MEDICAL SOCIAL WORK.
By Harriet Bartlett. Chicago: American Association of Medical Social Workers, 1934. 223p.
Medical Social Work represents the work of the Functions Committee of the American Association of Medical Social Workers. In this study they have asked themselves, What is this we are doing, why are we doing it, and with what effectiveness are we accomplishing the task of promoting health? Throughout all the answer runs the thread of thought enunciated by John Dewey in Philosophy and Civilization—that those who hope to advance science in the future must do so through synthesis of the knowledge that already exists. Its bearing here is that medical social work brings to medicine the social aspects of the case. The physician has the knowledge of the disease; it is the social worker’s function to interpret the patient in his setting to the physician, and again to interpret the patient with his disease to himself.
In clarifying their own ideas, the committee abandoned the previously tried statistical method, took twenty-five cases selected at random, and concentrated on three as best showing the types of service rendered. These show how the work of the medical social worker brings to the physician and the hospital that which lies without their grasp under modern conditions of hospital and clinic practice.
It is assumed that the individual needs more than just physical health—that recognition, however limited, gives him a status in family and society. This makes it necessary for the social worker to deal with the family and the community as well as with the patient.
The question then is, How does this service relate itself to clinical medicine? Here a much debated question in other branches of social work is answered positively. It does so by becoming one of a team, of which the physician is the final authority in treatment and diagnosis. The social worker’s contribution is expertness in method of social work and the understanding that this can give to the medical situation. Again we see synthesis between medical pathology and social pathology. It may be working with the patient in order that he may respond to medical treatment. It may take various forms—even that of further research such as a study of occupations in which cardiacs are engaged.
In the study of the three selected cases, we are shown the processes by which this synthesis with medicine is made. The first case is a girl treated for tuberculosis. The social investigation reveals a mortgaged home and an invalid sister. It is believed that there is evidence to support the hypothesis that the strain arising from this home situation was an etiological factor in the patient’s breakdown. Cure did not ensue until this was recognized and treated. Preventive work requires attention to these same factors to prevent recurrence.
In the next case, a boy who has lost his right forearm and part of his right hand in an accident is considered. Through legal aid there is adequate financial provision for his care, but ignorant parents and a disheartened boy are to be dealt with in the after-care if he is to become a self-sustaining citizen rather than a pitied cripple.
The third case is one of the terminal care of cancer. Early exposure to tuberculosis and a home lacking in security and happiness may be relative to the disease, but this question, as is pointed out, is academic. The point here is the very perfect acceptance of the inevitable on the part of the patient after the community has functioned to give the best care possible. It is hard to believe that any community would begrudge that care could it know the comfort it gives. A very pertinent question is raised here: How much of such care of a palliative nature can be undertaken without infringing on the law of diminishing returns?
From these three cases the conclusion is reached that the interrelationship between social factors is understood, though not scientifically demonstrated; that physical deprivation and social situations may be deprivations according as they affect the patient or, to use the author’s words, according to the psychic component.
After-care, it is seen from the case of the crippled boy, means that persons be helped to adjust to present conditions. As this case shows,it is not the work of a moment or a week or a month, but the result is a person who is socially useful instead of socially inadequate.
One of the most pertinent findings is that in this time of economic breakdown, the psychological aspects stand out as more important and less successfully dealt with than the physical. This neglect is not surprising when we consider the neglect of these aspects in other fields, but it points to a need of emphasis in training. The conclusion is reached that the understanding of “the social component of illness” is the first and most important step toward the medical social worker’s function. How often has one seen this demonstrated when, after an unbelievable number of treatments and operations, a patient in a general clinic is referred for personality and social study, and it is found that the psyche has, as Freud puts it, taken a flight into illness in order to escape the demand of a situation for which the individual feels inadequate.
The patient’s attitude is found to be of value and significance in dealing with physical illness, and by her understanding of this the social worker “extends the medical treatment in connection with plans and procedures relating to the patient’s activities or care outside the medical institution.” The patient must be treated as well as the disease.
Again, in more than half of the cases studied, in the judgment of the writer, measures are necessary to meet the psychological needs of the family. This points to the assumption that while man may not live by bread alone, some of it is necessary and that the financial side cannot be assumed to be non-existent except in the mind of the patient.
The activity of the social worker was devoted to a considerable extent in meeting these financial needs. The greatest amount of effort was put into helping the patient to understand the implication of his illness or handicaps in terms of his usual way of life, and a large amount of activity was directed toward the adjustment of the patient’s social role and relationship. The most important steps in these cases, and those most frequently emphasized by the workers who carried out the case-work, are environmental adjustment and interpretation, emotional support and guidance, education of family attitudes, and adjustment of the patient to institutional life and incurable disease.
Throughout the study truths are emphasized that in themselves offer material for detailed study—i.e., the utter uselessness of advice unless the patient is emotionally ready to accept it. How many records state that the social worker advises the client to do thus and so, with no regard for what the patient’s emotional state is at that time and what he is capable of doing. An example would be instruction to a diabetic person incapable of understanding its meaning and emotionally so adverse to any advice that the effort to give it not only is a waste of time, but may result in strengthening the resistance.
In conclusion it is again stated that the medical social worker is an integrating factor, a catalytic agent, bringing together the medical and social aspects of the case into a more effective plan.
As is brought out, points that need classification are the understanding of the patient as a personality, and the working with the patient in contrast to working for him. These points are put in terms that would be accepted by any internist or clinician and are free from some of the so-called visionary explanations that to the average physician lack any pragmatic value.
Throughout the work self-criticism is not lacking, and the superficial action may lead nowhere, while the deeper understanding of the patient is neglected, is pointed out. This is the 4 type of action that looms large in performance with little in the way of result. The lack of wisdom in treating disease without medical advice is also pointed out.
In the opinion of the committee, medical social work, though derived from generic social case-work, is part of the medical care of the sick person. The test of the appropriateness of the social worker’s activities will be the degree to which they increase the effective functioning of the medical team in the care of the patient. The social worker, to do this, needs to be more objective, to become less involved in her cases. She must organize her thinking and material with more clarity and conciseness. To anyone who has had to pour over voluminous records of activity on the part of the worker to find out what manner of person the patient is, such advice comes as cool air on a humid day. There must be joint thinking on the part of the physician, the social worker, and the patient, all directed toward the goal of health. Flexibility of thinking is recommended. To make a plan and stick to it is not always best. As a parting word, it is recommended that the social side of illness be more closely studied.
To anyone who wants to know what medical social work is, or to a medical social worker who wants to know what goals should be striven for, this book is recommended because of its clarity, comprehensiveness, and sanity.
By: Nancy Johnston. Richmond, Virginia.
Source: Harriet M. Bartlett Papers. Box 7. Folder 78. University of Minnesota, Twin Cities, Social Welfare History Archives. Minneapolis, MN.