Influence Of The Medical Setting On Social Case Work Services

By: Harriett M. Bartlett

A 1940 Presentation at the National Conference Of Social Work  Annual Conference in Grand Rapids, Michigan May 26-June 1, 1940

It is quite clear that there is wholehearted agreement between the fundamental purposes of medicine and social case work. Problems arise only because in particular settings purposes become confused and diverted under the pressing demands of daily practice. We shall purposely stress some of these negative aspects of the situation, since by learning to understand and control these limitations we may eventually hope to attain more positive results.

Since clinical medicine is the core of the hospital’s activity, let us start here. In medical social work it has been customary to follow the medical pattern in organizing a department, that is, to assign each worker (as soon as size of staff permitted) to one or another medical service. The advantage of this plan is that the social worker then naturally takes her place as a member of the team of professional and other workers which, under conditions of organized medical practice, cares for the patient. Let us assume that a worker is thus part of a medical or surgical service in a general hospital and that the chief of service, instead of referring patients individually, requests her to interview all patients who fall in one category or another, such as all patients with heart disease or cancer. Since patients do not ordinarily appreciate the medical-social aspects of their problem with sufficient clarity to make application themselves, this is a common method by which social workers in hospitals receive their cases.

What are some of the factors that operate here? This method of intake itself, by which the social worker takes the initiative in approaching a succession of persons in a category, has important implications for case work. From a broad viewpoint there are several points to weigh. How large is this group? How complex are the needs revealed? How long do the patients remain in the clinic or ward? How many interviews daily with each patient, his relatives, and others will be necessary in order to evaluate the social needs? To what further service on these cases is the worker committed? For what other patient groups is she responsible in terms of her whole job? Can she plan her work in such a way that these interviews will be meaningful, or will they gradually be reduced under pressure to a few minutes of hurried conversation, which hardly permits the development of a significant relationship with the patient? Frequently, as part of such a plan, the worker writes a social summary of each case on the medical record, supplementing this with oral interpretation to the physician in the more complex cases. In some situations she finds that the sifting of such a series of cases and the writing of reports have absorbed so much of her time and energy that she has relatively little left for what should be her major contribution, namely, the giving of assistance in relation to the needs which have been uncovered.

Each field of social case work has its special psychological problems for the worker. In this instance she will need to examine her own attitudes toward such diseases as heart disease and cancer. I suppose the most difficult aspect is the anxiety which ongoing disease is so likely to create. I still recall vividly the first time that, as a young worker, I confronted a patient who I knew was going to die but who did not realize it himself. I think most of us experience in such a situation at first a reaction which has the acuteness of emotional shock. The more the worker appreciates through her experience the probable effects of progressive disease, the more she may feel impelled to be prematurely active in new situations which confront her. A special difficulty in the medical setting grows out of the temptation to be authoritative, in an undiscriminating and overhasty manner. Since the physician’s expert recommendation seems so obviously the best plan for the patient and his family to follow, supported as it is by the whole weight of scientific evidence, and since the doctor himself may be urging the worker to bring about a certain result, she must watch her step lest she be impelled into a tempo too swift for the individual patient.

There should be careful evaluation of the purposes which the physician and social worker have in mind in undertaking responsibility for such a patient group. The social worker is primarily concerned in aiding the patient to meet the problems presented to him by the ongoing medical situation, or to prepare for the probable future course of the disability. She can work effectively only with those patients and their families who accept the problem and desire help. Are the physicians interested in assisting each patient to work out his problem in his own way? Are they interested in following the new trends in medical thinking which stress the psycho-social factors in illness? Or are they really more concerned with just keeping the whole group of patients under active medical care? Do they wish the social worker not only to do an exploratory interview, but also to keep in touch with every patient regularly so as to be able to report what is going on at any time and to keep the patients responding to clinic appointments without loss of time? Do the doctors also wish her to aid in bringing certain patients back for observation years after active treatment is completed, in order that end-results of medical care may be studied and registered for scientific purposes?

In such a situation it may happen that the worker unintentionally comes to represent to the patients a subtle but steady force toward clinic attendance and the following of medical recommendations. Under these circumstances patients may fail to sense that she has a special service to offer them in their need, a service quite distinct from what the other personnel in the medical institution offers. The worker, furthermore, may not realize that she is increasingly lifting from the patient and his family the responsibility for accepting and acting upon their own problem. It is obvious that these purposes on the physician’s part are socially valuable, since without them medical science could not advance; but the question arises whether the gap between his purposes and those of social case work may become too wide. Does not such a situation call for a redefinition of objectives, medical and social, which will be more consistent with the approach of social case work, lest the worker be pulled almost completely off her base? If the physician recognizes that medical social work focuses upon the social problems that illness and medical care present to the patient and his family, he will see how to use its assistance in the care of his patients and there will be no conflict of purposes.

With this review of some of the problems which may arise from the area of clinical medicine, let us turn to hospital administration.’ Out of the myriad activities involved we may select a few for illustration. There is a group of functions related to the running of the clinic, in which social workers frequently participate. When this is definitely the worker’s major function, she is usually described as a clinic executive. Problems arise less under these circumstances than under more indefinite conditions, when workers accept partial responsibility for the smooth running of the clinic while at the same time trying to carry case work functions.

The enormous detail and the executive character of the former duties are in such contrast to the flexible nature of social case work that it has often proved difficult to combine the two functions successfully. Furthermore, experience shows that activities of an executive character tend, through their very definiteness, to claim prior attention and thus to push case work services into the background. At still other times workers become involved in clinic activities in a less obvious but still time-consuming manner, by trying to fill the gaps created by inadequate and inefficient service and themselves stepping in to facilitate the processes of registering patients, assembling medical records, and making appointments. If the hospital has not provided sufficient personnel to man the clinics, the social worker almost inevitably gets diverted in this way, in the interest of those patients who have been referred to her, at least, if not for the whole patient group. Even when the personnel is relatively adequate, some workers seem to have a tendency to get involved in clinic processes (outside their case work functions), if their work keeps them in the clinic much of the time.

Note: It should be noted that in the medical setting the word “administration” is used with two meanings, first, in relation to a specific set of activities known as hospital administration, and second, in relation to any activities of an administrative character, wherever they occur.

Another area of work with an administrative emphasis has to do with discharge of patients from the wards. Where such cases are handled as individual referrals, with sufficient time to get to know each patient and to plan with him, fewer problems arise and valuable service can be rendered both to the patient and to the hospital. But when workers accept responsibility not only for reviewing every discharge in a relatively large patient group, but also for putting through the details of the procedure itself, the situation is more complex. This is a point in the patient’s care when the tempo becomes particularly rapid and pressures tend to accumulate, since beds must be cleared as swiftly as possible, particularly when a hospital has a waiting list. The difference between aiding patients with plans for after care, as a social worker, and being the person who actually arranges the discharge, an administrative function, should be noted. In the latter instance the worker may find herself in the position of pushing other personnel to carry through their duties, or even substituting for them, as in getting medical prescriptions filled and making appointments for return clinic visits.

We should not in this analysis neglect the significance of the worker’s own attitudes. Since the purposes and functions of the social worker are relatively more flexible than those of other members of the hospital personnel, it frequently happens that other staff members turn to her with problems for which no one is primarily responsible. It is easier to respond to such a request or pressure by following the line of least resistance; furthermore, friendly response seems the best way to improve working relationships with other personnel. Does the worker find it pleasanter to work in a defined role than to approach one case after another in which the need is freshly sifted? Does she find the rush of obvious services and activity which clinic and ward processes involve more satisfying? Does she have an urge to protect the patient from others and to take over their role if she feels they are not performing their work satisfactorily? Does she enjoy an administrative type of activity more than a case work job? Any of these motivations, conscious or unconscious, may play a part in determining the role that social case work will gradually assume in relation to administrative activities in the medical institution.

Since the hospital is a part of community life, there is a whole stream of influences coming from outside the institutional walls which must be understood and dealt with, but which can be only suggested here by one illustration. The community influence may be felt through the public health program, particularly in those parts of the hospital where communicable diseases like tuberculosis and syphilis are treated. If the social worker carries some of the more authoritative public health responsibilities, rather difficult problems are created in terms of her social case work role. Can she, for instance, establish a sensitive and understanding relationship with the patient that enables him to take responsibility in carrying through his own treatment, at the same time that she takes the initiative necessary to protect others from the consequences of infection? Is the follow-up approach mechanical or individualized? Has the relation between follow-up and social case work been thought through? How far is the case work approach used to establish a sound relationship between the patient and the clinic early in his treatment? Is the social worker skillful in drawing in the assistance of secretaries to help with the routine in the clinic and in herself relating her own role smoothly with the function of the public health nurse?

This illustration of characteristic problems that arise within various major areas of the medical setting shows how certain pressures and procedures tend to divert the social worker from her peculiar focus and how she must be continually alert to the nature of these influences and their effect upon her attitudes. Medical care is more rapid and more direct in method than social case work. Medicine is characterized by broad scientific knowledge, brilliant research, concise procedures, and high quality of practice resting on accepted professional standards. Because of his expertness and his natural relation with his patient and other personnel, the physician is in an authoritative role. Cooperating with him are a number of professions, such as nursing and dietetics, with an equally clear definition of purpose, body of knowledge, and set of skills. All these professional persons are accustomed to a rather direct and precise type of activity and expect the same of others in the medical setting. These influences are transmitted to the social worker through interpersonal relationships in the course of the daily job and thus operate with greater psychological force than impersonal rules and regulations. When it is recalled that social case work is only one small part of this large and elaborate setting, with purposes and methods of its own not as yet fully defined and by their very nature less clear and objective, the significance of this particular environment can be recognized.

The general nature of illness and the hospital setting further confirms these influences. Illness creates urgent situations that produce anxiety and call for rapid response. Where matters of life and death are concerned there must be not only swift, precise action, but also a body of rules to regulate the behavior of the personnel. Such standards and routines protect the patient and also economize effort and avoid delay. The reality of the needs associated with illness and the sense of this tempo are steadily impressed upon the social worker because she is surrounded by them all the time. Although she usually serves only a portion of the patient group, she is conscious of the crowded clinic benches and the ward beds full of acutely sick patients, in other words, of a mass of human need in bodily form constantly before her eyes.

A second type of factor, however, tends to produce a somewhat different influence. The great complexity of the modern medical institution, the extreme development of specialization, the multiple details required by clinic and ward administration, all combine to create a certain inevitable amount of confusion, overlapping, and delay. Where there are several professions working together, there are unavoidable duplications, gaps, and conflicts. Division of labor in the hospital has been carried to a degree where many of the activities have assumed an impersonal character, until the patient as an individual is lost to sight. Mechanical procedures and rigidities may develop until the very concept of the hospital’s purpose itself becomes narrowed. This means that it is at the same time both more important and more difficult for social case work to find and hold its own purpose in such a setting.

Looking back on these special features of the medical setting, we can roughly divide them into those that tend to carry social case work off its base through their onward course and those that tend to block and confuse its progress through their multiplicity, rigidity, or lack of coordination. The dominant medical purpose, the acuteness of illness, and the tempo of hospital activity fall in the first group, while the intricacies of organized medical care, specialization, detailed procedures, and size of the patient group fall in the second.

The concept of agency function, common in social case work, assumes a somewhat different meaning in relation to a larger setting, since there is a double set of objectives and functions-those of the hospital and those of the social service department-to be taken into consideration. This implies a need for integration, without loss of identity so far as the purposes of social work are concerned. I suppose that there are two constant errors into which social workers may fall in such a situation, either excessively stressing intensive case work with a relatively small number of patients, or spreading service so diffusely that the essential character of social case work may be lost. Of the two dangers, the second has seemed more characteristic of the medical social field up to this time. How far is this due to the special pressures of the medical setting? Or how far may this be expected in the early stages of any program, when there is need to try out various types of function and find a place for the new work? If at a later stage it is desirable to consolidate the program and deepen the work in the central areas, does it then become almost impossible to relinquish activities and change the focus?

In attempting to evaluate these problems involved in relating social case work to the medical setting I have come to the conclusion that the obvious and mechanical limitations that are usually thought of as procedures are basically less important than the psychological pressures. While the former do affect the social worker’s daily activity in a variety of significant ways, it seems to be the latter that really mold the broader policies and purposes of departments as a whole. These psychological influences are at the same time more important and more difficult to deal with because they operate invisibly, as it were. Yet their subtle impact brings about unconscious responses which in time may produce unintended shifts in basic medical social function. Taking the problem, then, at this level, what have we learned about constructive measures for orienting the work?

The unique contribution that social case work brings to the medical setting must be clearly visualized. The very multiplicity of opportunities for such contribution makes it particularly important that the central medical social focus should be maintained. In attempting to relate an activity like social case work to a setting where numbers of patients are large, needs urgent, and organization complex, it seems essential to recognize and accept the inherent limitation in the nature of the service itself -that social case work implies a degree of individualization, of social study and treatment, that cannot be indefinitely diffused without losing its essence. A sound medical-social focus here implies two things: that the work shows a consistent case work approach and that it continually bears upon the more significant social problems of illness and medical care. It means, further, that a series of cases and activities taken at random out of any skilled worker’s day or week will reveal this constant emphasis. We must be able to define more clearly than we now can both the opportunities and the limits of skilled briefer services in relation to case work quality, since it is here that questions regarding focus most often arise.

When social case work is part of a larger setting, an extra step is necessary (not required in separate social work agencies) in preparing the environment and increasing its readiness to use this service. Two methods have been found to have special value, one more general and the other more specific. The effort which has gone into teaching social aspects of illness and medical care to medical students, nurses, and others of the hospital personnel has helped to prepare the ground. But it is essential that this should be supported by an adequate demonstration of medical social case work itself. The full case work service should be seen somewhere in the setting, not overlaid and confused by secondary activities, but clear to all observers. Because social case work is a less objective type of service than most of the others in the hospital, great ingenuity and skill are needed to show that its methods, although often concerned with intangibles and not readily demonstrable, are actually relevant to the need and economical in practice. We are just beginning to develop some case material which is, I think, really effective in this direction.

It is essential that social case work should be genuinely integrated with the medical setting, taking its place as an appropriate part of good medical care. Mutual understanding and acceptance of purposes are more important than efficient procedures. In her eagerness to serve, the medical social worker must be careful to avoid the two extremes of taking responsibility away from the physician, or following his directions blindly in what should be her own area of competence. Steering a middle course here demands a nice sense of the setting as a whole and the particular role which social case work may play within this configuration.

We are increasingly realizing the importance of establishing a well-planned framework of organization, policies, and supervision to place social case work soundly within the larger setting. Such a framework orients the group of individual social workers who comprise the social service department, on the one hand to the hospital and community, and on the other hand to the various activities that make up the department’s own program. It supports each worker by giving perspective and stability to the objectives that guide her work. This means that whatever supplementary services are undertaken should be clearly subordinated to the central services, lest the lesser functions push the others out of the picture. A department may be unusually strong in several aspects of its program, perhaps in its work with the hospital administration or the community agencies, but unless good cooperation and understanding are also established with the medical staff, its position is likely to be insecure, since this is the core of medical social work.

Better formulation and wider recognition of the principles guiding the interrelationship between various medical social functions are needed. We have described the difficulties that may confront an individual worker when she tries to combine a variety of activities. Experience shows that a department as a whole can soundly serve such a variety of purposes by dividing them among the workers and setting up separate units for different functions. In such a form of organization the relation between the various services and units must be clearly defined. There are certain services, such as social admitting, which make use of social case work skills but which require the support of a case work unit to carry on the social study and treatment of those patients who have more complex social problems. Another way of putting this is to say that social study and treatment of the individual patient in collaboration with the physician (that is, social case work in clinical medicine) has been proved by experience to be a basic function, while the other case work activities of the social service department depend upon it for their effectiveness and validity.

In establishing a sound framework the department will find two concepts particularly helpful: the concept of focus upon a central set of functions and the concept of balance and interdependence between the total group of activities, primary and secondary, within its scope.

It seems clear by now that the situation is too involved to be met by a single arbitrary plan. The nature of the changing situation and the complexity of the subtler influences involved seem to demand not only careful evaluation before any new function is accepted but also repeated evaluation from time to time as the activity develops. It is because of the lack of such constant evaluation that unplanned shifts in function have apparently occurred. Since I am so particularly impressed with the importance of evaluation myself, I am also alert to its difficulty. The great problem, as I have seen it, is how to be able to carry the members of a whole staff along so that such questioning and analysis do not assume for them a confusing and destructive quality in relation to their work, but have the force of positive stimulation and growth. The more the purposeful evaluation emanates from the staff’s own relation to its work, the more it is likely to be of the latter character.

We find it essential in all this to understand the relation between social case work and the various other activities broadly included within medical social work. In the first place, we have learned that the case work method and approach may permeate our work, but it will not be there unless we put it there. It was not so long ago that we sometimes used to list the specific services offered by a department, such as convalescent or chronic care, on one side and then attempt to count case work services as something separate, as if they were of different quality. We now see that these specific services that are an essential part of medical care can either be performed in a case work manner or not, according to the focus of the department and the skill of the worker. In the second place, we see that it is particularly important to visualize medical social case work not only as a direct service to individual patients, but also as a base for many of the major concepts regarding social aspects of illness and medical care, on which rest the functions of the whole department and of the professional group itself. Understood in this way, social case work is seen to be, not necessarily narrow and limited in perspective, but a straight road to the viewpoint and skills which represent the social worker’s unique contribution to good medical care.

In conclusion, we must remind ourselves that this review has related only to the medical institution and that the medical setting is now broader. In a few years we should be able in our analysis to cover the role of social case work (and other social work functions) in public medical programs as well as in hospitals.

Source: Proceedings of the National Conference of Social Work Selected Papers Sixty-Seventh Annual Conference Grand Rapids, Michigan May 26 – June I, I940 – pp. 258-269 — http://www.hti.umich.edu/n/ncosw/