The Heavy Boredom of Medical Infrastructure

by Michael Esveldt, University of Washington

Life, friends, is boring. We must not say so.
After all, the sky flashes, the great sea yearns,
we ourselves flash and yearn,
and moreover my mother told me as a boy
(repeatingly) ‘Ever to confess you’re bored
means you have no

Inner Resources.’ I conclude now I have no
inner resources, because I am heavy bored.

—John Berryman, Dream Songs 14

 

Infrastructures, we think, seemed boring because they had mostly faded into the background of the work they enabled (Lampland and Star 2009). A social scientist researching infrastructure might therefore take it as their task to make the boring into the interesting, to promote the centrality of the seemingly modest and peripheral—to make, if only for a moment, the sun go round the earth. Pleasure can be had in the shift of the axis of investigation and new phenomena can be made to appear.

But there is a moral knot hidden in boring things. John Berryman was stricken with a very general boredom. He was heavy bored; not bored with anything in particular, but bored in general (Goodstein 2005; Dalle Pezze and Salzani 2009; Toohey 2012), and this boredom cut him off from outer resources (literature, poetry), which seemed to him no different from any other boring thing. If making the boring interesting brings to the foreground the neglected aspects of practice, then to be bored by practice is a special kind of anthropological and infrastructural sin. But what happens to the general boredom produced by working with boring things when interest turns the dull into the dazzling? When the concept of infrastructure makes the boring interesting, being bored may become obscure.

Some boring things make you bored

I have before me a stack of paper print-outs listing unbillable patient encounters generated by NextGen, an Electronic Health Record system (EHR). The stack in question, several inches tall, is sitting on a desk in front of Natalia, a Medical Assistant at Vine County Hospital, and Natalia is sitting in a poorly adjusted ergonomic chair in a fluorescent lit room in a hospital tower, and I’m sitting next to her, and it is 10am. Natalia’s job is to figure out why over 1,800 patient encounters, representing millions of dollars to the hospital, have been flagged by NextGen as unbillable, and then make them billable by finding the error in the record and sending it to someone with the authority to edit the record before resubmitting the encounter for billing. She can do quite a few of these an hour, but she only has one day a week of admin time. The encounters go stale and can’t be submitted after six months, which means most of the billable hospital visits in her stack will go unreviewed and unbilled before she gets to them. More pile up every day.

NextGen is owned by the improbably named Quality Systems, Inc., and is licensed to Vine County. It was purchased by the hospital because it’s relatively cheap, was already in use by satellite clinics, and because, we’re told in Medical Economics reviews, it’s good at automated billing. Unfortunately for Natalia, it’s not doing its job. The reasons many of these encounters are unbillable break down into categories. The encounter doesn’t have a billing code attached, information deemed inessential by medics (but essential for billing) has been left out of the record, or someone missed a box they were supposed to check. NextGen is hard to use. Beige dialogue boxes stack one on the other, a mockery of user interface design, and every task takes ten more steps than it should. Natalia crosses out another encounter on the printout, stretches in her chair, and hunches over the keyboard, entering another patient number in by hand (twice, for some reason) and sighing. Her Sisyphean work, intensely boring, is related to the usability of a computer system, itself related to standards, practices, economics, and policy trends elsewhere. Healthcare law, federal regulations, insurance company rules, and the past decisions of hospital administrators find their ends here in tiny, repetitive tasks. Yet again she discovers a physician failed to enter the right procedure code, and she sends the patient encounter back to a physician with the authority to correct it. Natalia’s job is to repair these moments of broken infrastructure so that the hospital can reproduce itself financially.

At her desk, the temporality of the EHR has taken over Natalia’s day and mine. The design of the system has caused it to appear to Natalia as a system, present at hand. In being broken, it has become unmoored from the chain of processes linking doctor to patient to medical assistant to exam room to lab to pharmacy, and on down the line. Instead we go line by line through the printout, entering a medical record number into the system, identifying the problem, and tasking it to another staff member. “I would rather be on the floor, moving.” This kind of repetition is not movement. She has become a hospital resource, but there’s no care, no medicine, no surprises, no medical problems to solve, and no one to treat. There’s only the manual correction of missing data holding up the billing process. I see Natalia staring across the room at nothing, and time slows down in the endless return of the same. When we both become heavy bored, systematic features of a technical system converge with ethnographic method and the ethics of work. The failure of inner resources appears as coupled with the failure of outer resources.

Representing boredom

So what is the right relation between my ethnographic resources, Natalia’s inner resources, and these boring and boredom-inducing outer resources? There is giving an account of endemic and systematic boredom, an experience of lifelessness. The boredom caused by some infrastructure is neither reducible to infrastructural properties, the product of something so routine, so full of little details; nor is it merely the experiential correlate of a meaningless task, for it is more than a bad feeling. Being bored is a way of working, the necessary consequence of a certain kind of activity. If the relation between boredom and the organization of work drops out of the picture in the foregrounding of a boring object, then an essential monotony of a moment of infrastructure fades into the background (Graeber 2016).

There are moments when the banal is rendered marvelous, when the medical record system appears as a subtle thread weaving medics with patients and protocols and materials. Not only am I interested in NextGen, but as an ethnographic object it positively delights me. This is pleasure in the apparently unpleasurable, a kind of fetishistic zest that might shade into theodicy of the ecology of infrastructures. But here I am as bored as Natalia. NextGen is both boring and boredom-inducing, and there isn’t a basic distinction between this work and other NextGen tasks. Sometimes the conditions of possibility of care are the condition of possibility of meaninglessness.

 

Works Cited

Dalle Pezze, Barbara, and Carlo Salzani. Essays on Boredom and Modernity. New York: Editions Rodopi, 2009.

Goodstein, Elizabeth. Experience Without Quality: Boredom and Modernity. Stanford: Stanford University Press, 2005.

Graeber, David. The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy. Melville House, 2016.

Lampland, Martha, and Susan Leigh Star, eds. Standards and Their Stories. Ithaca: Cornell University Press, 2009.

Toohey, Peter. Boredom: A Lively History. Reprint edition. New Haven (Conn.); London: Yale University Press, 2012.