The Relation Of Hospital Social Service To Child Health Work

By Ida M. Cannon, Chief of Social Service, Massachusetts General Hospital, Boston

A Presentation at the National Conference Of Social Work Formerly, National Conference of Charities and Correction During the Forty-Eighth Annual Session Held in Milwaukee, Wisconsin June 22-29, 1921

The term hospital social service is unfortunately not a very specific term, as it has come to be used to include a great variety of extra-mural service to hospital and dispensary patients. It has been used to designate such a variety of functions as a simple follow-up system to keep track of patients’ attendance at clinics, friendly visiting in the wards, various phases of public health nursing, a variety of administrative functions at admission desks and in the clinics, and medical-social case work. The fact is that all these various types of service are coming to be recognized as necessary to the improvement of hospital and dispensary service. All of them recognize the necessity of individualizing the patients and taking into account some of the social elements in the patients’ situation. Before we can discuss hospital social work intelligently, we need more specific terminology and definition.

I shall not attempt that now but shall choose for discussion the contribution that was made to the efficiency of medical treatment by the introduction of the trained social worker into the staff of hospitals and dispensaries. Visiting nursing in the homes of dispensary patients antedated the present hospital social work movement by several years and still remains in many cities the long arm of the hospital extending skilled nursing service and hygiene teaching to the patients discharged from the hospital or under supervision of the dispensary. Such service has long been recognized as essential to baby welfare and tuberculosis clinics and has stimulated the development of public health nursing organization in most of our cities.

Hospital social work, as such, came into existence as a logical development of organized medicine. No pediatrist would be content or successful in practicing medicine in his private office as he is expected to practice medicine in the course of his hospital or dispensary service. Medical diagnosis and prescription of treatment are a small part of medical practice. The background history of the child, knowledge of the parents, their co-operation in the plan of treatment, the following through of the treatment to its completion, are all vital to satisfactory medical service.

The medical-social worker attached to a children’s ward or clinic, if she is a trained social worker, fills the gap which has resulted from specialization and organization in medical service. She is a specialist, with knowledge and skill in social case work, who knows the community from which the patients come, the way families live and work and play, the resources for education, for safeguarding health and decency and normal family life. She is familiar with the methods and standards of other special social agencies, with the public health nursing organization, and can therefore make these resources of service to hospital patients. As an organic part of the hospital staff, she has a function that recognizes the truth that medical care, to be effective, must treat “not the disease only but also the man,” which in our present consideration is the child. And not only the child but also the parents and those who are vitally responsible for that child’s way of living and ways of thinking. The social worker contributes to the medical-social diagnosis and, working closely in consultation and co-operation with the physician, strives to secure social treatment that sustains and makes effective the doctor’s plan of medical treatment.

Two boys, each twelve years of age, occupied beds side by side in a hospital ward. Each had a diagnosis of acute endocarditis, the medical findings being almost identical. In each case the skilled medical and nursing care had resulted in a compensation of the heart and, since the symptoms had subsided, no further hospitalization was considered necessary, and the children were declared ready for discharge. The doctors stated that the prognosis in each case was good if the patient’s activity was carefully regulated, diet and hygiene safeguarded, and the return to normal life could be gradual and supervised by regular attendance at the clinic. The removal of the if was the task of the hospital social worker. One boy, an Italian, was the oldest of six children. The mother spoke no English and had little control over her little “American ” children, who interpreted freedom as license to do as they pleased. The father had irregular work in a slaughterhouse, and the family lived in three rooms in a third floor tenement in a crowded district. How simple was the hospital care of this child in comparison with the convalescent treatment after discharge!

The other little boy in the ward was an only child of an engineer living in a suburb. The mother was intelligent, a little overindulgent but ready and eager to try to put through the doctor’s orders, with the counsel and advice of the medical-social worker who helped her to see the ways and means of working out the boy’s recreation, his education, and the plans for vocational guidance, since the father’s occupation as engineer was one which his handicapped child could not safely follow.

It is a well-recognized fact among leading pediatrists that children do not do well under hospitalization. The use of foster homes for sick babies has been demonstrated as an excellent measure by Dr. H. D. Chapin in New York. We are now, with the co-operation of child-placing agencies, applying this same principle to older children whose homes are definitely unsuitable. The Children’s Mission in Boston, an excellent child-placing agency, has for several years accepted from Boston hospitals sick children whose chief need was intelligent mother’s care during a convalescent period, and whose homes were unsuitable or too far from the hospital to secure adequate medical supervision. Let me cite one case.

A child of four years with tuberculosis of the spine was reported ready for discharge from the ward in a plaster shell, following a Hibbs (bone graft) operation, and six months of recumbent care was ordered. There was a history of earlier hospital care for several weeks and discharge to his home with no special supervision and dire results. The family were Portuguese and lived on an island in southern Massachusetts. The mother, who married at fifteen, was too young and inexperienced to give him proper care, especially as she had two younger children. The parents were eager that the child should have care and consented to his being placed in a foster home near the hospital under the care of the Children’s Mission, where an intelligent foster mother is giving him excellent care. The foster mother comes with him to the hospital when notified by the hospital social worker to report. She and the social worker from the Children’s Mission are present when the doctor and social worker are talking over the plans for the patients, and they clearly understand the plan. This child has so far improved, that his prognosis is very good, and there will be one less crippled child.

Similar care has been extended to children with such diseases as infantile paralysis, persistent skin conditions, chorea, heart disease, and with psychiatric conditions needing study and mental hygiene. This supplemantary social service and the making available community resources for hospital patients is possible because there is within the hospital staff,’ correlating with the medical service, someone who can see not only the need but also the possibilities of articulating the hospital service with social agencies outside.

The greatly extended use of-public health nurses-visiting, tuberculosis, baby hygiene, school and industrial nurses-is also thus made possible. On the principle that every effort should be made not to overlap and duplicate the community resources, social service departments have arranged in several instance to have series of lectures and clinics for the public health nurses connected with boards of health, the schools, and visiting nursing associations on such subjects as diseases of the eye and ear and their treatment, tuberculosis in its varied manifestations, and problems of nutrition and diet. Many of the best public health nurses have not had much experience in their hospital training in the care of patients who frequent dispensaries. It seems to me quite fitting, instead of developing in each dispensary special visiting nurses, that the hospital social worker should enlist the interest of the hospital and its staff of physicians, who are only too ready to give such medical lectures to the public health nurses in the community who are ready to serve hospital patients, and can do so very well if they are given some additional knowledge of special diseases.

Aside from making possible more effective medical treatment, the hospital social worker sees rapidly extended opportunities for preventive health work among children. The examination of the children in families where the original patient had a diagnosis of tuberculosis or syphilis has brought many children under treatment before serious symptoms have been manifest. The deaf or blind child whom no medical service can help present a very real problem of education. Sometimes no suitable resources exist for such education. The hospital then becomes an important center for getting facts concerning the extent of this lack, and in several instances accumulated evidence presented by hospital social workers to boards of education has been very enlightening.

The physically handicapped child needing vocational guidance and training again offers an opportunity to the hospital social worker. It is not the hospital’s function to provide the necessary training, but should it not be one of the most effective means of arousing the interest of the public to the necessity of educational and vocational opportunities for children who may otherwise become not only dependent, but what is worse, sources of moral delinquency as well?

Within the past few years we have seen a tendency toward group treatment of dispensary patients who have chronic disease and whose treatment necessitates the co-operation of both the patient and his family. Among children, these groups include patients with heart disease, infantile paralysis, scoliosis, tuberculosis, rachitis, eczema, and malnutrition. Social service has been an important element in the development and maintenance of this group treatment and in studying with the physician the social factors involved. The trained social worker makes available to the physician the technical data from the social side which he has heretofore been able only to surmise.

The value of the hospital social worker lies, I believe, in the uniqueness of her contribution, and the future value must rest upon the more skillful development on the social side. While medical-social work is in part a merging of two skilled services, the value lies in their not being identical.

The sphere of medical service is almost as complex as life itself, if we see it in all its relatedness. That the social aspect of medicine is one of the most important that is emerging at the present time is well recognized by those of the profession who have the power and the will to see ahead. The education of the physician of the future will surely include at least interpretation of the social causes and complications of disease and the health legislation that necessarily concerns the physician. We often hear that one of the stumbling-blocks of public health movements is the indifference and sometimes the definite opposition of medical men. Those of us who are impatient of this should remember that heretofore the training of physicians, even in our good medical schools, has given practically no consideration to the public health and social aspects of the subject. It will be of interest to this group to know that the American Pediatric Society in I920 presented an outline of “Didactic Instruction in Preventive Pediatrics” which was recommended for incorporation in the curriculum of all medical schools. This action on the part of socially minded physicians indicates the tendency of the times. In a few centers where social service departments are a part of hospitals giving clinical experience to medical students, the hospital social workers have taken part in teaching medical students by case work method the interrelations of medical and social work. The extension of this kind of practical demonstration and teaching, related as it is to his direct contact with the patients, cannot fail to impress the young student who is getting his first vivid lessons in preparation for his profession.

While we are rejoicing at the improvement in medical education, we must be sure that we are much more concerned with better training for the hospital social worker. Those hospital social workers who are privileged to work with children should feel it a professional obligation to keep it abreast of the best thought and most carefully worked out methods and principles that are represented in the various phases of social work for children. Thus the socially minded physician and skilled medical-social worker may together study the problem of childhood as they see it in the hospital and dispensary, seek to discover why so many children need to enter our medical institutions, work out better methods of medical-social treatment, make fuller use of the community resources, and add something to the progress of preventive medicine.

Source: Proceedings of the National Conference Of Social Work Formerly, National Conference of Charities and Correction at the Forty-Eighth Annual Session Held in Milwaukee, Wisconsin June 22-29, 1921 — http://www.hti.umich.edu/n/ncosw/