Guest Editorial: Towards a Deeper Understanding of Time to Avoid Burnout

Time can be a scarce resource in the ICU. The unpredictable nature of the ICU demands that we always be ready to accommodate a sick patient. Our next patient can be a new patient from our own hospital’s emergency room, ward, or delivery room, or an emergent transfer from another hospital. We are also expected to be immediately available for the surgeon to report on a patient’s operative course, the operating room handoff from anesthesia, or any team member who has concerns about how a patient is progressing. While some of these demands are a part of many aspects of work – availability to speak with a colleague, a parent—what differentiates our work in the ICU is the potential risk to patients if we aren’t available immediately.  And even once available, the timeliness of completing a required task- central line, invasive airway, re-escalation of a medication – can have consequences. There is no truly protected time for an event to unfold. Even OR handoffs, which should ideally be done without distractions, can be interrupted by the unstable patient. And even when we would like time to honor a family’s decision to redirect care of their child, we cannot guarantee we can be there without interruption.

I’ve always had a tumultuous relationship with time. Growing up in a family with a Japanese mother and a Taiwanese father, I believed that timeliness was a sign of respect. Both being on time and getting things done on time were important ways to show that you respected the person who had requested your time.  If we had to travel to an appointment and weren’t sure of the way, we would either drive out the day before to make sure we knew the correct path (pre-Waze) or leave a couple of hours early. When I was a critical care fellow in a busy 40+bed unit, I would always cherish the extra hour at the end of daylight savings because it meant I had more time to get the tasks done before my co-fellows returned in the morning.

It wasn’t until years later that I realized that my relationship with time- what an expert on time like Dawna Ballard PhD would call “time urgent,” where I constantly feel like I am racing against the clock– could affect the longevity of someone like me in ICU medicine. While my relationship with time­­­ probably influenced my decision to go into critical care, my training in critical care also fostered a greater intensity to my time urgency. Even today when I am resuscitating a patient, I have flashbacks to my days as a critical care fellow in Pittsburgh. One particular attending would be pacing back and forth in a patient’s room until the lines, fluids, and antibiotics were all given to a patient in septic shock. He instills in each of his fellows the urgency of the golden hour of septic shock. Thinking about it now, maybe some of us felt that clock ticking louder than others.

Humans created our current understanding of time with the concepts of seconds, minutes, and hours becoming universally accepted as measures of time. This perception of time as “clock” time is a product of the industrial age and is meant to give us the illusion that all time is the same. But we know that isn’t true. Certain events, such as the unexpected death of a loved one, can shatter this illusion of time, and its power over us immediately diminishes. We see this in our unit when a patient suffers a cardiac arrest at the change of shift for our nurses. We joke that it’s the best time for eCPR because we have so many nurses who are not only coming in ready to help but those who stay late, despite being exhausted from a busy 12 hour shift. At that moment, the event- a patient’s cardiac arrest- is more powerful than the clock telling them their work is done.

I now believe that the relationship we have with time and specifically, our own individual sense of time urgency and time scarcity can lead to burnout. I think a lot about who and what controls my time in the unit. Who is the pacesetter in the unit? The patients? Computer-related tasks? Surgeons? And is there an ideal? In the prior example, where the patient and the event set the pace, and our teams adapt, is this really a sustainable model? What influences the allocation of my time? Do I suffer from unconscious bias as I make decisions on who gets my time? Is it always based on the needs of the patient or do some parents receive more time because they are well educated, speak English, and are more powerful advocates for their children?

Levine and Bartlett (1) are time researchers who developed measures for a country’s “pace of life.” They operationalized the “pace of life” by measuring the average walking speed of the people in a given city, the time it took to mail a letter at the post office, and the accuracy of the clock at a bank. This “pace” was then correlated with health measures such as coronary artery disease with those countries with faster paces having more disease. (2) How would this type of work translate to our field? Would a CVICU have the fastest “pace” in a hospital? Would it vary across the country? Across the world? How would that correlate with burnout?

Remembering that humans constructed our current understanding of time empowers us to rethink how we allocate it. As with any scarce resource, daily reflection on this allocation to ensure it aligns with our goals of service to our patients and their families, to our colleagues, and to ourselves is important.

1. Levine RV, Lynch K, Miyake K, Lucia M. The Type A city: coronary heart disease and the pace of life. J Behav Med. 1989 Dec;12(6):509-24. doi: 10.1007/BF00844822. PMID: 2634107.
2. Levine RV, Bartlett K. Pace of Life, Punctuality, and Coronary Heart Disease in Six Countries. Journal of Cross-Cultural Psychology. 1984;15(2):233-255.