At the headquarters of Worldwide Teleradiology in southern India, the dimmed light of the office is pierced by dozens of screens glimmering with images of human bodies. A brain scan. An X-ray of a torso dotted with the solid white of bullet pellets. The shades of bones and flesh light up the faces of radiologists in the room. These images of suffering and pain contrast with the serene silence of the office. Sent from emergency departments in the United States, they will need to be interpreted and diagnosed within half an hour by radiologists working for the company. This urgency has led Worldwide Teleradiology to establish an intricate infrastructure, involving workers and technology, to ensure a highly efficient workflow that navigates time zones and jurisdictions.
On the screens of the workflow management team, efficiency looks like a tidy table of assigned cases and color-coded notifications that show if radiologists are keeping up with the timeframe. Five team members buzz around their computers and check the stats. But the aesthetics of efficiency on the dashboard hide hierarchies in the division of labor sustained through specific economies of affect.
The goose that lays the golden eggs
Teleradiology outsourcing from the United States has created a particular figure in the company that is simultaneously overexploited and privileged—the radiologist certified with the American Board of Radiologists (known as ABR in the industry). ABRs ensure ongoing contracts with American hospitals; they are “the most valuable assets of the company” (as the HR department explains to me), and the whole structure of the workflow is oriented towards ensuring their speed and productivity. Each ABR diagnoses between 75 and 200 images a day, which leaves six minutes or less per study—an intensity of labor that is made possible through a series of operations that determine what is valuable and efficient work and what tasks will be absorbed by lower-paid workers. These operations not only streamline efficient workflows but, in the process, also redefine what expert cognitive labor is and how it is enacted in relation to other types of labor in the company.
The majority of ABRs work from their home offices around the world—one in Israel, a couple in Europe, a few in the United States, and several in Indian cities. Leaving the hospital for a remote computer screen linked to specialized information systems means also leaving some of the aspects of radiology labor behind. Lakshmi, an Indian-born ABR who lives in Chicago, shares that she was relieved to be freed from administrative work. Giacomo, an Italian radiologist who works from Sydney, is happy to be away from the “pain and misery” of suffering patients in the corridors of clinical buildings. For both of them, the transition to teleradiology means that their professional work is subjected to a specific division of labor, stripped of administrative and vicarious affective labor.
Cognitive labor and its helping hands
While Lakshmi and Giacomo are relieved to no longer deal with paperwork and suffering, these changes have profound consequences that go beyond their personal preferences. The history of labor efficiency in capitalism is ridden with a long-standing distinction between cognitive and manual labor tasks. Part of the logic of early scientific management and, especially, the experiments of Frank and Lilian Gilbreth, was to separate tasks and distribute them to different workers in order to increase the speed of work and eliminate “wasteful” gestures and actions. Looking at the work of teleradiologists, much of the labor they would normally perform is construed as wasteful and outsourced to lower-paid workers. Radiologists look at images, recognize patterns, and dictate reports. Any job that could slow them down is handed off to others.
Call center workers handle communication between hospitals and the teleradiology company, recording and passing on demands and special instructions. Local, Indian accredited radiologists preread the studies for them and draft reports to save them time. The final radiology reports are typed out by transcriptionists (and, in some cases, voice recognition software). Transcriptionists have become so adjusted to complementing the ABRs that they don’t need deliberate dictation. All they need is to listen to the comments a radiologist makes while looking at the study. These comments are quickly shaped by the attentive ears and nimble fingers of the transcriptionist into the genre of the radiological report. There is no need for ABRs to pause and dictate; they proceed seamlessly from one study to the next. But even so, every second lost and every unnecessary movement is time wasted.
Every time an ABR opens a new study to read on the computer, it takes up to 10 seconds for each image to load; this is 10 seconds too many of their valuable time. This perceived lag in the workflow has led to the introduction of a special role—the loader. The loader’s sole job is to log into the computers of ABRs around the world and load up the images for their next studies while they are diagnosing their current case. The system is designed to eliminate any vacant time from an ABR’s daily schedule, to put each and every moment to optimal use. They use two computers or a virtual machine, so that one is always at the disposal of the radiologist while the loader is opening and loading images onto the other. As the ABR sits in their home somewhere in the world, the loader will be working from the Bangalore office, quietly adjusting to the tempo of the radiologist, loading image after image, and then synchronising with the ABR to swap machines. Transcriptionists and loaders take on the gestures and actions that are deemed waste—the ones that slow ABRs’ progress and, hence, the profits they generate. Their perfect synchronization with the radiologists also requires a continuous affective labor of attuning and responding to somebody else’s rhythm, an affective coregulation of pace, technology, and time.
The workflow management team oversees how cases are distributed to the radiologists, even taking their personal preferences into account. Its leader, Surash, takes one look at the dashboard and quickly adjusts the case allocation: “Oh, this ABR doesn’t like reading bodies. Too many organs.” The team performs a subtle emotional labor that has become ingrained in the logic of efficiency and eliminating wasteful activity. Some of this labor comprises an intimate knowledge of preferences, characteristics, and life circumstances for each radiologist. Surash keeps mental track of minor details: who needs to take a break every couple of hours to breastfeed, who is doing home renovations, who is in an inconvenient time zone and working night hours, who can be a bit abrupt in the chat. All this information helps him and the rest of the team navigate the allocation of cases. On the one hand, they are keeping track of which radiologist is busy and, on the other hand, they have adapted their fine perception to anticipate and prevent anything that might disturb the workflow. Irritation caused by the allocation of an unwanted case can lead to a tense chat—minutes wasted for the company. Any preemptive word or action from the workflow team that accommodates preferences and idiosyncrasies means happy radiologists, less time spent typing in chat boxes, more cases read, and greater profits.
This economy of affects designed to keep ABRs happy and productive permeates all functions of the company. Everyone is attuned and accommodating to the ABRs. But ABRs need not concern themselves with such obliging emotional labor. With a teary voice, Surash confides that the messages he receives are often terse and abrupt. Such abrasive instructions and complaints have been freed from the wastefulness of politeness, consideration, or a will to compromise. His job has come to encompass acts of absorbing the negative affects of these encounters and cushioning the interaction with softness and care.
In her work on affective labor, the philosopher Shiloh Whitney writes that in the relationship between different types of work such instances of “metabolizing waste affects and affective byproducts” intersect with racial and gender hierarchies. Unwanted and painful affects “stick” (in the words of feminist scholar Sara Ahmed) to feminized and racialized bodies; these bodies become the vessels of affective surpluses that cannot be commodified and converted into profit. In the Indian teleradiology company this economy of affect is partially informed by the value placed on the ABR certification in teleradiology, which leads to an international division of labor. In this division of labor, the level of recognized expertise is determined by national accreditation. The work of local radiologists, even when reading the same images and giving the same diagnosis, is not as profitable and, hence, valuable as that of their ABR colleagues. The higher status of ABRs (regardless of their nationality) reinforces a logic of outsourcing that characterizes outsourced labor as comprising of tasks Kalindi Vora describes as “in service of” and “in support of.” Such tasks, historically considered low-skilled and reserved for women, people of color, immigrants, and workers in the colonies, now form the basis of many outsourcing enterprises. Underlying this international division of labor, however, is also a hierarchy established through the definition of what expert cognitive labor is and what it entails.
The notion of expertise and professionalism in health care is construed through a hierarchy of affective involvement, where being affected and performing affective labor are both construed as antithetical to the figure of the professional. The sociologist Talcott Parsons refers to this desired disposition as “affective neutrality,” and his views that affects diminish the authority and expertise of professionals continue to influence the way cognitive labor is understood and practiced. The idea that affects are detrimental to the work of professionals facilitates the way labour hierarchies are enacted through a specific affective economy. Affective labor and negative affects slide down the hierarchy and stick to those whose work is considered less valuable. The hierarchy established through processes of defining cognitive expert labor becomes entangled with hierarchies in the capitalist division of labor, driven by the imperative for profit. And so ABRs’ money-making medical expertise is assisted by a chorus of supporting characters whose job it is to ensure their work is swift and unimpeded—call center phone operators, speedy loaders, skilful transcriptionists, and ever-attentive workflow managers.
This affective economy of the efficient workflow reveals the inefficiencies and waste that are hidden behind, yet permeate, the business management fantasy of optimized work performance. Indeed, when Frank Gilbreth attempted to increase the productivity of surgeons in the early twentieth century, his contemporaries remarked that efficiency is only accomplished by delegating the more tedious and time-consuming tasks to other workers. The hierarchical distribution of affects in today’s teleradiology industry suggests that it is also the performance of cognitive labor that creates the conditions for “affective byproducts” that are deflected and metabolized down the line by workers whose jobs are racialized and feminized in the process. ABRs also internalize this division and endorse the perception that they work better and enjoy their job more when it is disengaged, detached from affective dimensions and administrative and routine tasks. They take pride in the intellectual and expert nature of the work they perform. Yet the cost of this consensual exploitation and optimization of the process is borne by the workers who must absorb the waste—the inefficiencies, the negative affects, and the general tension created by an accelerated workflow.
Author’s note: All the names in this story are pseudonyms.
Charlotte Corden is an illustrator and fine artist whose work often centers around what it is to be human. She has an MA in anthropology from University College London, and has studied at the London Fine Art Studios and the Arts Students League of New York.