The Chronemic Variable

Time talks. It speaks more plainly than words. The message it conveys comes through loud and clear. It can shout the truth where words lie.

-- Edward T. Hall

Chronemics (also referred to as temporality) is the study of how we perceive, structure, and react to time and the message we interpret from such usage. In chiropractic, we spend time with our patients, allow time for certain procedures, calculate our earnings according to time, buy advertising time on radio or television, and take courses to learn how to efficiently manage time, not waste it. In short, we structure our lives according to time: work, sleep, play, etc.

Time is linked to status. The college student is not expected to be late for class. His professor, however, is permitted to be five or 10 minutes late. But, if the professor has an appointment with the dean, the dean is extended the privilege of being a little late. Traditionally, at least in our culture, the physician's time is taken to be more important than the patient's time. With few exceptions, patients have come to expect to wait either for an appointment or in the doctor's waiting room. That must be why it is called a waiting room.

The longer you keep patients waiting in your waiting room, the more you are implying that they are insignificant to you. In point of fact, some patients who are made to wait excessively long periods of time are prone to develop a serious resentment toward the doctor. This, in turn, could significantly detract from any forthcoming therapeutic relationship. To counteract such a chronemic dilemma, the doctor (or nurse) should make every effort to avoid keeping a patient waiting. If a prolonged period of waiting is inevitable, a respectful apology and explanation should be given for the delay.

Attitudes toward time are not universal. Each culture has its own way of viewing time, and each has established definite patterns for using it. There are three different time systems: technical time; formal time; and informal time. Technical time is the scientific and precise way time is measured. Formal time is the traditional way we view time: seconds, minutes, hours, days, months, or years. Informal time is the most difficult to learn and understand because it is so loosely defined. For instance, in our culture, we have the concept of duration. Informally, there are eight levels of duration: immediate; very short; short; neutral; long; very long; terribly long; and forever. Doctors are continuously asked such time-related questions as, "How long will each treatment take? How long will I need these adjustments? When will I be better? How often should I take these vitamins?" Ambiguous responses like "regularly, in a little while, soon, and shortly," are common to the health field.

American businessmen have told angry tales of having to wait a half-hour, or longer, to see an Arab or Latin American associate. To the American, a waiting period of this length is an insult, but in other cultures it is appropriate. An extreme example of this cultural difference can be found among the Sioux Indians. In this language, there is no word for time, late, or waiting. Then, there are the Hopi Indians who also pay very little attention to time as we know it. They believe that each thing, whether a person, plant, or animal, has its own time system.

Researchers at the Neuropsychiatric Institute in Princeton have isolated three time-types and suggest that these different perceptions of past, present, and future influence how people behave. The past-type tends to live in the past and continually makes judgments about the present in terms of how things used to be. The present-type lives in the here and now: doesn't like waiting for action, makes decisions quickly, and works effectively. The future-type spends much of the present thinking about how things are going to be and then works backward to the present.

Two other important time-types of people should be added to the aforementioned classification: monochronic and polychronic. The former can only do one thing at a time and becomes frustrated when confronted with multiples. The latter is extremely comfortable doing more than one thing at a time. While this difference in the way health care givers handle time can occur in a solitary practice, it becomes proportionately disturbing in a group practice. Not infrequently, you will find one doctor who can easily treat three patients simultaneously, while another becomes completely unnerved if several patients require his attention at the same time.

A busy practice must run on schedule. In the moment any member of an office team fails to respect scheduled procedures, confusion often results. We all know how a few late patients can interfere with a smoothly running office. When either patients or doctors have to wait for each other too long, emotional climates tend to rise.

Doctors, staff, and patients each display time-related behavior. For example, every office has its own unique rhythm. In some offices, everything happens quickly and patients are rushed through their treatments. Other offices are more casual and easy going. Doctors and nurses speak slowly and quietly, take their time moving from room to room, and from patient to patient. Nobody appears to be in a hurry.

The consequences of an office rhythm can have either a negative or positive impact on a new patient. Imagine a hypokinetic (slow-paced) individual entering a frenetic office, where everyone walks and talks with a sense of urgency and impatience. Such a person might easily feel uncomfortable and threatened. Conversely, a hyperkinetic (fast-moving) individual would be impervious to the accelerated pace.

Chiropractic treatments also have a time-related dimension. Despite arguments to the contrary, a great many patients genuinely believe that the more time a doctor spends with them, the better the treatment. Compare the following two patients: One receives, in succession, diathermy, sine wave, ultrasound, and an adjustment. The other, without disrobing is in and out of the treatment room in a matter of minutes. While the therapeutic value of any treatment should not be judged by its duration, many patients have a tendency to equate duration with benefit.

The length of time taken to administer a routine adjustment is also a worthwhile consideration. Each chiropractor approaches the adjustment differently. Some can deliver it in a couple of minutes, others spend significantly more time. Nevertheless, that is not the point I wish to stress: I am more concerned with the amount of time doctors allow for their patients to psychologically prepare for the actual adjustment. The conventional instruction, "Take a deep breath and let it out slowly" usually works well. On occasion, however, the thrust is met with considerable muscular resistance and produces pain. Because patients occasionally say, "Doctor, please give me a little more time to relax before you make the adjustment," the patient's plea for a little more time must be respected. The doctor must make a concerted effort to patiently wait for all the air to be released before making a thrust. Hence, the ideal adjustment is one in which there is a chronemic coordination between doctor and patient: a mutual synchronization of intent and purpose.

This broad conception of time, and the role it plays in health care, definitely warrants more attention. I have tried to illustrate the importance of timing in a well run chiropractic office. This is especially true because we live in a multicultural society, one in which both staff and patients may come from different parts of the world and bring with them varying perceptions of time. A perfect example of this cultural mix can be found in any inner-city hospital.

Although the success or failure of any practice could most certainly be attributed to a number of different factors, I assure you that the management of time will, undoubtedly, head the list.

Abne M. Eisenberg, D.C., Ph.D.
Croton on Hudson, New York