My time, your time, our time. Older patients’ and GPs’ time sensibilities around email consultations

ABSTRACT

In this study, we discuss how email consultations in general practice operate as a temporal technology, transforming working conditions and power relations between general practitioners (GPs) and patients. We draw on empirical material from Denmark in the form of a set of semi-structured interviews with 53 patients and 15 GPs, including two focus group discussions with 17 GPs. Our theoretical point of departure stems primarily from media theorist Sarah Sharma’s (2014) concept of power-chronography, which describes how power is embedded in temporal relations and everyday life and secondarily from sociologist, Judy Wajcman’s (2015) concept of multiple temporal landscapes. Patients and GPs calibrate their own time and attune their mutual time according to their expectations and ideas about the other party’s time. The patient and the GP can both be viewed as ‘time workers’ and the email consultation as a digital technology fostering the recalibration of one person’s time to that of another, requiring significant labour. The email consultation rearranges the GP-patient boundaries and thereby the power relations. Health institutions ought to consider whose time and labour is being ‘saved’ with digital systems.

KEYWORDS:

• Older patients
• general practice
• time
• power-chronography
• invisible labour
• email consultation

Introduction

Digital health care solutions are often proposed as ways to increase efficiency and save time - but how are the temporal aspects of digital health care solutions experienced by patients and health practitioners? Email consultations are one form of digital health. In this article, we present a qualitative study focusing on GPs’ and older patients’ perceptions and enactments of time in relation to email consultations. In Denmark, one of the most digitalised countries in the world, older citizens, born in 1957 or earlier (65 + years), are the most digitally adept in Europe (Statistics Denmark, 2022) and patients of 65 + years participate in email consultations with the highest frequency compared to younger patients (PLO, 2023a).

Investments in digital health care are often proposed by health authorities as ways to save time and improve efficiency in patient treatment (Hoeyer, 2023). For example, digital health solutions are pitched as enabling patients to save time by not having to transport themselves to the clinic and by not having to wait in a frequently long telephone queue (Pols, 2012; Funderskov et al., 2019; Ebert et al., 2019). Similarly, the old-age dependency ratio (i.e. the share of economically inactive old people versus the number of people of working age) will increase from 31.4 to 57.1 percent (Eurostat, 2021), which places an increasing burden on health consultations and has been described as a worldwide health care challenge (Bavngaard & Grønning, 2021; Cao et al., 2020). In this respect, email consultations offer a solution that potentially saves time and increases efficiency. Moreover, the Danish National Health Strategy emphasises patient centeredness as an important principle, as well as the authorities’ intention to empower patients by letting people’s time and opportunities control the system, and not letting the system control people (Danish Ministry of Health, 2018). In this way, email consultations can be viewed as offering patients more control of their own time.

From the perspective of health practitioners, working days are long and often hectic in a rapidly changing environment (for example, see: Watts & Pinskier, 2001; White, 2000). Moreover, institutional obligations and ritualized cultural practices (daily routines) that follow a certain schedule often colonize an individual’s time and normalize certain temporal rhythms (Wang, 2019). Focusing on general practice and the concept of institution-time (Klitzman, 2007), several studies show that, in general, GPs’ job dissatisfaction is highly influenced by a shortage of GPs, lack of time, too many working hours, administrative duties, and little free time (Marchand & Peckham, 2017; MacBride-Stewart, 2013; Pedersen et al., 2021).

In 2009, email consultations were implemented as a mandatory service in general practice in Denmark to ‘increase efficiency and quality through the digitalization of health care’ (Grønning et al., 2020; Klausen & Grønning, 2021; PLO, 2010) and as of 2022 constitute 25 percent of all consultations in general practice, corresponding to more than seven million email consultations per year (Statistics Denmark, 2022). GPs are renumerated by the public health authorities through a mixed capitation (number of citizens they serve) and fee-for-service system (Rose Olsen et al., 2016). Each email consultation is remunerated with DKK 48,99 (EUR 6, 57) with the limitation of only one remunerated email consultation per patient, per day. In comparison, in-clinic consultation is remunerated with DKK 156,39 (EUR 20,97) per October 2023 (PLO, 2023b). Although email consultations were implemented with the goal of increasing efficiency, GPs report spending too much time on email consultations. In one high-profile media example, during a Danish prime-time news programme, the head of the Danish Organization of General Practitioners stated: ‘We spend too much time on email consultations’ (Clausen & Kongsted, 2016). More recently, an article in one of the dominant Danish omnibus newspapers, carried the following headline: ‘Physicians spend more time on the screen and less on patients’ (Høgh-Olesen & Nielsen, 2021). Headlines such as these illustrate what sociologist Judy Wajcman refers to as a ‘time-pressure paradox’ (2015, p. 16): The new digital technologies are imagined to reduce the amount of time spent on performing different tasks, yet they not only introduce new tasks (connected to using and maintaining the technologies) but also a set of new expectations about how time and labour should be managed. This close relation between ideals of efficiency, user-centeredness and quality through the introduction of digital communication in the Danish health sector calls for empirical examination to uncover workers’ and citizens’ perceptions and lived experiences of digital technologies’ (potential) redistribution of time.

To investigate the time-pressure paradoxes and temporal dimensions of email consultation as part of the Danish health care sector, we primarily deploy media theorist Sarah Sharma’s (2014) critical approach to time and temporalities and secondarily sociologist Judy Wajcman’s (2015) concept of multiple temporal landscapes. Sharma’s concept of power-chronography, which is further introduced in the next section, highlights a focus on lived, experienced time (vs. objective time) and the role played by synchronicity in everyday microscale orderings of bodies and material relations. In this study, we draw on empirical material to present and discuss how the email consultation within a general practice setting can be analysed as a temporal technology introducing a heightened focus on time and an increased time sensibility among both GP and patient. This can, as others before us have pointed out, in no simple way be linked to either a speeding-up or slowing down, but unfolds instead through ‘multiple temporal landscapes, both fast and slow’ (2015, p. 18), a point which according to Wajcman applies to digital devices at large.

Investigating the connection between email consultations and the time aspect is useful to further understand patients’ and GPs’ perceptions of their digital practices. Based on the high number of email consultations, the public debate focusing on time pressure in health care and on the governmental wish to let people’s time control the system, this article is guided by a principal research question, namely: How does email consultation as a digital technology reconfigure the patient’s and GP’s perceptions of time? This question is answered through a qualitative analysis of a set of semi-structured interviews with 53 patients and 15 GPs, including two focus group discussions with 17 GPs, conducted from February 2016 to June 2019.

Email consultation and time – a research overview

Studies about email consultations and time in health care settings have primarily been concerned with the evaluation of digital tools, time pressure and effectiveness (Cowie et al., 2018), workloads (Drennan, 2018; Farr et al., 2018), waiting time (Caffery et al., 2016), improved access (Assing Hvidt et al., 2021; Fagerlund et al., 2019; Keely et al., 2013; Nijland et al., 2009) and coherence (Parikh et al., 2017). For instance, the potential of email consultations to offer a more timely and convenient method of accessing outpatient services has been recognized and discussed, as an additional method of accessing GP services with the potential to improve patients’ self-management. (Cowie et al., 2018; Wong & Lam, 2016). However, some studies have shown that using email consultations has increased rather than decreased practice workloads, although some patients use email consultations to try to save their own and/or their GPs’ time (Farr et al., 2018; Lichtner et al., 2013). Other studies have shown that email consultations from provider to provider can be used effectively to reduce waiting lists and waiting times for specialist outpatient services (Caffery et al., 2016).

A study about consultations and time more broadly, by Rhodes et al. (2015), based on interviews with 38 patients from 19 general practices in Northwest England, pointed to a number of temporal barriers impacting access to general practice from the patient’s perspective: practice opening hours, getting through on the telephone, persuading reception staff of the urgency of the patient’s need and obtaining an appointment within an acceptable and safe time frame. Rhodes et al. (2015) stated that some questions related to time (e.g. when to make a referral or order further investigation) can become a source of tension between GP and patient.

One study that had a particular focus on patients’ and GPs’ time was that of Klitzman (2007), who focused on perceptions and definitions of time among GPs who become patients. Klitzman argues that time is enacted and experienced differently for patients, doctors and health institutions, and these different temporalities affect patient experiences of care. Moreover, while tensions between these temporalities cannot be entirely eradicated, recognising these conflicts and their effects can improve care experiences.

While the above literature addresses many aspects of doctors’ and patients’ views and approaches concerning time, research into the multiple temporalities of care experiences in relation to email consultations remains limited. With this article, we aim to generate new insights into the potential for email consultations to redistribute time and labour for GPs and patients alike.

Theoretical framework: time and temporalities

To analyse our data on email consultations, we adopt a dynamic framing about time and temporality that involves more than past, present, and future. We apply the concept of power-chronography as defined by Sharma (2014), which brings forth awareness of power relations as they play out in time and various temporal architectures and modalities of (invisible) labour. For Sharma (2014), power is central to time, and temporalities must repeatedly be recalibrated to fit into a larger temporal order, or to be mutually attuned between people. Power-chronography is based on a conception of time as lived experience, always political, and produced at the collocation of a range of social differences and institutions. In our analysis, this concept is useful for exploring how the temporal orderings of social space play out differently for different bodies, in our case in the relation between the patient and the GP, which is reconfigured by the email consultation.

In using email consultation, we argue that patients and GPs undergo ‘related shifts in their own experiences of space and time (…) with different horizons of political possibility tied to where they exist within a larger temporal order’ (Sharma, 2014, p. 147). We approach the email consultation as a temporal technology through which the productive capacities of the individuals and the health care sector at large functions as ‘a biopolitical tool’. Hence, power-chronography has to do with time sensibilities and with how current discourses about speed and the fixation on optimization through control of time leave individuals, in our case patients and GPs, more vulnerable to biopolitical control (Sharma, 2014, p. 17), for example, difficulties in deselecting email services and/or managing own time. Furthermore, practices changing from physical to online are likely also to have major consequences for the objective and subjective aspects of time (Couldry & Hepp, 2017, p. 102). According to Nowotny (1994), the focus on temporality and digital connectivity may also lead to a growing sensitivity of the ‘little temporal differences’ we notice and often judge negatively, for example, when an email remains unanswered for a day (Nowotny, 1994, p. 106).

Within this theoretical framing, our work is guided by the principal research question: How does email consultation as a digital technology reconfigure the patient’s and GP’s perceptions of time?

Materials and methods

The data collection for this study was part of a larger qualitative research project exploring the potential of email consultations from the perspective of patients and GPs. Data are drawn from semi-structured interviews with patients and GPs, including 53 individual interviews with patients (aged between 65 and 91 years old) and 15 individual interviews with GPs. In addition, two focus group discussions with GPs were conducted: one group with 9 GPs and the other group with 8 GPs. GPs in focus group discussions were between 37 and 70 years of age. The majority of the patient interviews were conducted individually, but one interview was held as a double interview with a married couple based on their preference. All patients were recruited via their GPs through an open call disseminated orally in our professional network within the Region of Southern Denmark. We used our contacts with GPs from several networks and approached them in meetings, in the clinic, by email and telephone. All patients who were interviewed had had or attempted to have email consultations with their GPs.

The interviews were conducted by the authors AG, LMS, EAH and MK face-to-face in a setting of the patients’ own choosing, such as their homes (32), our offices at campus (9), a senior centre (10) and a public library (2). The interviews with the patients lasted between 22 and 75 min. A semi-structured interview guide included open-ended questions, such as: ‘In your opinion, what are the advantages of an email consultation?’; ‘What are the challenges?’; and ‘In what ways, if any, do email consultations have an impact on your relationship with your GP?’ The GP interviews were conducted in the clinic (23) or by telephone/Zoom (7) and included two focus group discussions with nine and eight GPs, which were conducted by XX in a meeting room at [name of location]. The interviews with GPs lasted between 10 and 97 min. The two focus groups were held in a meeting room at the university and lasted 61 and 191 min, respectively. All participants of both interviews and focus groups gave written consent. All interviews as well as the focus groups were conducted in the Danish language. Selected data for the purpose of this article were translated by the authors and subsequently proofread by the Language Services Unit at our university.

The interviews were transcribed verbatim, pseudonymized, then coded using the software programme NVivo 12. The transcripts were coded in two phases: an initial open coding process, including note-taking, abstracting and comparing, checking and refining in an abductive process following Kozinet’s netnographic approach (2015).

None of our interviews were planned beforehand to focus explicitly on time and temporal aspects but rather on more general questions about the interviewees’ use and perception of email consultations, including challenges and opportunities. Retrospectively, we found that orientations about time and temporalities were explicitly present in the majority of the interviewees’ utterances. These emerging findings left us with a strong conviction that this topic was important for further analysis.

Our initial coding process led to an attention to temporality and Sharma’s (2014) concept of power-chronography as possible analytical and interpretative tools. A deductive coding of the data was subsequently performed via the following four themes: the patient talking about their own time (1); the patient talking about the GP’s time (2); the GP talking about their own time (3); and the GP talking about the patient’s time (4).

Findings: time and temporalities

My time: patient perspectives about their own time

Patients’ descriptions of their own time affirmed hegemonic health policy discourses that email consultations ideally offer efficiency. A recurrent topic was that email consultation was perceived as easy to use and that saving time was a dominant factor, as this female patient (91 years) expressed:

I think it’s very simple and easy for me to use the digital form of consultation and contact with the GP. Then I also feel like all that medicine I get, I have it on the computer, and then I can then go in there and cross off what I need, and then he writes back if it's okay that I get it, and it's a great relief, because that way I save time.

As described above, the concept of power-chronography highlights a focus on experienced time and the role played by synchronicity in everyday practices. For the patients, emailing infused the perception of being in control over one’s own time, leading to an enhanced sense of agency. In that sense, the patients ‘recalibrated’ (Sharma, 2014, p. 20) their own time in relation to their own needs, including their wish to save time. As an example, one female patient (72 years) described the email consultation as a pleasant priority, and when asked to justify why, she associated the pleasant feeling with the perception of saving time by answering:

Well, that means not first sitting and gasping in the waiting room for a hundred years, right, and then in to the doctor to ask about what you might as well have asked about in another way. And then go home again with the answer, you know. By pleasant, I also mean that you do not spend time, and I like that, because there are many other more fun things to spend time on, right?

Importantly, for older patients, such as patients with terminal diagnoses (Lindén, 2021; Plage & Kirby, 2022), and generally in the transition from work to retirement (Wanka, 2020), ‘life-time’ is perceived as precious. The feeling that this life-time is ‘running out’ increases the quest to experience time as meaningful (Plage & Kirby, 2022, p. 108) and the pressure not to waste time (Wanka, 2020, p. 509). In our study, the older patients seemed quite aware of this, in fact challenging the implicit power structure within the commonly held prejudice that older people might have plenty of time and not much to do. On the contrary, several patients emphasized the importance of optimising and not wasting their lifetime as they were ‘running out of time’, as one patient explicitly formulated it. Moreover, some patients found visiting the GP in general not as pleasant an activity compared to other activities. Therefore, they found it more convenient and easier to send an email. Furthermore, some patients stressed the benefits of the asynchronous mode and the possibility to prepare an email, leave it in the draft folder and send it to the GP a few hours later or the next day. For these patients, consulting by email related to their time sensibility, including their wish to be able to control or have power over their own time, while also in the process planning when to write, when to edit, when to reflect and when to send the email to the GP.

For some patients, the mere possibility of sending an email meant something to them, even if they did not make use of it. In that sense, the email consultation as a temporal technology offered a permanent, albeit latent, written contact that was different from all other consultation forms (telephone, video, physical attendance in the clinic and home visit). This also corresponds with the more general argument emphasizing the positive digital exchange potential and ‘the sense of togetherness (mutual presence) […] maintained in the exchange of e-mail at a pace comfortable for both participants’ (Rooksby, 2002, p. 111). However, as we shall see in the following, the patients also related their time sensibilities to an optimization of the GP’s time and pointed to potential time-related problems.

Your time: patient perspectives about the GP’s time

The GP’s time was perceived as highly important by patients, of whom several mentioned that they did not want to interrupt the GP in a busy working day, nor take up their time. One patient (female, 73 years) expressed that email, due to the asynchronous communication mode, could lead to a better and more controlled organization of the working day for the GP, who could choose to answer when there was time for it:

I think that for the GP, that you write - then the GP can read it when there is time. It must also impose a different workload. So, on the phone, you’re right there, it’s here and, and you sit and wait. You can write when you have time, and then you get an answer when they have time - usually.

In this example, the patient deployed the email consultation as a way to achieve (imagined) synchronization of her own time to that of the GP. Her experience of own time becomes structured and to a large extent controlled by the institutional arrangement (institution-time) of which she is part in the role of being a patient. Likewise, another patient emphasized the GP’s workload and workflow through the following utterance, focusing on a more pleasant way of working for the GP:

They [the GPs] do not have to adjust in the same way by being able to sit and read on a screen or on a printout, I don’t know what. So, I think that it provides a more pleasant way of working for them, because then it is, I think, quite tiring to have to relate to new people all the time, to new impressions and new information.

In this quote, the email consultation is mobilized as a technology through which the GP is imagined as gaining more control over their working day and being relieved of the exhaustion of having to adapt to constantly changing settings. We see how the technology plays a significant role in the affective labour performed by the patient when imagining and trying to be mindful of the GP’s well-being and work life. The patient interviews revealed a general sense that GPs were perceived as busy, which affected their availability to provide care. Because of that, patients believed that they should not bother the GP, even to the point that some patients felt they should be protective of the GP’s time (also seen in other studies, e.g. Davis, 2006). Through the asynchronous email contact, the patients could initiate their own part (time) of the consultation without taking time from the GP – in a sense also trying to perform ‘doctorability’, which points to the finding that patients regularly orient towards legitimizing their visit to the doctor (Heritage & Robinson, 2006; Nielsen, 2015).

In relation to multiple temporal landscapes, both fast and slow, that come into play with the email consultation, one could argue that the patients in our study create their own slow part of the landscape and try to bear some of the burden of the GP’s fast-moving and time-stressful working day or at least help the GP with what the patients thought was meaningful for the GP and themselves. This left the majority of the patients with a good feeling, since they knew that the GP was very busy. The email consultation then emerges not so much as a digital form of communication that enhances efficiency and patient centeredness while saving everyone’s time, but more as a biopolitical technology interlaced with affective labour and the hierarchical ordering of bodies through time.

Moreover, some patients had insight into the GP’s work rhythm, which also can be seen as another kind of time sensibility. A 70-year-old female patient expressed a sense of her GP’s rhythm in this way: ‘And I know that when Hanne [the GP] comes in the morning, then I know that one of the first things she does is to look at the messages she gets and maybe answer[s] them, maybe not’. When writing in the evening, this patient tried to capture the GP’s work rhythm and hoped for an answer the next morning. In other words, the email consultation brings a new kind of perceived time sensibility, by the patient, into the relation between patient and GP.

My time: GP perspectives about their own time

Seen through the concept of power-chronography, the GPs’ descriptions of their own experience of time in relation to email consultations can be interpreted as an enrolment in practices of temporal labour. For some GPs, email consultations were regarded as ‘overtime work’ and not part of the formal organizational routines. In one clinic, three GPs took turns at spending two weeks each with the role of what they called the digital ‘mail reader’ (cf., Simonsen, 2021). One of the GPs explained:

It is overtime work these two weeks, that's just the way it is. And then you have to, even if you read it at home - we have a remote connection, most of us sit and read it at home on the couch while we watch television. It is also very effective.

These thoughts about overtime work are in keeping with Wajcman’s critique of digital technologies and their introduction of ‘time pressure paradoxes’ (2015), in which new routines and so-called ‘workarounds’ (Timmermans & Berg, 2010) are being invented to incorporate specific technologies and digital forms of communication into the workflow, thus sometimes creating more work instead of less. The work process, including overtime work, was linked to efficiency, including answering the patients’ emails while lying on the couch at home watching television. In another clinic, one GP described the work process and overtime work less optimistically: ‘We're never able to empty the inbox. It's always overflowing, and that's a bit of a disadvantage. Nobody has an obligation - it's overtime, it's just there as extra work’. A third GP informed us that she liked to take a look at her email consultations before she started working in the morning. She explained:

See what kinds of things I actually have to deal with out there in those correspondences [email consultations]. And maybe also because I actually think it’s quickest to respond to them before I get too tired or exhausted later in the day.

Again, the time aspect was in the GP’s mind as she considered at what time during the working day she could reply in the fastest possible way. These utterances by GPs represent an approach to email consultations in which the email consultations were not incorporated in the daily routines but rather had to be executed before or after ‘the real work’ (cf. Whiting & Symon, 2020). One explanation for this might be the way that email consultation was introduced in 2009, by the authorities imposing the implementation of this kind of consultation in general practice, entailing that it should not be ignored or opted out of by the clinics. How the GP in the above excerpt experiences email consultation in relation to a sense of institutional-time pressure put upon her also demonstrates the entanglements of email consultation and institution-time. Another explanation for the lack of implementation of email consultations in general practice might be the GPs’ lack of a deeper understanding of the organisational aspects of the daily routines and workflow in the clinic, including organising when and how to answer the email consultations.

Moreover, one GP described that, for the patient, the email consultation opened up access to a physical consultation, and thereby to more of the GP’s time if the GP assessed that the patient had a problem:

And it is clear that the econs [email consultation] is a way of getting hold of me, if now it is someone who has - thinks they have a problem, and if they think they have a problem, and they write an econs [email consultation] to me, and I also think they have a problem. Then it's also a very quick way to get me to look at it, because if I think they have a significant problem, then I see them the next day at some point - if nothing else at a zero time – that is, at a non-existent time – (…)

In that sense, the GP controls whether the patient will gain access to the GP’s time. If so, the email consultation becomes a quick way of entering the GP’s time, ‘if nothing else [as] a zero time (zero appointment) – that is, at a “non-existent time – (…)”’. When asked what the mentioned ‘zero-time’ meant, the GP answered: ‘A zero time is a non-existent time that exists in my world if I think it is important. But it’s one that risks going into either my break, or my free time, or another of the patients’’. In this case, email consultation is experienced as having the potential to disrupt the temporal arrangement of the GP’s working day by carving out a spatio-temporality referred to by the GP as a ‘zero time’. In this way, the GP can be viewed as a ‘time worker’ and the email consultation as a digital technology fostering the recalibration of time to that of the other – which holds true for both patient and GP – as a significant condition of their labour.

Your time: GP perspectives about the patient’s time

Similar to the patients, who mentioned the importance of the GP’s time, some of the GPs also mentioned the importance of the patients’ time, as this quote illustrates: ‘Well, I think that email is so smart, because patients write when they have time, and the GPs write when we have time’. In line with Sharma’s way of thinking, this quote emphasizes the mutual attunement to the other’s time that is a central element of power-chronography, in this case in the relation between GP and patient. Although most of the patients seemed conscientious and tried not to waste their GP’s time, some of the interviewed GPs did not always perceive the situation in the same way. As an example, one GP expressed annoyance towards what she called her ‘anxiety ladies’, who would email her in the middle of an anxiety attack but who would be fine the next day while she (the GP) would be wasting her time answering them. She further explained:

That's how the written language is today, isn't it? All that short message and everything, so it is - it is delivered just as you’re thinking it, when you are thinking it, without perhaps always having respect for the fact that there is someone at the other end who then spends time on that, right? So … 

It seems as if the GP in the above excerpt found it difficult to be the ‘someone at the other end’ who is wasting time. Moreover, the quote illustrates that when reflecting on email consultations, the GP mentioned the entry of another communication genre, namely short messaging, to which other expectations might be attached, such as faster exchanges and shorter messages. These expectations relate to the temporal landscape and speed.

Furthermore, emails allowed GPs to reflect on how to make best use of the patient’s time thus emphasizing the point made earlier that email consultation increases the GP’s time sensibility vis à vis the patient. One GP mentioned that when he answered by email, he felt that his messages were more thought through than in instant replies (e.g. via telephone consultation). As one of few GPs, he stated that he would like to receive a higher number of email consultations because he perceived them as being what he called ‘better medicine’ for the patient than telephone consultations. He emphasized the fact that in an email consultation, the patient received a written document stating what the GP thinks, and that the email message permanently remained there, something the telephone contact did not. He added:

(…) It's more thought through when the doctor answers by email than on the phone, where it's more off the top of your head: I do not think you should deal with it, come on, take two Panodils [acetaminophen] and move on.

The GP in this quote linked the email consultation with both a certain slowing down of pace as well as with permanence. The email consultation’s temporality was experienced as distinct from synchronicity and speed. This slower pace of communication and its permanence enhanced the email’s value as a GP-patient communication form, hence the GP’s perception of it as ‘better medicine’ compared to telephone and/or physical consultation. In line with the previously mentioned argument that patients perform ‘doctorability’ (Heritage & Robinson, 2006; Nielsen, 2015), one could argue that the opposite holds true in this example, as the GP prioritizes their own limited time to increase quality of treatment, thus performing ‘patientability’. This slower pace was associated with time to reflect before and during answering. Time to reflect thus emerged in relation to the asynchronicity of emailing and in opposition to the speed of synchronous communication forms. Furthermore, permanence is afforded by the email being archived in the patients’ inbox, allowing them to re-read exactly what the GP wrote. In this respect, we can return to Wajcman’s approach to digital technologies as unfolding through various temporal landscapes of both fast and slow (2015, p. 18). This example points to the aspect of slowness entailed in email consultation and demonstrates Wajcman’s point that technological devices ‘can be allies in our quest for time control, preserving time as well as using it’ (2015, p. 139). The examples we have presented frame the email consultation technology as contributing to a general perception of the GP being short of time. Below, we further discuss the temporal ambivalences of email consultation.

Discussion

With the governmental policy goal to make every third contact with a doctor digital (Danish Regions, 2018), time is a dominant factor in the institutionalisation of email consultations in general practice in Denmark. When politicians formulate digital strategies (Digital Health Strategy 2018-2024) and introduce mandatory email consultations based on ideals of efficiency, user-centeredness, and quality, they are not necessarily attuned to the detailed manner and circumstances in which time is organized and perceived in daily routines by patients and GPs, and how it is negotiated and enacted within their relationship. Consequently, they neglect to see that the introduction of email consultations is not saving patients’ and GPs’ time in all cases, and in some cases quite the reverse. More importantly, as shown by our data, the use of email consultations contributes to a much more complex and ambivalent picture than simply saving or wasting time, and more nuanced answers to the questions related to time are needed, e.g. how to relate to each other’s time through email as well as questions about suitable working routines.

As shown, email consultations mediate the GP’s and the patient’s time according to their own expectations and ideas about each other’s time. Thus, these expectations become implicitly entangled in the social relation between the GP and the patient. In relation to the concept of power-chronography, it is the GP, and the workings of institution-time, which combine to determine whether the patient gets consultation time with the GP, including how much or how little. Here, the email consultation can be seen as a demonstration of how the temporal orderings of social space play out differently for the GPs and the patients.

In keeping with power-chronography, we note that the email consultation for these patients came to serve as a technology which enables a prioritization of or sensitivity towards the GP’s time over that of the patient’s own time. We see how perceptions of time mediated through digital practices of communication thus become entangled in the social relation between the GP and the patient. The email consultation then comes to serve partly as a technology facilitating the aforementioned ‘recalibration’ (Sharma, 2014, p. 20) of the patient’s time to that of the GP’s. Time, as Sharma points out, referencing human geographer Doreen Massey (1994), does not function as a mere backdrop for social life, time co-produces it. Along these lines, we argue that the temporalities enacted in connection with the use of email consultation need to be made visible as a way of co-producing health care, including the GP-patient relation and roles. For older patients, the importance of not wasting their remaining ‘life-time’ seems important based on the fact that during their retirement they are actively re-negotiating the waste of time (Plage & Kirby, 2022). Thus, the email consultation is regarded as a convenient and easy way to consult their GP. In this context, in the sense of Sharma, slowing down can be seen as a privilege for these patients. Moreover, email is positively experienced as a slow asynchronous communication form with time to plan and reflect before disturbing others (the GP) and with the typed documentation, including the possibility to re-read the messages, email consultations seem to suit the patients in our study well, in the light of slow and fast temporal landscapes (Wajcman, 2015).

Our findings show that the relation between patient and GP that is mediated through email consultation encompasses an intertwined temporal sensibility of shared time. For instance, as described, the patients feel that sending an email will not disturb their GP as much as other consultation forms. However, an interesting question is whether patients would still perceive it as disturbing their GP less if they knew that their GP was answering while lying on the couch at home watching television or early in the morning before the ‘real work’. In that respect, the patients’ perceptions are highly influenced by their own expectations and thoughts about the GP’s time and are not necessarily in line with the GP’s actual daily rhythm and expectations, and vice versa. Likewise, the GPs are aware of the patients’ time, for example, when email consultation is experienced as more flexible for the patients as they can write when they have time, and also when the GPs emphasize the email’s strength of permanence and documentation, thus saving the patient’s time in the long run compared to the non-permanent telephone conversation.

As mentioned, Sharma points to the importance of tracing how differential relationships to time organize and perpetuate power inequalities (2014, p. 137). In that respect, a highly relevant question is whether the often invisible work ie. The ‘digi-housekeeping’ (Whiting & Symon, 2020) in and around the inbox by patients and GPs, and the perception of email consultations not being ‘real work’, can be said to increase or decrease inequalities. Viewed through the lens of time sensibilities, the use of email consultations by patients and GPs might indicate that some patients (those who are aware of these sensibilities) are preferentially treated, while others are overlooked, and such a marginalization could be interesting to investigate further by focusing on other patient groups (e.g. chronically ill patients, non-native speakers).

Finally, in our study, email consultation is experienced as having the potential to disrupt the temporal arrangement of GPs’ working day by carving out parts of their temporal landscape (e.g. the GP’s ‘non-existent’ time slots). Exploring GPs and patients as ‘time workers’ brings new perspectives into their relationship, in this case around the email consultation. Hopefully this study can inspire research of other digital technologies, such as video or chat consultations. In particular, we find it interesting to point out the complexities of GP labour and older patients as having limited time left, which produces different relationships with the idea of ‘speeding up’ health consultations. As our study highlights, there is no clear power hierarchy that can be mapped onto these groups. However, the institutional organisation of time (and speed) can multiply these inequities by reorienting care time in terms of labour and capital.

To our knowledge, this is the first study combining GPs’ and patients’ time perceptions with email consultation. A major contribution of our study is to make visible some of the many implicit temporal sensibilities and choices around email consultations and highlight their prevalence and importance, as these empirically grounded choices and sensibilities at times clash with the promises entailed in digitalising the healthcare sector (Hoeyer, 2023). In particular, this could be helpful for decision makers as to expand and nuance their knowledge in the field.

Conclusion

This study explored how email consultation in a Danish general practice setting can be analysed as a temporal technology that introduces a heightened focus on time and an increased time sensibility among both GPs and patients. Our data showed that email consultation contributes to a general perception of the GP being short of time and brings a new kind of perceived time sensibility into the relation between patient and GP.

Using Sharma’s (2014) concept of power-chronography, we demonstrated how perceptions of time mediated through digital practices of communication become a co-producer of social relations and health care, in this case the GP-patient relation, opening for a permanent (latent) written contact. Patients and GPs calibrate their own time and attune their mutual time according to their expectations and ideas about the other party’s time. The GP and the patient can be viewed as time workers and the email consultation as a digital technology fostering the recalibration of time to that of the other – which holds true for both patient and GP – as a significant condition for their labour. We argue that patients create their own slow part of the temporal landscape and try to bear some of the burden of the GP’s fast-moving and time-stressful working day. Likewise, the patient is time-disciplined by the GP through the email consultation. For the GPs, several temporal ambivalences are also tied to the email consultation in a busy working day. Thus, the email consultation blurs and rearranges the boundaries between the GP and the patient and thereby the power relations as they play out in time and invisible labour.

Acknowledgements

This work was supported by the VELUX FOUNDATIONS Grant number 18158.

The study was approved by the institutional review board of the University of Southern Denmark, the Research and Innovation Organization (RIO) (Journal no. 10457) and conducted in accordance with the GDPR and AoIR's report Ethical Decision-Making and Internet Research (Markham and Buchanan, 2012).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the VELUX FOUNDATIONS Grant number 18158.

Notes on contributors

Anette Grønning

Anette Grønning holds a PhD in digital communication and is associate professor at the Department of Design, Media and Educational Science, University of Southern Denmark. Since 2003, Grønning’s research has focused on digital communication and social media, primarily in different workplace settings. Her research interests include various aspects of digital communication such as mediated discourse, memory, participation and social presence. Grønning is leading the project ‘Digital consultation’, funded by the Velux Foundations, and the Danish part of the project ‘Demography and Democracy - Healthy Ageing in A Digital World’, funded by the Kamprad Family Foundation.

Line Maria Simonsen

Line Maria Simonsen holds an interdisciplinary Ph.D. that bridges humanistic research of healthcare, media and technology, professional collaboration, and patient treatment with ecological psychology, cognitive science, sociology, and dialogism. Her research profile pivots on microsociological and ethnographic investigations of social interactions, organizations and societal changes emerging in real world settings.

Elle C. Lüchau

Elle Christine Lüchau, Master of Arts, Media Studies. PhD Student at the University of Southern Denmark, Research Unit for General Practice, Department of Public Health, [email protected]. She carries out research into societal, organizational and relational aspects of the use of video consultations in general practice.

Elisabeth Assing Hvidt

Elisabeth Assing Hvidt is an associate professor at the University of Southern Denmark, Department of Public Health, Research unit of General Practice. Her key research areas are person- and relationship-centred medicine, empathy and digital consultations in general practice.

Maja Klausen

Maja Klausen is an associate professor at the Department of Design, Media and Educational Science, University of Southern Denmark. Her work combines perspectives from media and cultural studies and research areas include critical digital health, datafication, participation and ageing. These topics are explored through bottom-up user/patient/citizen perspectives.