“I circled 30 minutes … but it feels more like five hours getting ready for work Monday to Friday and only 15 minutes in a hot bath on weekends,” my patient relayed to me.
Greg (name changed, obviously) is an ambitious young professional who has axial spondyloarthritis. He’s also a really funny guy with a knack for saying things that are philosophically deep in a very comedic way. Here, he told me something that made me rethink much of what we do as rheumatologists. When is a minute actually an hour? And when does a month pass faster than a day? Let’s rheuminate.
Worse yet, the sensation of pain changes the way we view the world. Pain has a remarkable capacity to extend the passage of time. When viewing the role of pain as a nerve signal to identify a source of harm, we understand that pain, indeed, would heighten the senses to the passage of time. Rheumatic conditions are often painful, and it is important to acknowledge that, when disease and pain are uncontrolled, time seems to pass slower than we want it to.
Another element is at play in rheumatic conditions. Sympathetic outflow is often increased in patients with rheumatic conditions, even independent of pain. Ensuring that we make time for fight-or-flight responses makes complete sense in the evolutionary context. But when it comes to autoimmune disease, this survival reflex—and its effects on the sense of time passing—seems downright counterintuitive.
Embrace the Golden Minute
Here’s where things get even stranger. The concept of chronos is fairly universal but kairos is individualized. It is fascinating to think that when two people are in the same room during a 60-minute clinical consult each person is experiencing time distinctly. One challenge for the practicing rheumatologist is to coordinate this time so that it feels less discordant. A busy rheumatologist may be looking at the clock to ensure their clinic schedule is on time. The patient, on the other hand, may be noticing the passage of time in context to the long trip to the office, the anticipation in the waiting room and prior experiences in the examination room.
The clinician may be tactically using the time to extract the most information from the patient, but the patient may in turn be using that time to relay all the information since their last appointment they wish to share. That time is valuable to both people, but what they invest in each minute of the encounter may be radically different. How do we reconcile this?
Patient experience experts have long talked about the golden minute—the first minute of an encounter in which the clinician should pay full attention to the patient without any interruptions or distractions. There’s some evidence to support its utility. Data from a scoping review in 2022 suggest that patients’ opening statements last approximately 40 seconds, but physicians tend to interrupt them after about 20 seconds.1 Rheumatology-specific information is sparse, but it stands to reason that rates are similar in our specialty.
But why stop at a minute at the beginning of the encounter? Rheumatologists should aim to minimize interruptions throughout the entire course of the encounter. Of course, rheumatologists sometimes need to engage in redirection and facilitation, but that should be the exception rather than the norm. If we minimize interruptions, we can not only receive vital information but also gain insights into how our patients sense the passage of time.
Maintain the Flow
It’s not just in the clinic that we see time isn’t always neatly ordered. I’m sure you’ve had instances in which you’ve lost track of time doing something really enjoyable, like watching or participating in sports or video games. First named in 1970 by the psychologist Mihály Csíkszentmihályi, this phenomenon of being completely immersed in an activity leading to alterations in sensing time has been called flow.2
Everyone seems to experience flow differently, but I have experienced it in teaching clinics. It is incredible how fast a morning can pass when you enjoy being around enthusiastic learners committed to improving the health of individuals and society. Occasionally when I write columns, I also find myself in the flow and am shocked that the entire afternoon has passed by.
Dr. Csíkszentmihályi’s flow model has important implications for well-being for rheumatologists. According to Dr. Csíkszentmihályi, flow only occurs when three preconditions exist: 1) clear goals and progress; 2) clear and immediate feedback, and 3) confidence in the ability to complete the task.3 When we are at our best, we should feel that we are entering this trance, but we can only do so when those three critical conditions are met.
The electronic health record (EHR) has been an impediment to achieving this flow state because it has made sure we have no sense of clear goals or progress. After all, most EHR systems have been made for administrators, with billing in mind, rather than for clinicians, who seek cognitive and empathic engagement with their patients.
Interprofessional teamwork is another aspect of making sure time passes pleasantly through the flow experience. When we are around people who make us feel valued, we can achieve flow as an entire unit.4 Rheumatology is rarely a solo activity; ensuring we have teams that can get into this flow is important for quality care.
Time Management
A week after Greg’s appointment as these ideas churned in my head, I started to comprehend a deeper meaning to “time management.” Admittedly, as a student and trainee, I wasn’t the best at time management. Procrastination has been a companion of mine since high school—one I have been unable to shake off. But looking at this discordance between chronos and kairos, I’m starting to see that my procrastination is less a failing of mine than a desire to manage the passage of time. By procrastinating, I’m looking at extending the time that I’m enjoying and putting myself into a forced flow state for a challenging time-driven situation with clear goals and immediate feedback.
I wish I had known Greg earlier because it would have saved me so much self-loathing and would have provided me a positive direction for my work. There is no shortage of gurus out there who peddle solutions for fitting more tasks into one day. I’m guilty of reading their books and blogs and listening to podcasts only to realize that none of their methods is sustainable. The time management that I seek is mastering the sensation of time passing.
At times, like when I am playing with my daughters, I want those moments to linger on, knowing they won’t last. At other times, I want to relish a sense of victory or accomplishment and freeze it for all posterity. And of course, there are some times, like busy hectic mornings, that I’d rather compress away. It feels paradoxical that we forget about the time in which we are truly enjoying ourselves and recall the drudgery when time seems to hang in the air. In rheuminating about what Greg mentioned, I’m now seeing how vital it is to be mindful of the happy times and ensure that we have a sense of control over the time we spend.
Greg is coming back to clinic in about six months. I’m looking forward to hearing his stories and his accomplishments from the moment I enter the examination room. I would be lucky to be in that flow state as I talk with Greg about how, hopefully, his back pain and morning stiffness are more manageable. Those six months between now and then are going to pass very quickly, but I hope to make every moment between now and then worthy of remembering.
Bharat Kumar, MD, MME, FACP, FAAAAI, RhMSUS, is the director of the rheumatology fellowship training program at the University of Iowa, Iowa City, and the physician editor of The Rheumatologist. Follow him on X @BharatKumarMD.
References
- Coyle AC, Yen RW, Elwyn G. Interrupted opening statements in clinical encounters: A scoping review. Patient Educ Couns. 2022 Aug;105(8):2653–2663.
- Peifer C, Wolters G, Harmat L, et al. A scoping review of flow research. Front Psychol. 2022 Apr 7;13:815665.
- Csikszentmihályi M, Abuhamdeh S, Nakamura J. Flow. In: Handbook of Competence and Motivation. New York, NY: Guilford Press; 2005.
- Salanova M, Rodríguez-Sánchez AM, Schaufeli WB, et al. Flowing together: A longitudinal study of collective efficacy and collective flow among workgroups. J Psychol. 2014 Jul–Aug;148(4):435–455.
