The Voice of the Phone Tree

by Shannon Satterwhite, UCSF San Francisco

Fieldnote, Primary Care Clinic, Monday Morning:

I am sitting in the nurses’ station, which holds three computers and a printer, as well as cupboards of supplies. The space is narrow and I am only a few feet behind two of the registered nurses who work side by side at their computers. It is quiet while Carol charts about a visit with a patient who dropped in this morning.

Then, we both hear her colleague, Richard, say “pharmacy” in the flattest of tones. We both laugh.

“The voice of the phone tree,” I say.

Rick replies, “You can write that on your paper. ‘Ph-AR-macy.’”

Rick and Carol work in a publically-funded urban community clinic in California. I observed Rick and Carol’s work as part of an ethnographic exploration of the temporalities of primary care practice in safety net settings in the United States. In the American health care system, public and non-profit safety net clinics serve low-income patients who cannot afford private insurance. These patients are publicly insured (Medicaid and/or Medicare) or uninsured (with or without assistance from local programs). A complex set of regulations around prescribing and variations in insurance coverage led clinic staff to interact frequently with pharmacists, helping patients obtain medications.

One Thursday afternoon, I observed Rick’s work. In the course of four hours, he answered or made at least fourteen phone calls. Some of these were internal to the clinic, others involved addressing or triaging patient health concerns over the phone. Several calls related to helping patients obtain prescription medications. He spent the time in between calls documenting their contents in the electronic record and responding to other electronic communications.

He turns to me and glances at my notebook.

“What exactly do you write down?”

“What’s happening,” I shrug.

“There’s nothing happening!” he laughs.

I timidly agree to the sentiment but also respond that I think the “TEs” [electronic care coordination tasks] he is working through are important. He nods and says, “Okay.”

… The TE he is working on now is about an issue with a patient’s prescription, possibly requiring a prior authorization. Rick calls the pharmacy. On hold, Rick asks me, “You getting a lot of information from us right now?”

I hesitate for a second, smile and nod slowly.

“You lie!” he exclaims.

Caught off guard, I admit, “It does seem like a super slow clinic right now.”

Another of Rick’s colleagues agrees, “It’s true! Usually we’d be seeing more patients.”

Rick says, “It seems to go like this, I’ve noticed,” moving his hand like a wave of water. He tells me that his very first day here, it was just him and Carol and “we got SLAMMED… .” He jumps back into his phone call when someone picks up. Done with pharmacy call, he documents that the patient’s insurance does cover the medication, but the deductible is high.

Often, a nurse at the clinic will receive a message if a patient is unable to pick up a prescription at the pharmacy. This may happen because the patient’s insurance requires additional paperwork, known as a prior authorization request, before they will pay for the medication (or refuse to cover it). Prior authorizations are one of many administrative tasks that Rick and Carol and their colleagues are responsible for and that cost U.S. healthcare clinics significant time and resources.

In this particular case, the patient’s insurance did not require prior authorization, but the high deductible meant that the patient would have to pay a large sum out of pocket before the insurance would cover the balance of the cost of his medication.

Attending to the phone and what these nurses make of phone work helps me to outline what they consider legitimate or valuable nursing practices. For instance, Carol specifically identified time on the phone as something that took away from time caring for patients face-to-face. Still, in a fragmented healthcare system in which an enormous amount of time and energy is spent on coordination of care, “troubleshooting” insurance issues and prescription coverage becomes part of quality patient care and good clinical teamwork.

Rick’s ambivalence about whether or not anything is “happening” when he is on the phone is instructive as to the sometimes boring nature of care work. One day, he tells me to write down his bored command to the automated phone tree standing between him and a pharmacist. This instruction to take note tells me that something about this activity matters for Rick. Navigating phone trees is a part, however boring, of nursing work when it assures patients’ access to medications. Another day, though, engaged in similar activities, Rick told me “there’s nothing happening!” and felt like I could not possibly be learning from watching him make calls and chart them. He contrasted this to his first day, seeming to take pride in the memory of getting “slammed” with a high volume of patients who came to clinic for care in person.

This ethnographic attention to the phone poses a methodological quandary. My interlocutors seem to clearly understand my desire to observe them in direct patient care activities. However, when it comes to charting and phone calls, arguably essential and certainly unavoidable activities in the day-to-day routines of primary care, some clinicians (and I, in turn) become self-conscious. Rick’s questions to me about what I write down highlight the potential discomfort of direct observation of “boring” bureaucratic labor, for the observer and observed. Yet, these boring objects and practices are so embedded in daily practice that they do not easily arise in conversation or interviews.

Anthropologists like Bowker, Lampland and Star have argued for the importance of “foregrounding the truly backstage elements of work practice, the boring embedded things” (Lampland and Star 2008:17). Even though the nurses I observed spent significant time on the phone, on hold and in phone trees, Rick marks this work as “nothing,” as boring. Yet, it takes a great deal of time, energy and skill to make the “ph-AR-macy” phone tree work, that is, to help patients obtain their medications. Attending to the phone as an ethnographer was uncomfortable for me because its boring nature seemed to make Rick self-conscious. Yet it allows me an opening to examine how backstage elements and infrastructure of the health care system shape nurses’ work and patient care.

Participation by clinical ethnographers is often limited in bureaucratic and clinical settings by our lack of qualifications to participate in tasks, “boring” or otherwise. If we press into the boredom, sometimes interlocutors open up new insights as they work. The perception that certain tasks must not be of interest to us can serve as an opening to discussing professional identities and values. Avoiding the discomfort of observing “boring” procedures can push much-needed ethnographic attention away from studying and understanding fundamental structures that shape the work that nurses, such as Rick and Carol, do as essential moments of care.

 

References

Bowker, Geoffrey C., and Susan Leigh Star. 2000. Sorting Things Out: Classification and Its Consequences. Cambridge: MIT Press.

Lampland, Martha and Susan Leigh Star, eds. 2008. Standards and Their Stories: How Quantifying, Classifying, and Formalizing Practices Shape Everyday Life. Ithaca: Cornell University Press.