Contextualized Time and Kairotic Care in Health and Medicine

Kirk St.Amant, Louisiana Tech University and
Rachael Graham Lussos, George Mason University

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Introduction

In this interview, Kirk draws on his work in usability, intercultural technical communication, and health and medical communication to describe the role of contextualized time in the design and use of medical technology. How time is valued and whose time is valued is rhetorical. Cultural values of time, then, dictate how health care is administered, who administers it to whom, and of course, when it happens. Confronting this complex problem, Kirk discusses research challenges and perspectives for scholars in technical communication, usability studies, and rhetoric, with the ultimate goal of enabling a standard of “kairotic care.”

Interview

RGL: I heard you did a presentation at COMET in Indianapolis last year, and you said when studying usability in health and medical contexts, rather than start with the questions, “Where does it hurt?” or “How are you doing?” the first question one should ask is, “When?” Can you explain how you came to that? Why is “When?” the most important question?

KSA: It all begins with “when,” because “when” then dictates “where.” For example, we’ve all experienced an injury when we’re in a space where we cannot treat it. Perhaps we are driving and we get a headache, or perhaps we are on a public bus or public subway, and we feel a distinct pain, but we can’t expose parts of our body to check that area to see if something has happened. This inherently delays when we can actually engage in the process of performing a diagnostic or even checking something.

It’s a societal convention, because we even train our children from very early on: There’s a time and a place for everything. So “when” we actually engage in the diagnostic process greatly affects “where” we are and “what” we can do. If we get a headache when we’re driving a car, we’ve got to pull over alongside the road. The space we’re in whenever we experience something greatly affects what we have available to us to treat the condition. Maybe we are in the hospital when it happens. But when it happens greatly affects the where we can engage in—administer or receive—care(giving).

It all begins with “when.” When does it happen? It’s a timing issue. The reason I bring that up is most medical technologies are designed for the “when” of best case scenario: when you are in the clinic, or when you are in the examining room, where there is every technology you need, and where there’s every kind of expertise available. But for most of us, that’s never the case.

So when we design medical technologies, how portable are they to use in a variety of settings? Are we designing for worst or minimal case scenario, when we have no access to any ancillaries that can help us? When we have no access to any experienced medical care provider who can perform the process? When we’re at that bare bones basic, the ultimate “when,” what do we design for?

It’s relatively easy to build onto something, but it can be difficult to strip down complex designs built for specific contexts. If we build a technology that requires a physician to use it in a controlled space, retrofitting that technology to work when we’re in our car or on the subway, and need to use it ourselves, is difficult. If we build it for us, the patient, to use whenever the event happens to us, it’s comparatively easier for the physician to come in and say, “I know how to upscale this, or how to work it at my level, or what to add onto it.” So the timing is everything.

RGL: Time is never divorced from place or space. It’s always in those terms: time and space, time and place. It sounds like one of the issues here is that in usability studies, when thinking about health and medicine, that place is always presumed.

KSA: In general, yes.

RGL: So if the place is always the hospital, the time is always the time in the hospital.

KSA: Yes. And to take it further, in most cases, when we talk about time and usability for medicine and health, for the most part, we are referring to physician-centered time or caregiver-centered time. At what point in the physician’s or the caregiver’s schedule will he or she meet the patient to do X? That question is predicated on the idea that we don’t have high blood pressure until we’ve had the chance to meet with our physician (on her or his schedule) to inform us we have high blood pressure. (I’m exaggerating here to make a point.) That’s problematic in terms of design and usability.

We need to invert that relationship. These things happen on the patient’s time, not the physician’s time. The question becomes, where is the patient most likely to be when this happens? For example, if someone has high blood pressure, when are they most prone to have a cardiac event? It’s going to be probably when they’re engaging in a certain kind of physical activity. So you ask the patient, when during the course of your day are you most likely to climb stairs? To have to run after a child? To have those prime exertion points. So the patient’s schedule, the patient’s time, drives the process of design and development, versus the physician’s time.

We’ve become so obsessed with physician-dominant time in medicine that it’s greatly affected everything, from when we have a cardiac event to when we give birth to our children. Having been present at the birth of a child, the process is kind of like, well, you’re going to have your child on this date.^[1]See, for example, “In Delivery Rooms, Reducing Births of Convenience” (opinionator.blogs.nytimes.com/2014/05/07/in-delivery-rooms-reducing-births-of-convenience/) Do you realize how odd that perspective is in all of human history?

RGL: Both of my labors were induced, and when I was offered options of when to be induced, the options were Monday through Friday, starting at 9:00 AM.

KSA: And not your schedule. Rarely your schedule. It’s about the physician’s or the hospital’s schedule. Think about how strange that is when you really think about it.

In many respects, we seem to have adopted an attitude where we seem to be attuning biology to chronology. It’s as if we can only have any sort of health or medical event happen on 9:00 AM to 5:00 PM during the conventional work week.^[2]See, for example, “Doctors Seem to Schedule Births So They Can Make It Home for Dinner” (psmag.com/social-justice/lets-schedule-you-for-eight) Forget if you want to have a child on the 4th of July. That’s just not going to happen. In fact, you have to wonder how birth dates have changed based on this common acceptance of inducing labor, driven by hospital or physician schedules. Does anybody get born on Christmas anymore? Do we have anymore New Year’s babies? Or have we seen a precipitous drop in those numbers? Because now hospitals’ or physicians’ schedules are dictating biological time, or medical time, if you will. (Yes, I’m exaggerating here for effect, but it does make you wonder about these things.)

So that’s my crux with usability: We’ve come to this point where the physician’s schedule—whether driven by the hospital, the physician, or some other factor—is dictating how care providers use technology to meet the scheduling needs of caregiving versus how the patient is being treated and recognized as a distinct individual based upon the operations of her or his biology.

One of the things that usability needs to address in terms of medical context is that each of us is a distinct biological, biochemical entity. We each have our own inherent sense of biochemical time. Your metabolism is different from mine, which is different from the person sitting next to us. Yet whenever a health or medical product is designed, it’s often assumed we all have common biomechanical times and our bodies will react and respond in the same way. The time it takes for the body to do X is the same for all of us. The duration of time it takes for X to become effective is the same for all of us. The duration of latency…etcetera. (I’m exaggerating here to make a point.) Suddenly we’ve become this aggregate normed time for a group of distinct units.^[3] S. Scott Graham is doing important work in this area of pharmacology within the rhetoric of health and medicine and would be a resource for learning more about this topic.

RGL: It sounds like one of the issues that we have here is that time is unique to each individual. And the “where,” as you said, is determined by the time. So you’ve got an individual impacting the time at which they can do something, impacting the place in which they can do something. So where this becomes a usability issue becomes really obvious. You’ve got your “who,” your “where,” and your “when” all on the line, impacting each other in that way. This sounds really complicated. What do you see as an approach that either usability analysts or technical communicators can take to address this complex issue?

KSA: It’s difficult to gather the data, but the mechanism that you can start to work with in usability is something called a persona. A persona is an archetype of a kind of individual, or a kind of user. I’m a 47-year-old male, so based upon that, you’ve already started an archetype of health. If you combine my age and sex with my height and weight, rough idea of my health. If you pull my educational background and ask me to chart out the course of my day, you can come up with a pretty good composite of what individuals of my background do over the course of their day.

Based upon that, you’ve got one sort of archetype. For this kind of patient, the kinds of health crises they’re going to encounter are one, two, and three. And the chances they will encounter those crises are A, B, and C. It’ll be in these contexts at these times.

So, for example, if I’ve got high blood pressure, and I’ve got a very active lifestyle. Let’s say I’m working construction. You know that there are certain particular times of the day when I’ll be engaging in the heaviest physical kinds of labor. If, by contrast, I’m a truck driver, then you know there’s certain times of the day when I’ll be particularly sedentary for long periods of time. And then I’ll have to go from extended lackadaisical behavior to high energy. I pull the truck into the loading dock; I’ve got to jump out and help unload it. I’ve gone from sedentism to really high levels of exertion. Something’s going to happen there, particularly if I’m overweight and over the age of 45, and I’ve got high blood pressure.

It’s not a perfect system, but you can begin to pinpoint more effectively the ranges in which certain types of patients might have events. Now, as you pointed out, the difficulty is that it’s time-consuming, and it requires us going beyond collecting data through surveys. We’ve all been to the hospital where someone asks, “Tell us about your family history background, your personal background,” and they take your diagnostics, but they don’t ask you a whole lot about your lifestyle.

We’ve got to add that lifestyle component and start to figure out, based upon lifestyle components, when something is likely to happen. There’s something called “journey mapping” in usability, which can entail having individuals keep a journal of when they go through their day and what they do. You can then use those journals to figure out where different kinds of activities take place. If you could digitize those and make them parts of medical health records, that could be a really valuable resource to begin to simply build into the current electronic data gathering systems we have.^[4]Cathryn Molloy is doing key work in this area of using patients’ everyday clinical experiences to examine patient-centered care and how individuals experience various aspects of health and medicine.

We have the technology to do it. We need to think through what kind of data we need to collect with it and how we need to aggregate it. But to get all of this done…all of a sudden, insurance that pays for medical care could start reconceiving how we have medical episodes and treat them. You mentioned having labor induced. How much of that is driven by the physician, and how much of that is driven by the insurance provider? At what stage are financial decisions governing what our biological health should be?

So it’s a twofold approach: It’s education of the financial backers as well as education of the physicians, or the medical-industrial complex, for lack of a better term.

RGL: That thought definitely came to mind when you talked about this overemphasized focus on physician time. Well, time is money: We’re paying for the physician’s time, or we’re not paying for the physician’s time. It’s not surprising that so much of healthcare would involve physician-centered time, because it’s that time that is driving the cost. As long as it’s cost-centered, it’s going to be physician-time-centered.

KSA: But how much of that is also culturally driven? In different cultures where there isn’t that financialization of healthcare, with more socialized medical systems, are things being done according to different perceptions of time? And I think that’s where things get interesting. Take diagnostics, for example. You would have some sort of pain or something happens, and you really need to get a physician to see it. Well, your chances get bottlenecked because of your availability to access physicians and the spaces in which you can get to physicians.

Now in France, the individuals who run pharmacies have a certain degree of medical training that allows them to engage in basic diagnostic processes and prescribe prescriptions on the spot.^[5]See, for example, “French ‘Pharmacies’ – More Than Just a Chemist” (anglophone-direct.com/chemists-in-france/) Suddenly, we’ve markedly increased the number of medical providers we can go to when—notice the time factor. We’ve increased the “where”—places we can go to get treatment— “when” something happens.

By expanding that kind of “where” to go “when,” we increase the chances of something getting caught before it becomes problematic, that it gets treated very quickly and efficiently on the spot, and the treatment is contextualized. What does that pain feel like right now versus what did that pain feel like when you had it four days ago? It’s a matter of rethinking our approach to healthcare in terms of “when something happens, where can we go?” What venues do we have available to us?

The danger in that becomes, for many of us in the United States, we go to the internet.^[6] See, for example, “More Than One-Third of U.S. Adults Use Internet to Diagnose Medical Condition” (cbsnews.com/news/more-than-one-third-of-us-adults-use-internet-to-diagnose-medical-condition/) I have a pain. When this happens, here’s where I’m going. I’m going online. And as most folks know, the kinds of information you get online…it’s all over the place. It can be very accurate to just downright deadly.^[7]See, for example, “Wikipedia vs Peer-Reviewed Medical Literature for Information About the 10 Most Costly Medical Conditions” (jaoa.org/article.aspx?articleid=2094721)

We’ve become so conditioned in the United States to “when” that we’ll take anything for “where,” because we need to address it immediately. The venues we have don’t address the time at which we’re experiencing something, and therefore, we settle for a default. For example, when something happens to one of my kids, I do two things: call 911 and hit the web. Why do I hit the web? Because there’s no one who can provide, at that moment, immediate care, for the most part.

And that begs the question: Should we look into emergency telemedicine, invest in that on a larger scale so that when something happens, the person on the other end of the line does more than schedule a call? They do in some cases, but how well-informed is the person at the other end of the line, in terms of basic emergency care, so they can begin to talk you through provisional diagnostic and emergency treatment practices in the moment?^[8]Elizabeth Angeli is doing some interesting work on how emergency care providers are using technology to engage more directly and effectively with individuals to address healthcare contexts. See … Continue reading

So we’re back to my earlier point: It’s got to be patient-centered time.^[9] In many ways, these ideas are similar to patient-centered care (see catalyst.nejm.org/what-is-patient-centered-care).

RGL: What are you working on now that looks at patient-centered time?

KSA: I’m working with a team of biomedical engineers who are trying to come up with technologies for anticipating and treating epileptic seizures.^[10]See neuronem.latech.edu/index.php So time is everything, and patient-centered time is everything, because you have to figure out what the onset of a seizure looks like. You can say, “These are trigger points when seizures often happen,” but that’s different from when the seizure happens.

You need to look at the individual. When does it happen for the individual? What do you measure in the individual? This is where the notion of patient-centered time becomes very important. The one-size-fits-all approach to medicine is not sustainable. We’ve got an industrialized society, and therefore we’ve got an industrialized healthcare system. But we’re not widgets. We’re not car fenders. You can’t treat human beings as massified products. They don’t work that way.^[11] Under the directorship of Michael J. Klein, the Cohen Center at James Madison University (see jmu.edu/cohencenter/) has sponsored public lectures that examine various aspects of these issues.

Historically, we’ve had several levers of superstructures that were designed to address the “when” of something happening. Someone in the local community was the repository of medical knowledge, and rings of individuals represented different levels of medical professional specializations. From the birthing perspective, you had the doulas and midwives, who are part of a community as well as the physician.

Over time, we began to remove those individuals who played a critical role in terms of “who” you go to “when” something happens. We’ve stripped them away to say, “Go to the source.” We’ve moved from “when” to “where.” We’ve limited the “who” to turn to in times of crisis, instead directing people to a space and saying “all will be provided to you there.” It’s shopping mall healthcare.

If we begin to look at societies that have not yet stripped away those different levels of care, how do they respond whenever something happens? There’s a crisis in that moment. Who do folks turn to?

In the rhetoric of health and medicine, I’ve heard it referred to as “bringing the body back.”^[12]Lisa Meloncon is doing some foundational work in this area; see, for example, her entry “Bringing the Body Back Through Performative Phenomenology” in Methodologies for the Rhetoric of Health … Continue reading We’ve mechanized humanity to the point where we think we should all operate like well-oiled machines. Well, no. What does the body mean? How do we bring it back and treat it as a system or unit of an individual?

Neil Postman is a media critic and author of the 1985 book Amusing Ourselves to Death, about the effects of television on society. In that book, he says there really is no such thing as naturally occurring units of measurement. Rather, there are technologies we develop, and those technologies bring with them the units we use to measure things that the technology has inherent to it.^[13]The units of measurement of a clock, for example, affect if we think about, or try to address, time in terms of days, hours, minutes, or seconds depending on the units the related device uses to … Continue reading

In essence, times gets fixed by the technology used to measure stuff. So as we create more technologies to measure our health, they begin to dictate what we must do at certain times, based upon what the technology is capable of doing.

RGL: The way we measured time when we had sundials is different than the way we measure time when we have clocks.

KSA: Exactly. Like average pulse rate. Was there an average pulse rate before we had watches? What did physicians test? They could test if you had a pulse. But how did they figure out what the average rate was? We had blood pressure, but what was high blood pressure before blood pressure cuffs? How is technology dictating these metrics of health, and then dictating when we need to get treated for things?

We’re back to the difference between preemptive care and responsive care. Rather than treat something only when it happens, if you measure the signs that could lead up to something, viewing medical time as anticipatory time, you greatly change how you address medicine and how you approach health and wellness.

And then we’re back to money. Is it more cost-effective to treat before, or is it more cost-effective to treat when it happens?

RGL: When you have issues like “we’re treating the body like a machine,” or “technology development is dictating what we measure,” I find that there can be a knee-jerk reaction to remove oneself from the machine metaphors and from the control of the technology. And then there’s an attempt to backtrack. “Well, we’ve moved away too far. What we really need is to bridge these concepts, where humans are unique units, they’re not just one big aggregate system.” Is this a case where something like big data is part of the solution? In a lot of work in rhetoric, there’s a huge emphasis on the qualitative, especially when it comes to the importance of embodiment, which is very difficult to measure. Then more recently, there seems to be this call to give more respect to what quantitative data can give us. This seems like a case where in order to get at individualizing care based on patient time, one of the answers is to use technologies to get these larger measurements, to get this huge population of data so that we can start to see trends among truck drivers and 45-year-old men who have two kids. Do you see a possibility for big data to be part of the solution?

KSA: It can be, once we take big data and parse it into units, so it’s not just all of humanity. This is the blood pressure for all of humanity, but this is the blood pressure for these different groups. I think that can work. But the problem with big data is, again, we’re back to the “when.” I know “what” kind of data it is. “When” was it generated?

Do we have the technology and nuance to compare when this person had a cardiac event here versus when this person had a cardiac event there? That’s the distinction. Again, big data can only be useful if it can be correctly contextualized. It has to be contextualized according to the chronology of the individual’s biology, not according to what a generic metric says. If we design big data collection systems to build time into data collection, and to mark and measure that timing, then we’ve got something we can work with.

So we need to design technologies that link the timing aspect of events with when data is collected. I think the best example of that are insulin pumps that measure in the moment someone’s insulin level, of a specific individual. Now, there are going to be privacy issues at stake, but if all the insulin pumps that individuals have are linked together and you have enough demographic data on the people who have these pumps, you can come up with some pretty good information in terms of when there’s most likely to be an event. And now we’ve got big data that’s got meaning, because it’s been tied to individuals and contextualized time. It’s the same thing with pacemakers. If we could integrate systems so we know when certain individuals are more likely to experience an arrhythmia based upon pacemaker data, then we’d have something we can work with. But until we begin to build that component of contextualized time into the data collection mechanism, it’s all guesswork.

RGL: When I hear context, I think of rhetoric, so when you say “contextualized time,” I think of kairos. How does kairos fit into this concept?

KSA: The framework for all of this is kairotic care. When you have kairotic care, you begin with who the individual is, what they are experiencing, where they are, what kind of data we can collect, and how we treat it in the moment. You consider preemptive treatment versus restorative treatment. All of these things factor in.

Care right now is logos-driven. It’s logical, methodical, mechanical, science-based, which is great if we all have the same event at the same time in the same place. But that’s not going to happen. So it’s got to be kairotically driven. Where are you when this happens?

The fear for me is that we’ve spent roughly 200 years figuring out all this stuff—modern medicine—through, for lack of a better way of putting it, trial and error. And now we’ve come to the point where we’re actually forgetting it because it doesn’t fit into our schedules.

We mentioned childbirth earlier. Breech births historically have been a very dangerous thing. It took medical science a very long period of time, relatively speaking, to figure out how to effectively deliver babies with breech birth. Now, my understanding is that some physicians are not really being taught how to address breech births anymore. They’re being taught, instead, to do a C-section.^[14]See, for example “The Vanishing Birth Method” (elle.com/life-love/a44842/decline-of-breech-birth/) and “15 Signs The Doctor Doesn’t Know How to Handle a Breech Birth” … Continue reading

So there is the chance that this medical knowledge that took years to generate, produce, and perfect, could be lost, because it’s not convenient. That is a scary concept. That’s why, at this point in time, it’s really important to begin exploring these things. What medical knowledge are we going to be losing, simply because it’s not convenient?

The work that you are doing and others are doing—looking at these notions of time as related to space and where things take place—is so crucially important right now. These ideas need to be discussed more widely, more openly. Not as a separate facet of the rhetoric of health and medicine, but as a core component, discussed as part of every aspect of the rhetoric of health and medicine. That’s the takeaway, that this isn’t ancillary. This is central.

Biography

Kirk St.Amant is a Professor and the Eunice C. Williamson Endowed Chair of Technical Communication at Louisiana Tech University and an Adjunct Professor of International Health and Medical Communication at the University of Limerick.

Interviewer Biography

Rachael Graham Lussos is a PhD Candidate in Writing and Rhetoric at George Mason University. While her dissertation research focuses on the rhetorics of quantification in the context of chronic pain, she has previously researched the rhetorics of proposal writing, verb voice in sexual assault news reporting, and activist composition. Her research appears in Journal of Technical Writing and Communication (JTWC), The Journal of Multimodal Rhetorics (JOMR), Kairos: PraxisWiki, Journal of Mason Graduate Research (JMGR), and Computers and Composition. She is a professional writing consultant and an adjunct professor with American University’s MPA program.

©2018 Kirk St.Amant and Rachael Graham Lussos, used by permission

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Technoculture Volume 8 (2018)