of training. Other questions. Yep. You know, I mean, that came that does come up this in that one paper by Braddock and Snyder, they're just sort of qualitative time versus quantitative time, like, you know, that that how do you define adequate is partly what you do in that time. Right. Like, I could probably give, you know, you five minutes to do an informed consent and you can do a really good job. I could probably give you 20 minutes to do an informed consent. Probably. I mean, no offense to you, but right, like, you know, you're trained to really sort of do that and know what to sort of communicate. And so I think there are ways to sort of train around like what how we spend the time and really sort of think about how we spend that time. But I do wonder what, how can we potentially leverage technology to do some of the work that needs to be done in that time, such that we can sort of really focus on what needs to be done. What needs to be done by sort of the clinician in that in that in that time. Yeah, because as a medical student, you know, I'm sure once you, you know, hit hit the wars, people saying, Oh, it's great. You have the most time of anybody on the team, you go and talk to that patient and get a good social history really dive into their, their biography and all of that. And you compare that to the amount of time the resident might be spending or, you know, the attending who just pops in for five minutes. You know, to sort of really think about how are those different providers across those different levels, like spending time like a resident will probably hone in on very specific questions. After receiving information from from the intern and maybe doing all of this background work. Right. And so I think it is important as you go through your training to really think what am I, what am what is the goal and the focus of the time that I do have with my patient. Now it may be completely derailed by the family member that happens to be in the room and starts asking all these questions about this sort of red number that appeared in their in their my chart. Right. And so there's a bit of improv that comes into sort of the clinical interaction. Other thoughts or question. All right, well, thanks, thanks everyone. About enough time like this thing. It raises so many.