Chapter 4: Patients as "Tribes"

Exploring the Impact of Racial and Socioeconomic Classifications on Patient Care in Labor and Delivery Units

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To understand my journey, you first have to understand the culture and organization of a labor and delivery unit. There are three major stakeholders involved in the delivery of a baby. The first, and most important, is the patient—and by extension, her family and support personnel. The second is the nurse, who provides the most direct one-on-one care for the patient throughout labor. The nurse plays a critical role: she administers and titrates medications, continuously assesses fetal well-being through heart monitoring, and remains present for the entire second stage of labor—often the most dangerous period—guiding patients through pushing to optimize outcomes for vaginal delivery. Finally, she cares for the patient during the first few postpartum hours, when the risk of life-threatening complications such as postpartum hemorrhage is highest. All this to say: the quality of your labor and delivery nurse matters deeply. It is one of the most critical relationships during the labor process.

The final stakeholders are the physicians. We often care for several patients simultaneously, unlike the one-on-one attention provided by nursing. Our primary responsibility is to assess maternal and fetal well-being and to guide management decisions.

Race, ethnicity, and class are powerful classifiers that quietly shape the subtext of patient care. When I first arrived on the unit, I thought the way race and ethnicity were used was odd—but what did I know? I was only an intern. On the surface, some of it even seemed practical, until I began to understand the system.

For example, you have the “South Cove” patients, named after the South Cove Community Health Center in which they are cared for. This is a community health center in the heart of Chinatown serving a mainly Chinese immigrant population. On first glance, it seemed innocent enough to call these patients South Cove after the community health center they came from. It seemed reasonable—until I began to uncover the hidden meaning behind the name.

The South Cove is synonymous with the model patient. They are the most desired patients on our unit. The “good patient,” the patient who comes in, shuts up, pushes with minimal coaching, has her baby, and most importantly, never complains. Now, the problem with this dichotomy, beyond the fact that it is overtly racist and plays into racial stereotypes, is that whenever there is a “good”, by logical extension, there must also be a “bad”. So I started to ask myself, who are the bad patients? It didn’t take long to discover that “bad” was synonymous with poor, black, or brown.

Black patients walking on the unit are immediately assumed to be a “chief patient” (code word for poor and underinsured) and assumed to belong to the resident practice. This is in contrast to the stereotype of the more affluent, predominantly white patients who are assumed to belong to the private faculty practices.

The language was clinical, professional, seemingly neutral. But like so many things in medicine, the neutrality was an illusion. These weren’t just organizational labels—they were value judgments disguised as medical classifications.

And once I began to see the pattern, it was impossible to unsee it.

I started paying attention to how these labels shaped interactions before any medical assessment had even taken place. A “South Cove” patient would be greeted with patience and gentle encouragement. A “chief” patient might wait longer for pain medication, have their complaints met with skepticism, or be spoken to with barely concealed irritation. The same behavior—expressing pain, asking questions, advocating for oneself—would be interpreted entirely differently depending on which tribal category the patient had been assigned to upon arrival.

This stratification of patients by social class is by no means unique to our unit. Class, often conveniently overlapping with race, separates people in many hospital wards, sometimes prohibiting them from getting care in certain institutions altogether. As illustrated in the 2017 Spotlight article, this problem is not unique to BIDMC; it reflects the broader issue of racial segregation in Boston’s healthcare system. It’s the ugly part of medicine that few want to talk about.

However, what is unique about labor and delivery, unlike any other unit in the hospital, is that it is the only unit where patient effort directly plays into their outcome.

There is a reason we call it a labor unit; it is because women come there to work.

For those who have never seen a vaginal delivery, it is a surreal experience. I am still in awe of women in these moments. Seeing a woman push for hours against the tearing of her own flesh is a real testament to what you can accomplish through sheer force of will. It is truly remarkable. What is also remarkable is that women of all shapes, sizes, colors, backgrounds, ethnicities, and sexual orientations can hone that same strength in pursuit of a singular goal. There is only one non-surgical way to get that baby out, and it’s that she has got to PUSHHHHHHHHHHH.

Women come to us to help them through the hardest day—or sometimes days—of their lives, in the safest way possible for both mother and baby. That, in a nutshell, is our job. People place immense trust in us—that we will care for them regardless of how they look, where they come from, or how much money they have in their pocket. That we will always put mother and baby first.

Now, the problem with describing patients in terms of their “Tribe,” a term I have heard many times on our unit, is that you start to associate a person’s race or ethnicity with behaviors, and even worse, as a predictor of outcome.

I’ve heard every kind of ridiculous generalization about people who aren’t white. Some comments are laughable, like one nurse insisting that “Indian women are the worst at pushing.” A strange claim, considering India is the second most populous country in the world. Others are more insidious—complaints about difficulty monitoring contractions because “Dominicans are always getting abdominoplasties.” And some veer into the dangerous. I once stood beside another Black resident as an African American patient expressed pain, when a provider asked, “Is she of a different race?” We exchanged confused looks and asked, “Different from what?” The response: “The standard… (awkward pause)… You know, the Caucasian flavor.”

And then finally into the outright racist. Openly using the word Nigger to illustrate a point in a story. Or expressing sincere concern for a colleague’s young adult child now living in Miami, because how can a good Boston boy make his way in “little Havana.” Or in reflecting on your prior place of employment and how much you loved working there because the patients were so “affluent...well to do...white.”

The progression was always the same. It started with seemingly innocent observations, moved through increasingly explicit stereotyping, and eventually landed at outright slurs and expressions of racial superiority. What made it particularly insidious was how it was often framed as clinical insight or professional experience.

The job of any good obstetrician or labor nurse is to constantly assess a woman’s progress in labor. It’s one of our core functions and essential to ensuring a safe delivery. Many factors inform this assessment—exams, fetal status, prior obstetric history, and, of course, provider experience. It’s a complex process that takes years to refine, and even by the end of residency, you’re only beginning to master it. The ability to quickly and accurately evaluate progress is what separates a seasoned practitioner from a novice.

In making this assessment, you take in all kinds of objective and subjective information either consciously or subconsciously. I’m sure in some subconscious way race and ethnicity play a role in how ALL of us make this assessment—whether it is in interpreting social norms about expressions of pain, effort, resiliency. We are all human. However, when we start to consciously speak of our patients in terms of their “tribe,” categorizing some women as “weak”, others as “bad pushers,” or “complainers,” or “having poor pain tolerance,” then we turn that subconscious human fallibility into something deliberate and ugly. If we do this, there is no expectation that we can assess a patient accurately, or, more importantly, be a fair advocate.

This was the moment when everything clicked for me—when I realized that the same dehumanization I experienced as a physician was being inflicted on patients who shared my skin color. The same assumptions, the same stereotypes, the same failure to see full humanity were operating in both directions. The culture that reduced me to the “black girl with attitude” was the same culture that reduced laboring women to tribal stereotypes and predetermined outcomes based on race rather than individual clinical presentation.

It wasn’t two separate problems—physician mistreatment and patient disparities. It was one problem with two manifestations, rooted in the same soil of institutional racism and nurtured by the same willful blindness to how bias shapes every interaction within these walls.

The implications were staggering. If providers couldn’t see past race and class when evaluating their colleagues—people they worked with daily, whose skills and competence they knew—how could they possibly deliver equitable care to patients they met for only hours or days?

If brilliant, accomplished residents could be mistaken for one another solely because of their skin color, what chance did patients have of being seen as individuals rather than members of a “tribe”?

For the first time, I began to understand why the maternal mortality statistics looked the way they did, why African American women were dying at rates that defied explanation by traditional risk factors. The answer wasn’t hiding in complex algorithms or obscure medical journals. It was right there, in the casual conversations, the routine classifications, the everyday assumptions that shaped how care was delivered on our unit every single day.