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Falling through the cracks: Contradictions and barriers to care in a prenatal clinic Ellen S. Lazarus

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Research Associate in the Department of Anthropology , Oberlin College , Oberlin, OH, 44074 Published online: 12 May 2010.

To cite this article: Ellen S. Lazarus (1990) Falling through the cracks: Contradictions and barriers to care in a prenatal clinic, Medical Anthropology: Cross-Cultural Studies in Health and Illness, 12:3, 269-287, DOI: 10.1080/01459740.1990.9966026 To link to this article: http://dx.doi.org/10.1080/01459740.1990.9966026

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Falling Through the Cracks: Contradictions and Barriers to Care in a Prenatal Clinic Downloaded by [University of Alabama at Tuscaloosa] at 20:52 29 March 2015

Ellen S. Lazarus Prenatal care is often cited as a major factor in the prevention of poor birth outcomes. Yet, the social environment of care has been little studied. This paper illustrates how contradictory features in the structure of the health care system create barriers that weaken effective health care delivery. Social relations in a large urban public outpatient clinic are described and analyzed regarding their impact on clinic procedures. The paper focuses on: 1) the division of labor in which work is compartmentalized and power is diffused; 2) the asymmetrical doctor-patient relationship magnified by social class differences; and 3) the training of resident physicians who provide primary prenatal care. Improvements in the quality of care in public clinics cannot come about without an understanding of the effects that contributing factors have on the way care is organized.

Even when access to medical care exists, women often do not receive adequate care because of obstacles in the medical system itself (Antoniello 1988; Boone 1985; Poland 1988). In this paper I examine prenatal care for poor women in the United States through a case study of a public clinic. My thesis is that identifiable contradictions in the organization of health care create barriers to good prenatal care for poor women. These structural contradictions are harmful characteristics that debilitate or weaken a system's capabilities (Waitzkin 1983). In American medicine, contradictory relationships arise between those who own and control medical resources, technology, knowledge and wages, and workers who provide specialized and limited services, i.e., laboratory technicians, nurses' aides, midwives, receptionists, social workers and residents-in-training. In other words, conflicts in the capitalist production and distribution of health care involve class conflicts (Navarro 1976; Starr 1982). * An example from the setting of my research illustrates this point. Hospital administrators needed to increase revenue from private patients and government funding for public patients to help finance the remodeling and building of higher technology facilities to attract physicians and to serve larger patient populations. The increase in patients and shifts in work stations during construction contributed to a fragmentation of services and to dissatisfaction among hospital workers. Contradictions also exist between medical care providers and consumers. Physicians in private practice need to see substantial numbers of patients to make a living. Patients complain that they are not receiving the personal attention they demand. Contradictions in the delivery of care are magnified in the United States where some people are insured or directly pay a fee-for-service, while others must ELLEN S. LAZARUS is a Research Associate in the Department of Anthropology, Oberlin College, Oberlin, OH 44074. She is currently writing a book on prenatal care in the United States.

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270 E. S. Lazarus seek care in public clinics. Since those who own and manage the system are more interested in people who can pay, services for poor people are inferior.

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RESEARCH DESIGN I conducted research at the obstetric/gynecology outpatient clinic of a large innercity teaching hospital administered by the county and associated with a medical school. Almost 4000 births took place at the hospital in 1988. Administrators estimated that 80% of the deliveries were to women who receive outpatient care at the hospital's public clinic or at a satellite clinic. The Obstetric/Gynecology Department conducted perinatal research and provided sophisticated technological care. Resident physicians rotated through the clinic as part of their training and provided care to the majority of perinatal patients. Residents were assigned to a team (but did not work as a team) that saw patients on specific days. Patients were given the first available appointment after their initial call. An effort was made to have each patient come for all visits on the same day of the week, hopefully to see the same resident for several visits. About 10% of the pregnant women received care from certified nurse midwives. My goal was to investigate women's beliefs about pregnancy and birth, their use of the clinic, and their relationships with health professionals. Over an 18 month period in 1981 and 1982,1 observed 53 clinic patients through pregnancy and birth to the post-partum period. Twenty-seven women who identified themselves as Puerto Rican were compared to a group of women identified as white, native-born American citizens of at least second generation. All were poor, and most were receiving government assistance. Except for the ethnic distinction, the women who participated in my project shared similar demographic characteristics. Nineteen were between the ages of sixteen and nineteen, and the rest were in their twenties except for one white woman who was thirty-nine. Many were unmarried and over 60% had not completed high school (Table I). Ten (39%) of the Puerto Rican women were born in the United States, seven (26%) were born in Puerto Rico and came to the mainland as children, and ten (39%) were born in Puerto Rico and came to the United States after adolescence. All of the Puerto Rican women spoke Spanish, but only one was completely monolingual. I observed the women in 150 interactions with physicians or midwives and TABLE I. Demographic characteristics of informants.

Mean age at pregnancy Age range Primiparas Multiparas Mean years of education Mean number of living children Mean age at first birth Age range at first birth

Puerto Rican (27)

White (26)

21.8 17-29 9 (.33) 18 (.67) 10.5 1.12 18.5 13-24

22.4 16-39 15 (.58) 11 (.42) 10.6 .88

19.5 16-26

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conducted approximately 500 interviews with them at the clinic or in their homes. I met their families and was present at many of their labors and births. I conducted formal interviews, lasting two hours each, with eleven residents and eight midwives. Interviews focused on medical training and perceptions of perinatal care and clinic patients. Moreover, I observed all 35 residents interacting with patients and interviewed all of them informally throughout the study. In addition, I continually interviewed the nurses, medical receptionists, nurses' aides and medical faculty. In 1986 to 1988,1 returned to the obstetric/gynecology department to further study the organization of hospital based care. BACKGROUND

I originally came to the clinic to research issues of ethnicity in reproductive health care. For the women I studied, I found poverty far more telling than ethnicity in its effect on pregnancy management (Lazarus 1988). Though women who classified themselves as Puerto Rican maintained a strong cultural identity and shared some distinctive traditional practices, they did not have significantly different beliefs about pregnancy and birth nor was their behavior in the clinic distinctive from that of the other women in the study. Regardless of whether they were born or brought up in mainland United States or in Puerto Rico, Puerto Rican women, like the white women, were strongly influenced by the biomedical model of pregnancy and birth prevalent in both the United States and Puerto Rico. Both groups wanted healthy babies and good care though most of the women knew little about health care during pregnancy or about the birth process. Because I found women shared similar attitudes and experiences during their pregnancies and prenatal care, I began to focus on issues of social class. Poor women in a public clinic all faced long waits, depersonalized service and a lack of continuity of care, factors producing negative attitudes in both patients and clinic staff. Why do these problems exist? IDENTIFIABLE STRUCTURAL CONTRADICTIONS

Division of Labor in the Clinic

Jobs in the clinic were arranged in a hierarchy with three separate lines of authority, a plan described by the department administrator as a matrix. Nurses were responsible to a head nurse and she, in turn, reported to and received orders from the central hospital nursing coordinator; medical receptionists and physician aides were responsible to the obstetric/gynecology administrator; residents were responsible to a team chief who reported to a faculty physician. This organization was part of the hospital's administrative policy of providing a unified system of authority over the outpatient clinics. The system was unified in the sense that administrators set up the same three lines of authority throughout the outpatient or ambulatory care clinics.

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272 E. S. Lazarus In actuality, the three lines of authority diffused power widely. Therefore, it was easy to shift responsibility so that no one was forced to assume accountability for the functioning of the clinic. Clinic personnel blamed the system for inadequacies in care and therefore assumed less individual responsibility for patients. Problems were down-played instead of corrected. Personnel accepted the situation and generally kept their views within their own groups. I often heard the comment, "It's the system." At other times clinic personnel blamed each other. A nurse: "Everyone wants the same thing, a better situation for care, but people fight each other." Residents often said, "The secretaries (medical receptionists) run your life;" or, "The receptionists do not get the charts ready in time and the aides do not prepare patients for examinations quickly." From receptionists I heard, "The residents are not in the clinic on time;" or, "Residents go on vacation without providing for their patients," and "They schedule you. You go and do what they set up." From an attending physician I heard, "Residents never want to work and they always think they are right." In 1981, the medical receptionists were called clerks. Later hospital policy changed the title to receptionist. Throughout all these years receptionists derived little satisfaction from their work. They complained that there were "too many bosses—too many people making demands on us." One receptionist who worked at the clinic for over 5 years spoke about her job. There is an enormous load of patients and it is tough when people are out sick. . . . New people [workers] resent the old. [The administrator] doesn't care about people or the clinic and never comes. In the very beginning when she first started she may have spent a couple of hours on each side but she never fully got into all that we really do in the clinic. It's very stressful and I think we are all feeling it. . . . I bring home a great deal of stress. My poor husband . . . . I thought about quitting but my husband's work is not going well and I need the insurance. We've had people quit and I feel more and more people are going to. You are expected to do more and more things. We never know from one day to the next. Two of the receptionists left because of the work load . . . . because it was too much. Carol is leaving now. She said it was just like working in a factory and it is. You have to stand on your feet like eight hours and it is bad.

Recently out of medical school, new residents were unsure of themselves. They did not know whom to ask for assistance when they examined patients, or for laboratory work and appointment rescheduling. No one instructed them about the duties of staff members. During their first week at the clinic a brief orientation meeting was scheduled with the head nurse. Other medical responsibilities prevented some residents from attending. Those who did attend found the amount of information covering clinic routines and medical forms difficult to absorb. They learned by observing and asking questions on the job and this contributed to slowing down clinic procedures and to longer waits for patients. All eleven residents I interviewed extensively said that patient education about labor, delivery, proper health care and nutrition were important, yet they had little time to educate patients in 5 to 10 minute interactions. Nor were they expected to educate patients. Nurses were responsible for prenatal education. But, residents did not know what the nurses covered with patients, or what social workers or the nutritionist did. One intern asked a clinic nurse, "Do you teach women about labor,

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Falling Through the Cracks 273 about what really happens?" The nurse looked surprised and replied, "Yes." However, I rarely observed nurses teaching about labor and delivery. After a resident's physical examination, a nurse met with the woman to talk about the developing fetus, routine medical tests and warning signs, to discuss the woman's feelings about the pregnancy, and to review the resident's instructions. But by the time a woman saw a nurse, she was, after several hours in the clinic, usually in a hurry to leave. Her children were often waiting at home. One woman described her last visit: "I didn't see the nurse. Even if the nurse was around, I would not have wanted to see her at that point. I got out at 4:30. It's hurry up and wait." Another said: "I come late—it's better to use the system. I don't see the worth of the nurses. If I have a question, I ask the doctor. The nurse just asks if I understood what the doctor said." Nurses said they were able to sense women's feelings of impatience and therefore sometimes skimped on teaching or on handling patient problems. When a woman did meet the nurse, she was reluctant to speak about personal issues because of a lack of privacy. Several nurses and patients shared a consultation room at the same time. Or, they met in the hallway. Furthermore, a women often saw a different nurse each time she came to the clinic. One nurse made suggestions at an ambulatory nursing meeting about increasing nurse coverage and eliminating central hospital clinic registration. Since her statement was labeled an "emotional outburst" and criticized, she did not intend to bring up suggestions at future meetings. "I don't want trouble, things could be worse." She subsequently found a job at another institution. Administrators were aware of clinic problems. Their priority was to create an efficiently run revenue-producing system. The hospital is government funded and 27% of its revenues come from Medicaid payments. It was important to see as many staff patients as possible. The physician outpatient director addressing this issue said, "We need to bring in the masses. I mean a lot of patients—in a short amount of time—so we can make money." Later he added, revenue was needed "so that we can pay for the education of residents." To streamline care, a five-day study was conducted in 1982 by a "management engineer." As a result, the administrator and head nurse changed the medical receptionists' duties so that they worked more in an assembly-line fashion and became responsible for processing only one part of each women's visit. For example, they checked patients in or checked laboratory tests instead of following one patient throughout her visit. The receptionists were not consulted until the changes were instituted. At a meeting held to outline the changes, the administrator told the receptionists, "Follow these [changes] and you won't be blamed. If nurses don't like it, too bad." Instead of giving support to the receptionists who were uncomfortable with their new routines, the administration's approach was to divide the receptionists from the nurses. Receptionists complained among themselves but were not willing to speak up. A typical comment was, "Nobody cares what I think, I'm just a clerk." So rather than improving the day-to-day functioning of the clinic, the changes actually caused more problems. More recently, hospital administrators attempted another improvement; this time the goal was to enhance the receptionists' ability to process patients. Under the new plan receptionists "rotated" to various stations learning all the duties of all the

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receptionists. The advantage was that now receptionists could readily do each other's jobs when the clinic was short-handed, or when a receptionist was sick or on vacation. The disadvantages were that now receptionists had even less frequent contact with the same patients, and residents and midwives did not know which receptionist was responsible for their patients. The head midwife commented: I think our staff [midwives] feels that if the receptionist organization could change, then a lot of other problems would fall into place. It basically involves two major areas and one is consistency. We just find it real difficult to work with one medical receptionist one week and another medical receptionist the next week. This whole idea of their learning to do everybody else's job seems to be spinning wheels to me . . . . In no other area does everyone know how to do everyone else's j o b . . . . It's just not knowing who you are going to work with and they are different enough to make it confusing how they want things done . . . . some of the receptionists like the patients to go directly to the M&I [Mother and Infant Project] clerk and then bring their papers back up to the desk. Some of them would rather give the patient their appointment first and then have them go back to the M&I clerk. . . . if the clinicians don't know that, then [clinicians] get all confused. . . . There's even risk that they [clinicians] might miss their appointments because then they don't stop at the desk. So, if we knew what our medical receptionists expected, then I think we all would work better together.

She pointed out that the organization of the receptionists created a situation where there was little accountability. If you're here today and gone tomorrow, then what you do today is never going to be traced back to you anyway. So who cares. You're not going to make a special e f f o r t . . . . When we had one receptionist she had her own separate job and she had pride. She was very meticulous about the way these charts were done and even something simple like the way that the name was written on the chart holder. Other people were not doing that well. You know it created a lot of dissatisfaction in her. This assembly line violates everything about the way people feel about the way they work. Receptionists don't care now. I would love to sit down and talk to some of them from the standpoint of just an interested clinician and tell them how important what they do is . . . . I don't think they've ever been told that, some of them. That's why Martha [the midwives' former receptionist] felt so good . . . we told her how important she was. She got to know our patients. She was as involved with their progress and what happened to them as we were in many ways. I don't know how they [medical receptionists] work those phones or how they have it set up for how appointments are given. But however it is, there needs to be certain accountability, there needs to be some record keeping. They need to keep a record of that call so that when appointments are wrong we can get back to the person that made that appointment. There is no follow-up on defaulters.

The midwife's frustration with the change in the organization of receptionists also speaks to her awareness of its effect on women who come to the clinic. Some women take control, others fall through the cracks. If a patient calls in and says she has missed an appointment and she needs to be seen, she should be seen as soon as possible because she's already missed an a p p o i n t m e n t . . . . We had a young teenager come in and say she was term and she had missed an appointment at 36 weeks and was given a reappointment for four weeks which would have made her a couple days past her due date. She came in at 39 weeks—called in and made a specific appointment for that week and said to me "I thought I should be seen. It seemed like it was too long for me to go at this stage in pregnancy" . . . So she was smart enough to figure that out. A lot of people wouldn't think to call. Sometimes it's just the interest of someone calling and saying "you know you missed your appointment, we missed you. . .I'm setting up an appointment this day." I mean they may come in but if they are left on their own they may just not call.

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Falling Through the Cracks 275 Hospital administrators continually tried to improve the organization of the outpatient clinics. In the fall of 1988, they involved employees throughout the hospital in a plan to enhance relationships with patients and with other personnel. The Customer Relations and Development Department set up a program requiring each employee to attend a 2 Vi hour group meeting to air employee grievances and solicit suggestions for bettering work conditions and patient relations. Hospital workers were required to attend. But when doctors were informed of the meetings, many said it was a waste of their time, and their sparse attendance was not lost on the workers. In reports from several of these sessions, workers described snickers and snide comments when they were asked about conditions that would make working conditions better for physicians. Discussion leaders emphasized the importance of a positive attitude towards others. Administrators did not translate these words into actions. They did not sense that low morale was created by staff organization. They never focused on the relationship of employee satisfaction and low morale among clinic personnel and its effect on patient care. Workers were not treated differently after these sessions. They continued to carry out orders without participating in decision-making and then were blamed for poor management. How did all this affect pregnant women who used the clinic? Over the course of their pregnancies, the women in my study saw many different residents, nurses, aides, receptionists, nutritionists, and social workers. Few clinic personnel knew who they were. Women felt no one cared; no one could or would give them needed social support. The message transmitted to them as they received it, was that they were unimportant and even resented. Unhappy and unappreciated, receptionists scolded them. Nurses were superfluous. Residents rushed them. One of the women in my study said angrily, "I'm just a guinea pig." Overwhelmed by the attitude permeating the clinic, pregnant women, often those most in need of professional attention, fell through the cracks of the system—not rescheduling appointments, not seeing the nurse, never learning danger signs requiring a trip to the emergency room. Marlene's case was typical. She was twenty-nine years old, unmarried and expecting her fourth child. At her initial visit, her risk scores, derived from health histories and clinical tests including a previous Cesarean section, a previous premature birth, cystitis, heavy smoking, hemorrhaging during a previous third trimester, a previous therapeutic abortion, and a family history of twins, were exceptionally high. But Marlene was not seen in the special high-risk clinic because her risk factors were not considered by the residents to require special care in a clinic that served a large high-risk population; they merely bore watching. Marlene was anxious during her pregnancy because two years earlier her daughter was delivered prematurely at six months. Recalling that birth, Marlene spoke about her current pregnancy. I didn't worry with the first two, but having my daughter flipped me out. Also, I am o l d e r . . . . things bother me more when I'm pregnant. I yell at my kids more and then feel guilty. I drink about three or four pots of coffee a day [ten cups in each] with milk and a teaspoon of sugar. I've tried to cut down. I smoke a pack of cigarettes a day, down from two packs. Everybody told me not to smoke but I do. I like lots of pop [soda]. My appetite is down but when I am not pregnant it is not a problem. I am gaining enough weight.

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A nutritionist spoke with Marlene about the association of smoking with intrauterine growth retardation, infant low birth weight and prematurity. However, no one in the clinic learned the amount of coffee Marlene drank. Little is known about the effects of caffeine on fetal development, but surely Marlene was exceeding healthy amounts. Marlene said she knew what was happening to her body during labor and delivery because of her past experience. When I encouraged her to explain what she knew, she replied that the doctors were vague and did not tell her enough. At first she wanted to take the Lamaze birth preparation course but confused it with the Cesarean classes. She never did take a course. And no one addressed her fears. Shunted from one group to the next, women had little control over their pregnancy care. But they were not concerned with issues of control in pregnancy and birth as are many middle class women; that is, in making or sharing in health management decisions (Lazarus 1987; Singer 1987). They just wanted a doctor who knew their case and who cared about them. They wanted to be treated with respect. The Doctor-Patient Relationship

I kept a record of the length of each clinic visit from the time each women entered the hospital until the time she left. Waits for doctor examinations often took 2 or 3 hours, and on occasion, even 4 hours. By the time a woman entered a clinic exam room she was usually tired and bored. She was conscious of other patients' waiting, of the doctors' busy schedule, and of feeling rushed. Residents, hurrying from one patient to the next, were frequently tired. Several whom I knew had been up all night on call almost fell asleep during patient interactions. Thus, the usual asymmetrical relationship between doctor and patient with its concomitant power differentials was further widened by an environment where the many women who used the clinic experienced fragmented and rushed service, on top of their long wait. These characteristics set a tone of discontent and opposition when doctors and patients interacted. Class, race and gender barriers also contributed to the asymmetry. In my interviews, residents classified themselves as middle class or upper-middle class. Most were white and three-quarters of the thirty-five residents who rotated into the clinic during my eighteen-month field stay were male. Residents had little or no personal contact with poor or low-income women dependent on government services or with the distinctive ethnic or racial groups of the clinic population prior to their clinic experience. What little experience they had was usually as medical students in similar public clinics or wards. Konner, an anthropologist writing about his experiences in medical school, points out how medical faculty ". . . influence the emotional response systems and the ethics of future physicians." He gives an example of a medical professor speaking in a "condescending whine" to a large class of first-year medical students who had had little experience with patients. His ideas—and, not surprisingly, that of some of his younger colleagues—of how to relieve the sheer boredom of the lectures, was to make fun of patients and their illnesses. This, I learned, was something one became used to: vulgar jokes about patients are a ubiquitous feature of medical social life, excused

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(and perhaps excusable) as a "necessary defense mechanism" in the face of illness and death. But he was not an intern shooting the breeze in the middle of the night; he was a physician and scientist talking to a large class of first-year medical students who had not yet had any official experience with patients. [Konner 1988:18]

Experiences in the clinic further contributed to this same attitude. Residents spoke about women in stereotypical fashion. In private conversations, they made derogatory comments about patients' speech patterns, dress, and mannerisms. Although some criticized the hygiene of patients, I never heard residents address this issue with a patient nor did they refer this issue to the nurses. Some residents called clinic patients "dirtballs," a commonly used term among residents and medical students in public hospitals and emergency rooms (Konner 1988; Segal 1984). As the following statement shows, even the less overtly prejudiced residents revealed negative attitudes toward their patients. You are taking care of people who don't care about their bodies. If they don't care about themselves why should we. . . . We want to be Marcus Welbys but we get turned off. Nobody says thank you. Doctors treat them [patients] bad. One man whose wife I delivered gave me a long-stem red rose. I nearly cried, it was the first time someone showed appreciation. It is not so much racial as class. This is true for Blacks, Hispanics and white women. Women say, "I want the same doctor who 'waited' on me before." We are not waiters!

Patient complaints were little tolerated. When a woman in my study complained about the cold speculum, the resident laughed and said, "What do you expect from a metal instrument." Another resident commented, "What private patients classify as discomfort, poor women call pain." In contrast, more clinically experienced midwives observed that poor women were more tolerant of labor pain than middle class women. Several residents or residents' wives became pregnant and gave birth while I was at the hospital. They commented that their own experience made them more sympathetic to pregnancy discomfort and labor contractions. Residents expected clinic patients to ask questions and they assumed that women often did not because they were not interested in their pregnancies. Patient passivity reinforced these views. The women, on the other hand, wanted information but deferred to authority. For the most part they had a traditional view of the paternalistic doctor; some even preferred male doctors and they expected the doctor to tell them what they should know, hopefully, without having to ask questions. Above all, they wanted information. Again and again, women said, "I like it when the doctor explains; it helps me deal with things." They were intimidated by the brusque manner of many residents and embarrassed about their own ignorance of medicine. Many women, particularly those expecting their first baby, did not understand common birth vocabulary such as "dilation," "effacement," or "breech," (terms used routinely in the clinic) but they were too self-conscious to ask. Women were further inhibited when residents used acronyms and hospital jargon. When Puerto Rican women were unfamiliar with specific terminology, residents attributed the problem to cultural or language barriers. Toward the end of one Puerto Rican woman's pregnancy, a resident told her the baby had "dropped." Never having heard the expression, a look of puzzlement crossed the women's face.

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278 E. S. Lazarus The resident turned to me and asked if she understood English. I replied "yes" because the women had grown up speaking English; she had never heard the term. The resident then told her that her uterus had descended into her pelvis. This explanation helped her to relax. But, I usually did not participate actively in patientdoctor interactions and so rarely played such a brokering role. Women also felt foolish when they could not answer questions accurately. Many did not remember the date of their last menstrual period. To some residents, this illustrated patient ignorance and indifference about their bodies. However, I discovered in a project with middle class women, some who were health professionals, that most did not remember this date either. Another study of middle and low income women expecting their first birth found that women asked an average of only two questions or fewer per visit even though they wanted more information (Entwisle and Doering 1981). The middle income women in that study were just as inhibited in the doctor's presence as the low income women, but acquired information outside of the doctor's offices through magazines and books. The low income women had less time and fewer sources, and therefore tended not to seek outside information. Clinic patients in my study generally did not rely on outside sources either. According to Katz (1984), throughout the history of Western medicine the tradition has been not to tell the patient too much. Graham and Oakley (1981) found that doctors in Great Britain asked questions to alleviate patient anxiety rather than to obtain information. I found leaving patients in the dark about their health created additional anxiety in already distressed women. In 5 to 10 minute consultations, residents did not ask about the circumstances of pregnancy in women's lives. As a consequence, they were oblivious to factors that contributed to stress or poor daily prenatal health behavior. Yet, many women were undergoing stressful pregnancies. Twenty-two of the fifty-three women said they were often depressed. They worried about cutbacks in Medicaid and other government assistance and about unstable familial relationships. Additionally, forty-one women had unplanned pregnancies; many were ambivalent about having a baby. Women rarely had the opportunity to feel that they knew a doctor; more importantly, they wanted doctors to get to know them. They were pleased when they saw the same resident on repeat visits and a rapport developed. They were disappointed when that resident rotated off prenatal service. And, they became upset when "their doctor" failed to tell them that he or she would be rotating out of the clinic. One woman said: I like the idea of a private doctor better. The organization is better. They change doctors here and you can't get to know them. They don't get to know your history. I don't like the waits. But I had to come here.

On another occasion she said: "If it was my first baby, I wouldn't come—too scary here—never in a million years." Women wanted to learn that their pregnancies were progressing satisfactorily. They wanted explanations about their conditions, tests and medical procedures and became frustrated when they were left uninformed. They would ask, "Why did that doctor go out in the hall to talk to the other doctor? Is something wrong?" "What is this sickle cell trait that I have?" Or after a pelvic exam, "Why am I bleeding?"

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Falling Through the Cracks 279 In one interaction, a resident, concerned about a patient with a past history of serious perinatal complications who was having premature labor contractions, ordered a nonstress test to evaluate the fetus's condition. The resident did not explain the meaning of the test because, as she later explained to me, she did not want the patients to worry. The apprehensive patient tried to read her chart while the resident left to answer a telephone call. When the resident returned, anxious to conclude the interaction, she still did not tell the patient about the procedure, and the patient subsequently asked a nurse about it. The nurse told her, "Don't worry, we will take care of you." But, the woman did worry. She wanted an explanation to put her mind at ease. When women were asked to make decisions, their answers reinforced the stereotypical view that clinic patients were too ignorant to make meaningful choices. For example, women became confused when they were asked the kind of birth they preferred when delivery alternatives were not provided. Consequently, they had difficulty making choices. I frequently heard women say: "Natural, I guess," or "I don't know." The absence of continuity of care and an established professional-patient relationship further created stress later during labor. Since residents knew they would rarely follow a patient through labor and delivery, they believed that delivery decisions should be left to whomever delivered the baby. A few residents even said they did not inform patients of the choices of anesthesia and medication available until women were in labor. Women could hardly make well thought-out decisions under these circumstances. In labor they said, "Get rid of the pain;" "Take the baby;" "Give me a Cesarean!" Clinic patients respond to this kind of care with resignation. They have few options besides care in public clinics. Several private physicians, whom I interviewed, refused to see Medicaid patients or low income working women who do not have insurance. The clinic was the one place where poor people seeking prenatal care could be seen; many other patients in the clinic, not just those in my study sample, thought that the clinic and the obstetrics departments were "good" because "everyone" told them so; many women had used the hospital's clinics all their lives and it was important for them to know that the hospital kept their complete medical records; for some it was near home; for others the hospital accepted the "whole welfare package;" in several cases the hospital was recommended by satellite clinic personnel because of a woman's high risk status. Women worked out their feelings of frustration with the clinic in a variety of ways when unpleasant experiences in the clinic led to anger, annoyance or intimidation. Sometimes women told residents what they thought the latter wanted to hear: "Yes, I take my vitamins," when they did not. It was easier to tell the doctor what he wanted to hear than to feel embarrassed. One woman skipped her clinic appointments for eleven weeks because she thought she was healthy and the long waits were a waste of her time. Other women became argumentative, not with residents on whom they felt dependent, but with medical receptionists; a sixteen-year-old made faces at them when she was unhappy. These incidents disgusted residents and partially explain why they often did not discuss compliance and self-care with their patients. Remarked a third-year resident, "If a woman does not comply and do what I suggest, I lose interest in her case."2 Residents attributed noncompliance to patient indifference and ignorance, and for these reasons concentrated on the physical examination.

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Occasionally women in my study did not keep appointments. A few even threatened to leave the clinic permanently, though they never did. One teenager expressed the predominant view of study patients about prenatal care, "You'd never know if something is wrong if you didn't come in. Then you would think it is your fault." Also, they believed in the biomedical view of childbirth as a potentially pathological condition that should be medically managed. And they recounted prior experiences of their own and of family and friends to illustrate the risky nature of birth. Clinic visits with residents assured their progress was satisfactory and that problems would be diagnosed and treated. Some women who were not my subjects, but whom I observed and spoke with on occasion, were so negatively affected by their clinic experiences that they did not return. Coordinators of a government funded city-wide Maternity and Infant Care Outreach Project (M&I) tell me one of the major reasons women give for not coming for prenatal care is their prior experience with the prenatal health system. Women were embarrassed by their ignorance. Some were shy and intimidated in interactions. Others resented how they were treated. These factors contributed to an inability to verbalize effectively and to ask questions. Patient responses or lack of response reinforced residents' negative views of them. Residents, pressured for time, and with preconceived perceptions of patients, also failed in many cases to try to communicate. Ultimately, the doctor-patient relationship, fragmented by clinic organization and compounded by class distinctions, was not an alliance and gave little satisfaction to either women or to their doctors.

Resident Training—Clinical Patient Care

Training residents and treating patients in American teaching hospitals has been called a "marriage of convenience"—residents' need for training and experience and patients' need for care complement one another (Rosenberg 1987). Residents provide relatively inexpensive medical labor, gain experience, and "non-paying," government-assisted patients are served. However, in many ways, the goals of training residents and or providing primary care clash with one another (Scully 1980). Women view residents as their primary doctors. Obstetrician/gynecologists see themselves as specialists. One obstetrician at the hospital, following this prevailing medical view, described an Ob/Gyn residency as "essentially a surgery residency." Resident training emphasizes pathology, surgery and technological skills. Communication skills in obstetrics, as in most medical specialties, are not a focus. This fact has not changed from Carver's description of obstetricians' training fifteen years ago. The ability to listen to and talk with the patient; the understanding of the role of stress to disease causation and perpetuation; a knowledge and experience of the forces operating in society, the family, the workplace to produce mental and physical illness—these are far more likely to produce an effective physician for the majority of problems of most patients. But these are not characteristics and skills and knowledge that are currently being sought in medical school applicants-nor will they be emphasized or taught once the students are admitted. [Carver 1981:129]

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Falling Through the Cracks 281 In general, most residents planned to have private practices, which necessitate a great deal of patient communication. After observing more than one hundred resident encounters with clinic patients, I concluded that many residents were not developing communication skills useful with patients of any socio-economic level. Residents spoke openly about various colleagues' inability to communicate with patients and most felt it was each resident's responsibility to acquire these skills. Residents debated whether these skills could be taught or if they should be taught in medical school. They were not, however, concerned about their own communication skills, since almost all the residents I spoke with believed they communicated well. My observations revealed a wide variation in communicating skills. Commented a faculty member, "Some get it, some don't." And, that is just what happened; some got it, others did not. Residents had few role models to observe in the clinic. Faculty attending physicians were in the clinic infrequently. 'Attendings" were available for consultations through the hospital telephone system, another factor slowing up clinic procedures. One attending physician said, "Why should attendings want to t e a c h , . . . . one gets rewarded in academic medicine by research, not teaching." Procedures were also delayed when new residents were scheduled for a 30 minute faculty evaluation of their skills and performances during clinic hours. Residents left their patients waiting in the clinic. Faculty physicians assumed that first year residents had learned specific skills necessary for obstetric/gynecology practice in medical school such as the ability to give a pelvic examination or to take a medical history. One first-year resident told me that she was not evaluated by an attending physician on her pelvic examination skill until three months after she had entered the program. Residents in my study were satisfied with their training program in general; it provided excellent training in high-risk care. But as time passed during their fouryear residencies, they became increasingly dissatisfied with their rotations in the public clinic; it was something to get through, not a priority. Many residents told me clinic responsibilities were burdensome. Compared to gynecological surgery, routine clinic duties were tiresome. Residents did not see themselves as part of a clinic team of nurses, aides, social workers and receptionists. The clinic was a place in which to rotate in and out. Time was of the essence. "Spend too much time with a patient, you get behind and then you mess up the system," said one resident. A patient commented on this, too, "The doctor spends about five minutes with me. This is okay if there is nothing wrong but how would they know when they spend so little time with you?" Residents, in the group interviewed extensively, believed that the lack of continuity of care, necessitated in part by their rotations in and out of the clinic, affected their rapport with patients. They felt that it was impossible to develop an ongoing professional relationship with a patient. Residents said, "They don't' trust you." "It's hard to catch problems." "You don't have the pleasure of following a woman's progress." "You begin to see them as cases." "Too much to do and the women don't mean anything." Residents also believed that the lack of continuity with patients affected their ability to give care. For example, residents dated the start of a woman's pregnancy in different ways. Some calculated the date on their pregnancy wheel (a small

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282 E. S. Lazarus circular chart from which the date of birth, 40 weeks after the date of the last menstrual period, is estimated), others used the height of the fundus (the upper rounded portion of the uterus), and others used ultrasound (the visualization of the fetus by recording the reflection of sound waves). Dating is important because it indicates whether the fetus is developing normally and on schedule. But, dates computed by different methods lead to variations in records. Reading the notes of other residents was time consuming and confusing. To complicate matters, sometimes residents did not state which method(s) were used to date fetal progress. Residents got around this problem by depending on ultrasound testing. This led to additional patient visits to the hospital to have unnecessary tests. Residents were frustrated and women declared they were treated in a cavalier fashion. One patient commented: "It bothers me that nobody can tell me when the baby will be born." Women left the clinic with contradictory information. They are experimenting on me. It's nerve wracking. One doctor tells you one thing, another something else. This medical student (actually a resident) told me I had to have a Cesarean. Now I don't know what to do. This makes you hate to go. 3

Residents who saw the same patients for several visits in succession were able to check women more quickly because they could read over their own notes, thereby allowing them more time to attend to other patient needs. And when residents were able to spend more time with patients, some enjoyed following the same women through a series of visits. Several first-year residents wanted to set up their own "little practices" in the clinic in order to increase doctor-patient satisfaction. Essentially, the idea was to see the same patients for more sequential visits. The plan required patients to change their appointment visits to correspond to changes in residents' schedules. However, institutional resistance to the complications of appointment scheduling prevented the enactment of the plan. Medical receptionists were instructed to maintain patients on established team assignments and could not change the appointment schedules. One told me "I'm just following orders." Complained one resident, 'Almost all my patients are being seen by other doctors. I feel I am practicing ghetto medicine." Residents soon lost interest in the "little practice" idea. Many women in the study had poor eating habits and half smoked heavily, typical of the clinic population, according to the nutritionist. All the residents believed that good nutrition was a key factor in healthy pregnancies and that clinic patients needed to be aware of this. But they usually did not talk about nutrition with patients. They expected the nurses or a nutritionist to provide this information and assumed that they did. Yet, as I mentioned earlier regarding patient education, few residents knew what the nurses actually said. Furthermore, only half the residents interviewed had had nutrition training. Most medical schools do not emphasize the interdependency between diet and health; fewer than 20 of the 127 schools today have nutrition departments and most nutrition courses are electives (American Institute for Cancer Research Newsletter 1986). Many of the residents saw these "preventive" courses as non-essential or "easy" courses. Only one resident had learned about breast feeding; seven out of eleven had some lectures on family planning in medical school. Few residents took courses focusing on pain or human sexuality, nor had they had training in dealing with and counselling women

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Falling Through the Cracks 283 on incest, abuse and rape. There was little formal training in these topics during residency. Residents were under tremendous pressure to master technological procedures. The pressure toward technical training also provided a rationalization which absolved residents from responsibility for what they felt were essentially nontechnical interpersonal frills. On the other hand, women's desires, continuity of care and an ongoing relationship with a resident, were at odds with the actions and values inherent in resident training. By contrast, all twenty-one women who saw midwives for prenatal care or whose babies were delivered by midwives said they were pleased with midwife care and would use a midwife again. (Many resident patients did not know who or what midwives were). Midwives were less constrained by the structure of the clinic. Although they were officially responsible to the medical faculty, and did use the receptionists, essentially they practiced by themselves.4 The fact that they relied on other staff members less frequently facilitated their success with patients and generally they derived much more satisfaction from their work. Midwives conducted the physical examination, as did the residents, and then did the teaching delegated to the nurses on the resident services. A 20-minute scheduled visit, in comparison to the 5 to 10 minute resident interaction, established rapport. Although midwives consciously arranged for women to see several midwives during their prenatal care to avoid an overwhelming dependence on one caregiver, they prided themselves on sharing a consistent attitude and style with patients. Midwife ideology differs from that of residents, too. Midwives are not opposed to the use of technology, but their training and their experience is oriented toward reduced use. However, midwives did not see patients with serious complications whose conditions usually require more technology. Essentially, midwives viewed pregnancy as a natural process within a woman's life. They saw themselves as primary caregivers; patients were not a means toward an end of training. Midwife training includes understanding nutrition, breast-feeding, pharmacology, family planning, and applied psychology, all of which reflect a health rather than pathology orientation (Lichtman 1988; Rothman 1981). Midwives prided themselves in their sensitivity to patient needs and for this reason believed they were particularly adept with pregnant teenagers. In the words of one of the midwives, "How you say it to the patient makes a difference in compliance."

CONCLUSIONS AND IMPLICATIONS

The barriers and contradictions I have discussed: 1) the division of labor in the clinic; 2) the doctor-patient relationship; and 3) resident training and patient care, are some of the reasons that care in public clinics does not work effectively and efficiently. Problems in these areas are often seen by health administrators and clinicians as merely minor inconveniences in patient services. They are much more; they seriously affect health care. Dissatisfied lower-level hospital personnel, with low self-esteem and little pride in their work, inhibit clinic productivity. Long waits

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284 E. S. Lazarus communication between doctors and patients and the formation of attitudes of new doctors toward their patients. It is difficult to quantify quality care and its effect on pregnancy outcome. But findings suggest that care significantly affects wellbeing.5 If women most in need of care are to be attracted to public clinics, and if they are to be motivated to return to the next time they are pregnant, reforms in the public system must be addressed. Health workers must be given the opportunity to actively participate in the clinic. They know what works and what does not and they have a significant impact on the patients' willingness to return to the clinic. Health workers, like patients, must not be alienated. Medical care providers must not assume that patients are not interested in their prenatal care. Women must be given social and psychological support in a system that provides continuity of care and is organized so that women have positive views about the services and care they receive at clinics. These findings also raise questions about accepted aspects of medical education and resident training. Researchers of the socialization of physicians have come to similar conclusions (cf. Bosk 1979; Scully 1980). One particularly good example of this is the analysis by Mizrahi (1986) of how the professional socialization of internists, with its bias towards rewarding technical learning and the orientation of "getting rid of patients," has a negative impact on the doctor-patient relationship. Professionals resist overtly teaching communication. If residents are given the opportunity to observe attending physicians who are skilled in the art of clinical care, and are given the opportunity to see the same women for more extended visits during their pregnancies, some of these problems would be eliminated. However, medical educators say these reforms would be costly in money and in time. Additional personnel would be needed to cover services no longer available from residents who would be seeing patients for more extended consultations. Also, attendings cannot or will not take time away from private practice or from research to increase the time they spend as preceptors and mentors. Though obstetric residents are aware of class differences between themselves and their patients, they accept these differences as a given. They do not or cannot use this information to help them be more compassionate. The clinic's organizational barriers force the residents to focus on the technological aspects of care, rather than on combining both technological and communicative skills in their dealings with patients. Furthermore, as they become increasingly professionalized, they use these differences in addition to the contingencies of bureaucratic medicine to rationalize inadequate care beyond advanced technology. If the conditions illustrated in my case study are to be eliminated, we must place what goes on in the public clinic into a larger framework than the medical system. What happens in the clinic speaks not only about the way American health care is organized, it relates a specific social situation to society as a whole and informs us of the dynamic relationship between micro and macro levels. Barriers and contradictions in prenatal care in public clinics are the outcome of a social structure which perpetuates specific political and economic conditions of capitalist production, of bureaucratic control, of power relations. Changes in the delivery of health care are made by those who compete for power over profits. Or, as Singer (1987) points out,

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Falling Through the Cracks 285 health and healing succumb to the idiom of business. Prenatal care is affected by broader economic conditions which spur administrative changes. Health advocates and feminists have been instrumental in bringing some improvements in the way care is delivered. Medical administrators have been motivated to incorporate changes; they bring in paying patients. Many of these reforms chiefly address the care of private patients. There is less perceived need to cater to the captured audience in public clinics. That is not to say that poor women have not experienced some improvements in perinatal care. In trickle-down fashion, poor women have benefited from the pressures exerted from the Women's Movement. Two new birthing rooms have been constructed in the hospital with the expectation of attracting private patients; clinic patients deliver in these rooms as well, all on a first come, first serve basis. Clinic patients take the Lamaze birth preparation course, although many have difficulty getting to the hospital for classes. Fathers or a supportive friend or relative are allowed, even encouraged, to come into the labor and delivery rooms. In many hospitals women no longer are shaved or given enemas as part of routine birth preparations. For political and economic reasons, greater attention is paid to women in some ways. Private patients come to hospitals with the most attractive services which make them feel they are partners in the birth. But this is contradicted by greater depersonalization and interventions created by enhanced technology; IVs (intravenous fluids) are routine in the hospital and most women receive electronic fetal monitoring. Health policy makers and economists are increasingly aware that prenatal care is related to birth outcomes and that prenatal care is less costly than neonatal intensive care. There is a significant effort on the part of government to get women into prenatal clinics. But, there is no indication that structural changes will be made at the level of public patient care. Reforms have mainly benefited women during labor and delivery, not in prenatal care where private and public patients are treated separately. When care is separated into a two-tiered system, it is easy for discrimination to persist. Under the present medical system, public clinics cannot provide optimal care. Motivating forces for change, including the priorities of resident training and the organization of workers, do not presently exist. As long as they do not, contradictions and barriers in clinical care will persist. ACKNOWLEDGMENTS I wish to thank Hans Baer, Eileen Beal, Steve Lazarus, Merrill Singer and two anonymous referees for their critical reading and helpful comments on earlier versions of this manuscript. The research for this paper was supported in part by Grant Number MO1-RR00210 from the United States Public Health Service. lam grateful to the American Council of Learned Societies and the National Endowment for the Humanities for funding during the preparation of this manuscript.

NOTES 1. Waitzkin makes the point that socialist societies are class societies also, but their structure is based on bureaucratic authority and expertise rather than ownership of the means of production.

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2. Residents transmitted ideological messages that were not about medical cate. The prevalence of social control through the medicalization of social problems has been described in numerous studies. Notable are Ehrenreich and Ehrenreich (1974); Zola (1983); and Waitzkin (1983). Issues of sexuality, family life, and family planning were medicalized in the clinic. Some residents discouraged women from breast feeding because they believed it was psychologically difficult for this group of women. The diaphragm was discouraged as a means of birth control. Both residents and patients believed it was too much trouble. In one case an unmarried woman was asked to consider putting her soon-to-be-born baby up for adoption. 3. Some clinic patients participated voluntarily in research experiments. In the case here, the woman was frustrated because she believed doctors were withholding reasonable and available information on her baby's birth date. 4. Midwives were required to ask residents to write prescriptions or to confirm a medical diagnosis. They went to first- or second-year residents for these services. If they were truly puzzled they went to a more senior resident or to an attending physician. Midwives taught residents how to fit a diaphragm but they had to ask residents, including first-year interns, to write prescriptions for diaphragms. Like most of the staff, midwives felt discouraged. They need to feel valued by the medical staff and were pleased when residents thanked them for their support. 5. Clinical studies have demonstrated the importance of care in decreasing the incidence of preterm labor and delivery in high-risk pregnancies. lams, Johnson, and O'Shaughnessy (1988) demonstrate the significance of nurse attention to early symptoms of premature labor.

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Falling Through the Cracks 287 Lazarus, E. 1987 What Women Want: Women and Obstetricians. Paper presented at the 86th Annual Meeting of the American Anthropological Association, Chicago, IL, November 18-22. 1988 Poor Women, Poor Outcomes: Social Class and Reproductive Health. In Childbirth in America: Anthropological Perspectives. K. Michaelson, ed. Pp. 39-54. South Hadley, MA: Bergin and Garvey. Lichtman, R. 1988 Medical Models and Midwifery: The Cultural Experience of Birth. In Childbirth in America: Anthropological Perspectives. K. Michaelson, ed. Pp. 130-141. South Hadley, MA: Bergin and Garvey. Mizrahi, T. 1986 Getting Rid of Patients: Contradictions in the Socialization of Physicians. New Brunswick, NJ: Rutgers University Press. Navarro, V 1976 Medicine Under Capitalism. New York: Prodist. Poland, M. 1988 Adequate Prenatal Care and Reproductive Outcome. In Childbirth in America: Anthropological Perspectives. K. Michaelson, ed. Pp. 55-65. South Hadley, MA: Bergin and Garvey. Rosenberg, C. 1987 The Rise of America's Hospital System. New York: Basic Books. Rothman, B. 1981 Awake and Aware, or False Consciousness: The Cooption of Childbirth Reform in America. In Childbirth: Alternatives to Medical Control. S. Romalis, ed. Pp. 150-180. Austin: University of Texas Press. Scully, D. 1980 Men who Control Women's Health. Boston: Houghton Mifflin Co. Segal, D. 1984 Playing Doctor, Seriously: Graduation Follies at an American Medical School. International Journal of Health Services 14(3):370-396. Singer, M. 1987 Cure, Care and Control: An Ectopic Encounter with Biomedical Obstetrics. In Encounters with Biomedicine. H. Baer, ed. Pp. 249-265. New York: Gordon and Breach. Starr, P. 1982 The Social Transformation of American Medicine. New York: Basic Books. Waitzkin, H. 1983 The Second Sickness: Contradictions of Capitalist Health Care. New York: The Free Press. Zola, I. 1983 Social-Medical Inquiries. Philadelphia: Temple University Press.