UCSF

Time is a problem in primary care. Patients and providers alike lament short visits and long wait times. Meanwhile, continuity over time is a defining asset of primary care. Drawing on ethnographic fieldwork in three publicly-run clinics in California and theoretical approaches to temporality and governance, this dissertation examines the multiple rhythms and temporal logics at play in the clinic. Those who work in safety-net primary care are charged with ensuring the health of a socially vulnerable patient population while being attentive to each member of that population. I examine how clinicians and staff negotiate contradictions in the organization of clinical time in part by shifting between temporal frames.

Concern about patients waiting moralizes speed and efficiency in the clinic. This is always in tension with ideals of comprehensive care for each individual. Scheduling practices and management of clinic flow rely on a logic that I term enslotment, in which patients occupy uniform segments of time. I examine the practices that clinicians and staff use to reconcile patients and the schedule to one another. At the limits of these strategies, the non-congruence between the temporal norms of the clinic and patients’ needs generate a sense of temporal fragility.

I describe how a sense of potentially unlimited demand drives efforts to protect time through clinical teamwork in ways that are patterned by the valuation of labor time. I also examine the demands that documentation, incentive-backed quality measurement and the imperative of continuous improvement make upon clinic time. Metrics can generate a sense of urgency around needs otherwise neglected. Meanwhile, the tempos of reporting and payment are often out of sync with the temporalities of sustainable organizational or political change. In this context, I explore how clinic staff confront the limits of time and navigate the contradictions between their obligations to individual patients and the collective under conditions of socially structured time scarcity. Care over time through continuity creates space for potential beyond the time pressures of a given clinic session. By taking time as an object of focused inquiry, this analysis traces the logics and ethics of healthcare policy and practice across multiple scales.