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Professional contacts between doctors and social workers : a comparative survey of awareness and utilization… Moscovich, Shirley Saundra 1963

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PROFESSIONAL CONTACTS BETWEEN DOCTORS AND SOCIAL WORKERS A Comparative Survey of Awareness and U t i l i z a t i o n of Services, Vancouver B.C., 1963 by SHIRLEY SAUNDRA MOSCOVIC'H Thesis Submitted i n P a r t i a l Fulfilment of the Requirements f o r the Degree of MASTER OF SOCIAL WORK in the School of Soc i a l Work Accepted as conforming to the standard required f o r the degree of Master of Soc i a l Work School of Social Work 1963 The University of B r i t i s h Columbia In presenting t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e for reference and. study. I f u r t h e r agree that per-mission for extensive copying of t h i s t h e s i s for s c h o l a r l y purposes may be granted by the Head of my Department or by h i s representatives,, I t i s understood that .copying, or p u b l i -c a t i o n of t h i s t h e s i s for f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n permission. Department of The U n i v e r s i t y of B r i t i s h Columbia,. Vancouver 8, Canada. I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f / -t h e r e q u i r e m e n t s f o r a n a d v a n c e d d e g r e e a t t h e U n i v e r s i t y of . . . B r i t i s h C o l u m b i a , I a g r e e t h a t t h e L i b r a r y s h a l l m a k e i t f r e e l y a v a i l a b l e f o r r e f e r e n c e a n d s t u d y . I f u r t h e r a g r e e t h a t p e r -m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r . s c h o l a r l y p u r p o s e s m a y b e g r a n t e d b y t h e H e a d o f my D e p a r t m e n t o r b y h i s r e p r e s e n t a t i v e s , . I t i s u n d e r s t o o d t h a t c o p y i n g , o r p u b l i -c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l n o t b e a l l o w e d w i t h o u t m y w r i t t e n p e r m i s s i o n . D e p a r t m e n t o f T h e U n i v e r s i t y o f B r i t i s h C o l u m b i a , . V a n c o u v e r .8, C a n a d a . / V ABSTRACT In most modern communities, a large array of health services and welfare services are at least p o t e n t i a l l y available to a l l . Whether any i n d i v i d u a l or family receives a co-ordinated balanced welfare service, however, depends on many fact o r s , including the extent to which two "helping professions", s o c i a l work (as represented by s o c i a l workers employed i n various agencies) and medicine (as represented by general practitioners) know of each other's services and a c t u a l l y work together. The present study i s a preliminary ' survey of the s i t u a t i o n . As background, the impact of i n d u s t r i a l i z a t i o n and urban-i z a t i o n on the development and contemporary roles of medicine and s o c i a l work i s reviewed. Information for. t h i s q u a l i t a t i v e study was obtained through questionnaires submitted to sample groups of doctors and s o c i a l workers. The purpose of the questionnaires was to gain some d e f i n i t i o n of the concept of " r e c i p r o c a l awareness and u t i l i z a t i o n " . In each case, the attempt was made to evaluate the knowledge one profession had of the other's role and function, and the extent to which' t h i s knowledge was used f o r the benefit of the population they served. In addition, d i r e c t o r s of three key agencies were interviewed to determine t h e i r views on the r o l e of the agency i n furthering r e c i p r o c a l awareness and u t i l i z a t i o n . The findings of the study indicate, that a f a i r l y t y p i c a l s i t u a t i o n i s that the doctor's awareness of the s o c i a l worker's role and function i s limited and outdated. S o c i a l workers, i n general, are more aware of the doctor's r o l e and 1function, but' on the other hand, t h e i r expectations are somewhat high and perhaps u n r e a l i s t i c . As indicated by the t e s t of r e f e r r a l patterns, the u t i l i z a t i o n of each other's resources i s minimal. The doctor's u t i l i z a t i o n of s o c i a l work s k i l l s and resources i s hampered by two f a c t s : (a) patients have mixed feelings about being referred, and (b) doctors believe that agency policy and procedure i s i n e f f e c t i v e and f r u s t r a t i n g . There i s evidence that besides not recognizing a modern s o c i a l worker's role and function, general p r a c t i t i o n e r s appear to underestimate s o c i a l and emotional factors i n i l l n e s s . Reciprocity, the main concept evaluated i n t h i s study, i s minimal. Both doctors and s o c i a l workers recognized that there are gains to be r e a l i z e d from more co-operation and some methods are recommended; but the low degree of r e c i p r o c a l awareness and u t i l i z a t i o n e x i s t i n g between doctors and s o c i a l workers must be tackled by recognizing that rather than lack of communication, f a u l t y and h o s t i l e communication i s the issue. This does not necessarily apply to medicine and s o c i a l work i n i n s t i t u t i o n a l settings, and t h i s difference demands further exploration. v i ACKNOWLEDGEMENTS I should l i k e to convey my sincere appreciation to the agency d i r e c t o r s , s o c i a l workers and doctors, f o r t h e i r i n t e r e s t and co-operation which made thi s study possible. In p a r t i c u l a r I would l i k e to thank J.C. Moscovich M.D. and B.B. Moscovich M.D. for the suggestions and c r i t i c i s m s which they contributed as the study progressed. I am deeply g r a t e f u l to Mrs. Mary Tadych, School of Soci a l Work, University 'of B r i t i s h Columbia, not only f o r her keen i n t e r e s t , encouragement, optimism and astute evaluation of the material included i n t h i s study, but also, for two years of continuous support. I should l i k e also, to convey my sincere thanks to Dr. Leonard Marsh, School of So c i a l Work, f o r the invaluable technical assistance -and f o r the support which he gave so generously throughout the planning and conduct of the study. F i n a l l y , I am forever g r a t e f u l to my family, without whose support and encouragement, I would never have been .able to complete t h i s study. i i TABLE OF CONTENTS Page Chapter 1 Co-operation Between Professions: Theory and Practice * Premises of the study. H i s t o r i c a l background: Medicine and Soc i a l Welfare. Doctors and s o c i a l workers: the growth of medical teamwork. Prob-lems of co-operation and co-ordination. E f f o r t s toward co-operation. Methodology of the study 1 Chapter 2 The General Practitioner and the U t i l i z a t i o n of Welfare Services The doctors: education and experience. Under-standing the doctor's role: diagnosis and t r e a t -ment. Awareness and u t i l i z a t i o n : r e f e r r a l s . Contacts with welfare agencies. The doctor's understanding of s o c i a l work. The doctor's opinions about s o c i a l workers , . .• 34 Chapter 3 Soc i a l Workers and the U t i l i z a t i o n of Medical Services The s o c i a l workers: education and experience. Counselling. Awareness and u t i l i z a t i o n . The s o c i a l worker's understanding of the doctor's r o l e . D i f f i c u l t i e s experienced by s o c i a l workers in working with doctors. The s o c i a l workers' suggestions f o r ameliorating i n t e r -professional discord 65 Chapter 1+ Relations Between Doctors and Social Workers: Some Appraisals and Conclusions Awareness and u t i l i z a t i o n . Froblems encountered i n the team approach. Solutions to overcome bar r i e r s toward co-operation and understanding. E f f o r t s at co-operation: Medicine. Recommen-dations f o r the doctors. E f f o r t s at co-operation: S o c i a l Work and So c i a l Welfare. Recommendations for the s o c i a l workers. Conclusion 91 Appendices: A. Questionnaire f o r the Doctors and accompanying l e t t e r . B. Questionnaire f o r the So c i a l Workers. C. Bibliography. i i i TABLES IN THE TEXT Page Table A. Doctors: Length of Time i n Private Practice 38 Table B. Doctors: Social Problems Which Cause Functional I l l n e s s 40 Table C. Treatment Methods Administered i n Cases of Il l n e s s with No Organic Basis . 42 Table D. Referrals Made by Doctors to Community Resources i n a Two Week Period 45 Table E. Welfare Agencies Used Most Often by Doctors 46 Table F. The Doctors' Consideration of Available S o c i a l Work S k i l l s When Referring Patients to Health Agencies ... 48 Table G. Reasons that the Doctors Do Not Refer a Patient to a Welfare Agency 51 Table H. Resources U t i l i z e d by Doctors to Increase Their Knowledge of Welfare Resources 55 Table I. Opinions of the Doctors as to the Education Require-ments for So c i a l Work Practice 56 Table J. The Doctors' Understanding of the Social Worker's S k i l l s 58 Table K. D i f f i c u l t i e s Encountered by Doctors i n Working with S o c i a l Workers 60 Table L. Doctors' Complaints About S o c i a l Workers 62 Table M. The Doctors' Opinions as to the Soc i a l Workers' Best Contributions 64 Table N. Social "Workers: Educational Degrees 66 Table 0. So c i a l Workers: Education Related to the Understanding of the Doctor 68 Table P. Soc i a l 'Workers: Number of Years i n Practice i n the Welfare F i e l d and i n t h e i r Present Employing Agency.. 70 Table Q. The Social Workers: Purposes f o r Contacting the Clie n t ' s Doctor 72 .Table R . Problems Encountered by Social Workers i n Individual Contacts with Doctors 78 i v TABLES IN THE TEXT • (Continued) Page Table 3. The S o c i a l Worker's Understanding; of Medical Education Concerning S o c i a l Work and the S o c i a l Services 79 Table T. The So c i a l Workers' Opinions as to the Main Contribution Which Can Be Rendered to Doctors i n Health Agencies, Hospitals and Welfare Agencies .... 80 Table U. D i f f i c u l t i e s Experienced by Most S o c i a l Workers in Working xvith Doctors ' 8 2 Table V. Opinions of the So c i a l 'Workers Concerning Their Contributions to Inter-Professional Discord ' 84 Table W. Social Workers: Suggestions as to the Role of the Caseworker i n Ameliorating Inter-Professional Discord 86 Table X. Suggestions as to the Ways Soc i a l Workers, i n Other Professional Roles, can Ameliorate Inter-Professional; Discord ; 87 Table Y . The Social Workers* Opinions as to the Level at Which Most Can be Done to Promote Co-operation and Co-ordin-;' at ion : 89 PROFESSIONAL CONTACTS BETWEEN DOCTORS AND SOCIAL WORKERS A Comparative Survey of Awareness and U t i l i z a t i o n of Services, Vancouver B.C., 1963 Chapter 1 Co-operation Between Professions: Theory and Practice Premises of the Study Sp e c i a l i z a t i o n , a common c h a r a c t e r i s t i c i n a l l i n d u s t r i a l s o c i e t i e s , refers to the d i v i s i o n of labor i n the. growth of s k i l l s and i n some degree the a l l o c a t i o n s of authority i n society. The d i v i s i o n of labor i n the sense of the r i s e of s p e c i a l s k i l l s applies i n the helping professions 1 as well as industry and commerce. Wilensky and Lebeaux point out that s p e c i a l i z a t i o n a f f e c t s every sphere of l i f e and that i t prompts the growth of large formal organizations that exist to co-ordinate the a c t i v i t i e s of the s p e c i a l i s t s : ^ These trends i n s p e c i a l i z a t i o n are both cause and consequence of the dominance of the big organization i n industry, commerce, labor, p o l i t i c s , the m i l i t a r y , r e l i g i o n , education, recreation---in every sphere of l i f e . Large, complex, formal organization i s necessary to co-ordinate the e f f o r t s of large numbers of inter-dependent s p e c i a l i s t s , and the larger the organization the more necessity f o r s p e c i a l i z a t i o n , This i s true whether the s p e c i a l i s t be clergy In a . nationwide church, engineers i n a corporation, s c i e n t i s t s i n a university, workers in an assembly lin e or caseworkers i n a family agency. Large scale organi-zation with specialized personnel are c h a r a c t e r i s t i c of a l l i n d u s t r i a l s o c i e t i e s . 1 "Helping Professions" refers to the m i n i s t e r i a l , medical, law, nursing and s o c i a l work professions. 2 Wilensky, Harold L. and Lebeaux, Charles N. I n d u s t r i a l  Society and S o c i a l Welfare. Russel l Sage Foundati.on, New York, 1958, p. 95. 2 i The nature of s p e c i a l i z a t i o n r a ises several issues f o r a l l professions. It can be acknowledged that as services increase and become more sp e c i a l i z e d , not only i s the professional person uncertain of the proper resources to c a l l upon, but also the ordinary c i t i z e n knows, less about the help which i s a v a i l a b l e . In the growth of formal organization in health and welfare services, and problems of achieving e f f e c t i v e collaberation between the many professions and between specialized agencies has become an urgent one f o r people in most communities. This presents a considerable challenge to s o c i a l workers and i t prompts an increased acceptance of the necessity of teamwork among s o c i a l workers and members of the other helping professions. It also prompts the need for more awareness and more j o i n t study, as well as the recognition of l i m i t a t i o n s i n the f i e l d of welfare. This idea was discussed by H. Stalwick when he stated: ^ To adequately study t h i s problem i n any community, a l l of the helping professions should be included. The focus should be upon what the representatives of one profession recognize i n the other profession and to what extent they use t h i s knowledge for the benefits of the individuals i n that community. The objective of t h i s study i s to consider how much reci p r o c a l 1 This fundamental point was expressed by Michael Wheeler i n "A Report on Needed Research i n Welfare in B r i t i s h Columbia." This survey was undertaken by the Community Chest and Councils of the Greater Vancouver Area and was published i n March 1961. 2 Stalwick, Harvey N.S., Churches and Welfare Services i n  Richmond. B.C., Master of S o c i a l Work Thesis, University of B r i t i s h Columbia, 1962, p. 4. 3 awareness and u t i l i z a t i o n x i s present i n the two professions of s o c i a l work and medicine i n Vancouver, B r i t i s h Columbia. Emphasis w i l l be placed on the i n t e r r e l a t i o n s between general p r a c t i t i o n e r s and s o c i a l workers ^ employed i n primary settings. 3 In t h i s s p e c i f i c community focus w i l l be upon what s o c i a l workers i n the community recognize as the resources and s k i l l s of medicine and the extent to which these resources are used f o r the benefit of c l i e n t s . Of equal importance i s the objective of assessing the recognition doctors have of welfare services and the extent to which these resources are used f o r the benefit of the patient and his family. H i s t o r i c a l Background: Medicine and S o c i a l Welfare . Out of the complex developments which have and are taking place i n the profession of medicine, two themes are pertinent to t h i s study. F i r s t , i s the s c i e n t i f i c revolution i n medicine which underlies a l l others. Second, i s the technical revolution, with i t s f a r reaching influences. 1 This concept of r e c i p r o c a l awareness and u t i l i z a t i o n may be graphically explained i n the following chart of the i n t e r r e l a t i o n -ship between a Doctor and a Family Service Agency s o c i a l worker. Awareness - doctor learns of the nature of the Family Service Agency. U t i l i z a t i o n - he refers patients with marital problems to the agency. Reciprocal Aspect - s o c i a l worker as a res u l t of contact with the doctor, re f e r c l i e n t s with medical problems. 2 S o c i a l workers w i l l be defined as the personnel associated with administering the welfare services. 3 The term "primary settings" refers to agencies designed primarily to give s o c i a l services to c l i e n t s either as individuals or i n groups. These agencies operate under s o c i a l welfare aaspices and examples of such are Public Welfare Departments and family and children's s o c i e t i e s . 4 Since the days of the "medicine men" of the ancient world, when the foundation for the capacities of modern medicine were l a i d , medical practice has undergone many changes. The great s c i e n t i s t of the 17th century launched modern medicine by shattering obsolete authority, by laying the foundation for an accurate knowledge of the structure of the human body, and by demonstrating how physiological functions could be studied i n t e l l i g e n t l y . ^ From that time on, slowly and often p a i n f u l l y , the extension of knowledge i n physics, mathematics, astronomy, chemistry and biology and the development of s c i e n t i f i c methodology and instruments capable of precise i d e n t i f i c a t i o n and measurement, even of unseen, micro-organisms and c e l l s , inside the body l i n i n g — -became part of the essential progress i n medical science. Anatomy, physiology, pathology, histology;, bacteriology, and anesthiology were developed before or during the 19th century, followed by biochemistry, \ biophysics and even more specialized medical d i s c i p l i n e s i n the 20th century. The dependence of medicine on. the basic sciences can hardly be exaggerated. Medical science has progressed, often against much resistarice. Contributing forces to the advance of medicine have been;such : things as higher standards of l i v i n g and of mass education, the : acceleration of communication and transportation, i n d u s t r i a l i z a t i o n , s o c i a l organizations and the spread of humanism and democracy. The best example of t h i s can be seen i n the i n i t i a t i o n and development of the Public Health Movement. The s c i e n t i f i c advance of medicine has eventually resulted i n new and enlarged technology. Today i t i s transforming a 1 Somers, Herman S. and Somers, Anne R. Doctors, Patients and  Health Insurance. Doubleday and Company, Inc., New York, 1962, pp. 16-17. 5 highly i n d i v i d u a l i z e d profession into a vast and i n t r i c a t e l y interdependent network of services. Medical research and education have also become i n s t i t u t i o n a l i z e d . The physician can be s c i e n t i f i c a l l y accurate i n his diagnosis today only because of the s c i e n t i f i c development of a vast array of instruments and f a c i l i t i e s . More science and more knowledge mean increased s p e c i a l -i z a t i o n , which i n turn brings subdivision of labor and i n t e r -dependence of personnel. The d i v i s i o n and subdivision of labor, which have characterized v i r t u a l l y a l l other aspects of l i f e since the I n d u s t r i a l Revolution, when the great technological applications of science r e a l l y got under way, were inevitable i n the medical f i e l d . Each new discovery produced smaller and smaller f i e l d s of concentration and progressively more refined d i s c i p l i n e s . ^ A recent American Medical Directory ^ l i s t s t hirty-three d i s t i n c t s p e c i a l t i e s . Adding the more common subspecialties, there are some f i f t y types of physicians. In addition, the health services industry includes about t h i r t y - f i v e , other categories of professional, t e c h n i c a l , managerial and assorted paramedical occupations. The r a t i o of f u l l time s p e c i a l i s t s to a l l physicians has expanded from eleven percent i n 1923 to forty-one percent i n 1957. I f the count i s limited to private practice, the presumed 1 Somers, Herman, S. and Somers, Anne, R., Doctors, Patients  and Health Insurance. Doubleday and. Company, Inc., New York, 1963, p. 27. 2 Ibid., p. 27. 6 stronghold of general practice, the proportion of f u l l time s p e c i a l i s t s increased from t h i r t y - s i x percent i n 1949 to . forty-eight percent i n 1957, while the r a t i o of general p r a c t i t i o n e r s f e l l from forty-eight percent to th i r t y - n i n e percent. Unfortunately, i t i s arguable today, that the fragmentation of medical practice has resulted i n fragmentation of the patient. The task of reconstructing the "whole man" i s an es s e n t i a l next step i n progress of medical practice. The numerous approaches to t h i s urgent need, advanced by various sections of the medical profession include: 1. Upgrading the general p r a c t i t i o n e r . 2. Replacing the general p r a c t i t i o n e r by a better trained type of family or personal physician. 3. Training a l l doctors i n the philosophy and techniques of comprehensive care. 4. Promoting an i n s t i t u t i o n a l environment which w i l l f a c i l i t a t e a co-ordinated approach. Of the four approaches, three and four are of p a r t i c u l a r interest to t h i s study. The t h i r d approach, namely comprehensive care, i s used with two separate but related meanings: 1 1. Comprehensive care may mean the t o t a l i t y of desirable health services, promotion of health, prevention of disease, diagnosis, treatment and r e h a b i l i t a t i o n . 1 Somers and Somers, Doctors. Patients and Health Insurance, p. 31. 7 2. Comprehensive care may mean a " t o t a l approach" by the i n d i v i d u a l doctor; s p e c i a l i s t , as well as general p r a c t i t i o n e r ; to the i n d i v i d u a l patient, an approach that i s not confined to organic pathology and i t s treatment but encompasses the patient's emotional and family problems and the t o t a l i t y of his socio-economic environment. In order to advance t h i s new approach, many medical schools have t r i e d to "humanize" t h e i r curriculum. There has been a concerted e f f o r t to change the emphasis from disease to health, from exclusive emphasis on curative treatment to the whole spectrum of services l i s t e d above, with s p e c i a l emphasis on prevention and r e h a b i l i t a t i o n . A more detailed discussion of comprehensive care and medical education occurs in Chapter 4 . The emphasis on comprehensive care, w i l l not reverse the trend to specialism or change i t s e f f e c t . Thus the need for an i n s t i t u t i o n a l setting to f a c i l i t a t e a co-ordinated or comprehensive approach to the patient appears to be developing. Co-operative arrangements among doctors, formal or informal, are now v i r t u a l l y universal i n the United States and Canada. Most individual;"-p r a c t i t i o n e r s have a l i s t of s p e c i a l i s t s to whom he may r e f e r patients and he w i l l t r y to establish working r e l a t i o n s with a h o s p i t a l . There has also developed a broad range of formally organized group practices or combined practices: Group practice is a process, rather than a form of organization. The process i s one of combining the s k i l l s of physicians i n order to re-create the whole patient and to maximize the resources of modern medicine that can be brought to him. 1 Somers and Somers, Doctors. Patients and Health Insurance, p. 3 4 . Usually group practice consists of a formal association of three or more physicians providing services i n more than one f i e l d of specialty, with income from medical practice pooled and red i s t r i b u t e d to the members according to some pre-arranged plan. Just as medical specialism has led doctors to form medical teams or groups, so i t i s leading them into even broader health teams and co-operative arrangements with a m u l t i p l i c i t y of para-medical 1 professions. Optimum medical care has become a complicated and necessarily expensive undertaking, involving many di f f e r e n t d i s c i p l i n e s and i n s t i t u t i o n s including i n certain of i t s phases, the entire community. In essence i t represents the medical side of the h i s t o r i c a l technical evolution, away from i n d i v i d u a l craftsmen, toward ever-increasing subdivision of labor and i t r e f l e c t s the changed nature of medical care and the growing emphasis on comprehensive care or preventive medicine which by t h e i r nature require the services of a whole gamut of paramedical as well as medical personnel. Three developments i n medical care have significance for the profession of s o c i a l work: 1. The trend to comprehensive medical•care. 2. The growth of paramedical personnel. 3. The trend to co-operative practice. The f i r s t two trends indicate the medical profession's increasing awareness that they can no longer be t o t a l l y responsible for the 1 The term "Para-medical" refers to those members of other health professions and occupations which supplement the services of the physician. They include the therapists, s o c i a l workers, d i e t i t i a n s , l i b r a r i a n s , psychologists, s t a t i s t i c i a n s and medical programme administrators• 2 Somers and Somers, Doctors, Patients and Health Insurance, p. 41. 9 treatment of i l l n e s s . I l l n e s s today means much more than physiological pathology. The involvement of other helping professions, i n the treatment of i l l n e s s , i s almost mandatory. Social work, because of i t s philosophy and p a r t i c u l a r configur-ation of s k i l l s and resources, then becomes one of the primary helping professions that composes the paramedical team. In order to be members of a team and to be c a l l e d upon by the medical profession, s o c i a l workers w i l l have to interpret t h e i r role and function to the medical profession. The trend to co-operative practice presents two possible implications f o r s o c i a l workers: 1. Doctors w i l l increasingly '-refer patients to other medical p r a c t i t i o n e r s , p a r t i c u l a r l y p s y c h i a t r i s t s . This p o s s i b i l i t y w i l l be increased as more patients, covered by health insurance, w i l l be able to afford psychiatric fees. Thus u t i l i z a t i o n of s o c i a l work s k i l l s and some. welfare resources may decrease. 2. Social workers, as private p r a c t i t i o n e r s , may become partners i n co-operative practice. The trend to the former i s l i k e l y to occur unless s o c i a l work makes a va l i a n t e f f o r t to "educate" medical p r a c t i t i o n e r s about the d i s t i n c t contributions they are making to t h i s f i e l d and are able to make. This w i l l a f ford a more precise d i v i s i o n of labor, to the benefit of the patient as well as the members of the helping professions. The h i s t o r y and heritage of s o c i a l work are r e l a t i v e l y l imited i n comparison to medicine. Rapid and uneven development has marked i t s growth, which began i n B r i t a i n i n the wake of the i n d u s t r i a l revolution. Social workers began to be needed and 10 eventually trained as welfare services were brought into operation. Thus, "the profession" came a f t e r many decades of non-professional s o c i a l work. Today there i s some doubt as to whether s o c i a l work, in i t s present state of development, i s a profession i n the true sense of the word. U n t i l the period of the i n d u s t r i a l revolution, people had other sources of l i v e l i h o o d than the sale of t h e i r labor. Local churches and s e l f help groups were able to meet most phases of human want. The advent of i n d u s t r i a l i z a t i o n , accompanied by rapid s o c i a l change and s o c i a l disorganization, was responsible for the emergence of elementary welfare services. The s o c i a l concepts and l e g i s l a t i o n 1 of England i n the 17th and 18th centuries, have had a great influence i n the development of modern s o c i a l welfare and the profession of s o c i a l work. Early s o c i a l work on the North American continent, was undifferentiated from the s o c i a l survey movement. In 1879, i n the United States, the Conference of Boards of Public C h a r i t i e s , became an independent body c a l l e d the National Conference on 1 Examples of such l e g i s l a t i o n and s o c i a l concepts are as follows: 1. The Poor Law of 1601 set the pattern of public r e l i e f in England and l a t e r influenced American l e g i s l a t i o n f o r public welfare. 2. The Charity Organization Society established i n 1869, was the f i r s t main e f f o r t to overcome the lack of co-ordination between charitable church groups and philan-thropic s o c i e t i e s . 3. Settlement Houses such as Toynbee H a l l established i n 1884 set a precedent f o r preventive s o c i a l welfare. 1 1 Charities and Corrections. This was the f i r s t national associ-ation, with the s p e c i f i c purpose of discussing common problems i n the broad f i e l d of s o c i a l welfare. It became the National Conference of S o c i a l Welfare i n 1917. The Charity Organization Society, founded i n 1874, i n Buffalo, New York, was one of the most i n f l u e n t i a l organizations i n promoting the growth of s o c i a l work in the United States. The Charity Organization Society, i n i t s f i r s t years, emphasized the development and co-ordination of community services. Community Organization, as a method in s o c i a l work, therefore began to emerge. Community Organization emphasizes community wide planning and the development of needed services; the elimination of duplication i n services and the p a r t i c i p a t i o n of the whole community through fund r a i s i n g , board memberships, voluntary services and community councils. The Charity Organization Society l a t e r directed more attention to formulation of p r i n c i p l e s and more constructive methods of s o c i a l investigation, and diagnosis and treatment of family problems. These concepts and methods incorporated the democratic concept of the worth and freedom of the i n d i v i d u a l and eventually became the s o c i a l casework ^ of today. Mary Richmond, i n her book, S o c i a l Diagnosis, 2 written i n 1 9 1 7 , 1 Perlman, Helen, H., S o c i a l Casework. The University of Chicago Press, Chicago, 1 9 5 7 , p. 4. S o c i a l casework i s a process used by certain human welfare agencies to help individuals to cope more e f f e c t i v e l y with t h e i r problems i n s o c i a l functioning. 2 Richmond. Mary, S o c i a l Diagnosis. Russell Sage Foundation, New York, 1 9 1 7 . 1 2 i d e n t i f i e d the f a c t u a l basis and methods of d i f f e r e n t i a t e d treatment of individuals and f a m i l i e s . S o c i a l work, l i k e other professions, depended upon the knowledge and methods of other d i s c i p l i n e s . Thus in the 1 9 2 0 !s, s i g n i f i c a n t influence was exerted on s o c i a l work by the i n t r o -duction of modern medical and psychiatric concepts and practices. . These emphasized emotional and s o c i a l causes and tended to divert s o c i a l work from i t s e a r l i e r focus on environmental factors and the need for s o c i a l reform to correct s o c i a l i n j u s t i c e s . At t h i s time psychiatric and medical s o c i a l work, s p e c i a l t i e s within the profession were developing. Also, i n the 1 9 2 0 Ts a great interest i n the discussion method as a means of creative democratic group procedure, especially f o r adults, produced the concept of group work ^ as a methodology useful i n many settings. Thus at the end of two decades, i t was'evident that a strong sense of professional s e l f consciousness had developed. Special-i z a t i o n took hold early i n s o c i a l work in the United States as was evidenced by the development of three d i s t i n c t method! and o by the existence of four separate p r a c t i t i o n e r groups. J 1 Tr'eker, H., S o c i a l Group Work. Association Press, New York, 1 9 5 5 , p. 9 5 . S o c i a l group work i s a method through which individuals i n groups i n s o c i a l agency settings are helped by a worker who guides t h e i r i n t e r a c t i o n i n programme a c t i v i t i e s so that they may relate themselves to others and experience growth oppor-t u n i t i e s i n accordance with t h e i r needs and capacities to the end of i n d i v i d u a l , group and community development. 2 The three methods are casework, group work and community organization. 3 The four p r a c t i t i o n e r groups were the medical s o c i a l workers, the psychiatric s o c i a l workers, family s o c i a l workers and c h i l d welfare s o c i a l workers. 13 Professional education had been i n i t i a t e d , as schools of s o c i a l work were organized and developing. The M i l f o r d Conference report marked a high point i n the development of the profession, formulating the p r i n c i p l e reaffirmed i n 1947 by the Curriculum Committee of the American Association of Social Work, that the problems of s o c i a l casework and the equipment of the s o c i a l caseworker are fundamentally the same f o r a l l f i e l d s . Here began the emphasis on s p e c i a l i z a t i o n by method rather than by setti n g . The decade of the 1930*3 was an era of c r i s i s and impro-v i s a t i o n . Out of i t eventually came the recognition of the significance of le i s u r e time services and recognition of group work as a method i n the profession of s o c i a l work. The decade of the 1930fs saw too, to a large degree, the r e a l i z a t i o n of the modern American concept of government i n the s o c i a l welfare f i e l d ; a concept emphasizing*services f o r purposes of the general welfare. The development of public welfare, affected s o c i a l work practice d i r e c t l y and fundamentally. r. From 1940 u n t i l t h i s decade there have' been other changes in the profession. Developments i n casework have been ongoing p a r t i c u l a r l y with the growth of the s o c i a l sciences and the adaptation of s o c i a l role theory into casework theory and practic e . Developments have been rapid i n group work, as i t assumes an important role as part of therapy i n hospitals and c l i n i c s . ' Community organization has continued to develop, although there '< is some doubt as to whether i t i s exclusively a s o c i a l work 14 method. Acutely conscious of s o c i a l work's shortcomings, a f t e r World War I I , educators and p r a c t i t i o n e r s , are making conscientious e f f o r t s to increase and refine i t s research methods. Concern f o r administrative process i s a recent development i n s o c i a l work, as s o c i a l work p r i n c i p l e s and processes are emerging i n adminis-t r a t i v e theory. Doctors and S o c i a l Workers: The Growth of Medical Teamwork -The present r e l a t i o n s h i p between the two professions has a background of both co-operation and s t r i f e . Bruno ^ states that the medical profession has always recognized the importance of s o c i a l factors which have a bearing on health and disease. Before the advent of the s o c i a l worker, physicians were t h e i r own s o c i a l investigators, although they may not have used modern methods. The forerunners of modern s o c i a l work had an interest i n health, p a r t i c u l a r l y i n r e l a t i o n to poverty. Octavia H i l l and the Webbs were highly a r t i c u l a t e about the d i r t , squalor, ' congestion and fatigue, which contributed to i l l n e s s . Their descriptions of hospitals, infirmaries and the medical care given to the indigent, were used for b r i e f s which were responsible 3 f o r much of the s o c i a l l e g i s l a t i o n of the early 20th century. 1 Bruno, F.J., Trends i n S o c i a l Work, Columbia University Press, New York, 1948, p. 630. 2 DeSchweinitz, K a r l . England's Road to, S o c i a l Security. University of Philadelphia Press, Philadelphia, 1943. 3 The Poor Law Commission sat i n England from 1905 to 1909. The Commission reviewed the English Poor Law and made recommendations for broad encompassing changes i n s o c i a l l e g i s l a t i o n . 15 Edwin Chadwick, the Secretary of the Poor Law Commission of England, was the i n i t i a t o r of the movement for Public Health. In the late 19th century, medical p r a c t i t i o n e r s catered p r i n c i -p a l l y to those of the upper or middle classes. The untrained s o c i a l workers, working amongst the poor and dependent, may have worked with the few doctors who devoted t h e i r time and ere rgies to working with those i n need, i n hospitals, c l i n i c s and infi r m a r i e s . Hospital infirmaries were the only places that people of the lower classes could get medical treatment. In the United States, as early as 1902, doctors and Charity Organization workers, co-operated to better purpose when the New York Charity Organization Society, began, through a spe c i a l committee on Tuberculosis, i t s f i r s t campaign for prevention of disease. Other movements f o r improving public health, soon followed, some i n i t i a t e d by the medical profession and some by s o c i a l workers. ^ Although each one of these has influenced s o c i a l diagnosis, the most d i r e c t influence exerted upon t h i s process by the medical profession comes from the medical s o c i a l service movement. The medical s o c i a l service movement, i n i t i a t e d i n the United States, by Dr. Richard Cabot, saw f o r almost the f i r s t time, o f f i c i a l recognition by the medical profession of the value of the s o c i a l worker to the doctor, p a r t i c u l a r l y i n the h o s p i t a l . 1 Richmond, Mary. So c i a l Diagnosis, Russell Sage Foundation, New York, 1917, p. 35. 16 When the doctor looks f o r the root cause of most of the sickness that he i s c a l l e d upon to .help, he finds s o c i a l conditions. When the s o c i a l worker analyzes : need he finds physical conditions staring him in the face. Therefore team work of doctor and s o c i a l worker i s c a l l e d f o r . The medical s o c i a l service movement had f a r reaching effects on :-: the doctor, s o c i a l worker, re l a t i o n s h i p i n a l l settings. Mary Richmond, commented i n 1917, on some of the d i f f i — :, c u l t i e s encountered by the two professions when working with each other. She pointed out that the assistance which a s o c i a l • history could render i n the medical f i e l d was such a new idea that i t was being used awkwardly on both sides. Miss Richmond; explained that, at that time, s o c i a l workers were often handi-capped i n t h e i r use of medical resources, by t h e i r lack of knowledge of even the most elementary facts about disease, and ; by t h e i r lack of understanding of the d i s c i p l i n e necessary i n medicine. She also stated:"-^ An uncooperative attitude on the part of the physician, where the s o c i a l worker needs t h e i r help i n securing s o c i a l action (whether i n i n d i v i d u a l cases or i n other ways) can sometimes be accounted f o r by the i n a b i l i t y of the non-medical s o c i a l worker to make his d a i l y contacts with M e d i c a l sources as h e l p f u l as they should be.;, 1 Cabot, Richard, M.D. Social Service and the Art of Healing. Dodd, Mead, New York, 1923, p. v i i . 2 Richmond, Mary, op. c i t . . pp. 204-219. Miss Richmond i n her chapter t i t l e d "The Medical Approach" discusses the rel a t i o n s h i p between the two professions and makes e x p l i c i t suggestions to s o c i a l workers on how to work with doctors. 3 Richmond, Mary, Ibid.. p. 218. 17 Miss Richmond suggested, that at the time, the medical pra c t i t i o n e r s had a fa u l t y understanding of the role of s o c i a l workers i n that they pictured them as working, s o l e l y , with the economically dependent. In 1933, during the National Conference of Social Welfare, the following was said about the relat i o n s h i p between the two professions: In attempting to cast up the gains and losses, of t h i s combination, i t i s apparent that at times the s o c i a l worker has assumed the competency that he did not possess and has attempted to use the doctor as an aide i n working out his own plan. The physician does not fin d i t easy to work with anyone else as his peer. Even though largely i n t e l l e c t u a l , the autocratic habit of t r e a t i n g his patient as an i n f e r i o r , too often c a r r i e s over into the doctor's r e l a t i o n s with s o c i a l workers as well, leading him to id e n t i f y t h e i r shortcomings.rather than to welcome them as fellow workers i n a common task. In 1938, R.G. Leland argued that: 2 *• The s o c i a l worker may contribute to the medical diagnosis by bringing information pertaining to the environmental maladjustments. In the t h i r t i e s , the relat i o n s h i p between medicine and s o c i a l work became increasingly well established. Many positives emerged as well as negatives. The l a t t e r may be attributed to several f a c t o r s . That the doctor has t o t a l r e s p o n s i b i l i t y for the care of the patient'-was and to some extent s t i l l i s , a dictate of medical practice. The doctor-patient r e l a t i o n s h i p was very 1 Bruno, F.J., Trends i n Soc i a l Work as Reflected i n the Pro- ceedings of the National Conference of Soc i a l Work, 1874-1946, Columbia University Press, New York, 1948, p. 248. 2 Ibid., p. 629. important and the i n c l u s i o n of a s o c i a l worker was seen by some doctors as usurping t h e i r authority and destroying the v i t a l r e l a t i o n s h i p with the patient. Some medical pra c t i t i o n e r s often did not take s o c i a l and environmental factors into consideration and there was a tendency to doubt t h e i r value i n the treatment of i l l n e s s . In t h i s era of specialism doctors were preoccupied with the diseased organ, rather than with the "whole" patient. S o c i a l workers on the other hand, working i n a new and suspected profession, were often unsure of the role they played i n r e l a t i o n to the doctor and the patient or c l i e n t . Over the years i n d i v i d u a l s o c i a l workers and p r a c t i t i o n e r s , established fine working r e l a t i o n -ships which benefitted both the professions and the c l i e n t s . With the increase i n s p e c i a l i z a t i o n and the tendency toward " s p l i t t i n g the patient", medical p r a c t i t i o n e r s began slowly to turn to s o c i a l work, p a r t i c u l a r l y for personality and s o c i a l assessments. S o c i a l work' and s o c i a l workers were becoming more s k i l l e d and better trained, so that teamwork was more feasi b l e and a greater degree of co-operation was evident. In the 1940's and 1950's, events took place i n both profession -which led to a firmer foundation for co-operation between the two professions. Experience of the two world wars, emphasizing manpower as a nation's most valuable asset and the consequences of unmet health needs, gave impetus to the idea of a health programme for the whole nation. The World Health Organization, a specialized branch of the United Nations, defined health as: ^ 1 Chisolm, Brock, "Organization f o r World Health", Mental  Hygiene. July 1948. Vol. 3 2 , pp. 364-371. 19 A state of complete physical, mental and s o c i a l well-being, and not merely the absence of disease or i n f i r m i t y . This statement implies that health can only be achieved i n response to many favourable influences and forces, such as economic, s o c i a l emotional and physical. The point of view expressed by the World Health Organization i s representative of a trend voiced by leaders i n a l l helping.prof essions. This would tend to imply that medical care i s not by any means con-fined to the diseased organ, hut takes into consideration the t o t a l person involved, and such care requires planning on a community basis since r e h a b i l i t a t i o n requires many services. Medical care i n t h i s sense takes into consideration the economic and s o c i a l , i n addition to the physical aspects and implies the p a r t i c i p a t i o n of several professions. This concept of the relatedness of s o c i a l , emotional and physical factors in the cause and treatment of disease has been developed over a period of time. New findings were brought to l i g h t which broadened the concept of disease and medical care. The studies made by Franz Alexander, showed, that i n addition to the physical symptology, there are psycho-social components associated with most cases of i l l n e s s . The attention that each one of these factors receives, w i l l depend on the degree to which they contribute to the dys-functioning of the patient. The studies made by Canon 2 i n the 1 Alexander, Franz, M.D. Psychosomatic Medicine, W.W. Norton and Co., New York. 2 Canon, Walter, B. The Wisdom of the Body, Norton, New York, 1952. 20 area of psychological stress and by Dunbar i n the f i e l d of psychosomatic medicine are of p a r t i c u l a r importance, since they ,emphasize the concept of i l l n e s s as a reaction of the whole organism to i t s environment. Currently the investigations of such leading physicians as Professor Hans Seyle, 2 have helped to c r y s t a l i z e some of the thinking on the subject of the r e l a t i o n of the mind and body i n i l l n e s s . Couched i n c l i n i c a l terminology, the basic ideas of the "Adaptation Syndrome" and the "Stress Concept" express the modern concept of disease and the significance of environmental conditions i n the treatment plan. The doctor in medical practice today, more than ever shares the r e s p o n s i b i l i t y of formulating a diagnosis and e f f e c t i n g a treatment plan with a number of Other s p e c i a l i s t s , either of his own profession or of a u x i l i a r y professions, such as nursing, d i e t e t i c s , education and ' s o c i a l work. The doctor's knowledge of community resources and other s p e c i a l i s t s to aid him should be greater than ever before. So c i a l workers at the same time have been adapting not only the above mentioned concepts into s o c i a l work theory; but also they are attempting to incorporate them into s o c i a l role theory, ^ 1 Dunbar, Helen Flanders, Mind and Body: Psychosomatic Medicine. Random House, New York, 1947. ' 2 Seyle, Hans, M.D. "The Adaptation Syndrome i n C l i n i c a l . Medicine", The P r a c t i t i o n e r . January 1954, V o l . 172, No. 1027, pp. 6-15. 3 For a detailed discussion of role theory refer to: . Boehm, W., Curriculum Study, Volume X, Council of Social Work Education, New York, 1959-* 21 which has been adapted from s o c i o l o g y . P r o f e s s i o n a l educators are making e f f o r t s t o provide s o c i a l workers with a comprehensive c o n c e p t u a l framework w i t h i n which i n d i v i d u a l and f a m i l y f u n c t i o n i n g can be a s s e s s e d . For the purposes o f t h i s study i t i s not necessary to d i s c u s s s o c i a l r o l e t h e o r y i n t o t o . Yet i t i s important to i n d i c a t e the framework from which s o c i a l workers view i l l n e s s , i n order to demonstrate t h a t d o c t o r s and s o c i a l workers share s i m i l a r concepts. Role theory i n t e g r a t e s the concept of man as a b i o -p s y c h o - s o c i a l organism. Each of these p a r t s i s d y n a m i c a l l y i n t e r - r e l a t e d . D y s f u n c t i o n i n g i n one a r e a , can l e a d t o or c r e a t e breakdown i n a l l other areas of f u n c t i o n i n g . Thus, man i s viewed as a complex being and the causes of breakdown i n s o c i a l f u n c t i o n i n g , m u l t i p l e and i n t e r - r e l a t e d . In t h i s r e s p e c t , a l l c o n d i t i o n s of i l l n e s s have p h y s i c a l , as w e l l as p s y c h o - s o c i a l components. Doctors and s o c i a l workers, i n c o r p o r a t i n g s i m i l a r concepts i n t o p r a c t i c e , both found areas of communication and correspondence. Although the d i s c i p l i n e s of medicine and s o c i a l work, w i l l i n c r e a s -i n g l y share t h i s common body of knowledge, the focus and method of these two p r o f e s s i o n s w i l l i n e v i t a b l y remain d i f f e r e n t . The p h y s i c i a n w i l l use h i s knowledge about the s o c i a l components of i l l n e s s as a m e d i c a l p r a c t i t i o n e r , not as a s o c i a l worker. Problems of Co-operation and C o - o r d i n a t i o n S p e c i a l i z a t i o n of s e r v i c e s and s k i l l s has c r e a t e d problems of c o - o p e r a t i o n and c o - o r d i n a t i o n f o r the r e p r e s e n t a t i v e s of the 22 health and welfare services. The problems are many and: varied. Thus, f o r the purposes of t h i s study, two primary but related problems have been selected for discussion. At the same time that each profession was becoming more s k i l l e d and sp e c i a l i z e d , with increasing numbers joining t h e i r ranks, large bureaucratic organizations were developing through which these s k i l l s were administered. In the health f i e l d the h o s p i t a l became ever increasingly the center'of medical, pr a c f i c e . Outpatient departments developed i n North America as early as 1905. Public Health and Public Health agencies became prominent i n large urban i n d u s t r i a l centres. Health agencies developed tb : meet s p e c i a l needs that i n d i v i d u a l doctors could not handle. In these i n s t i t u t i o n s medical and para medical teams co-operate to* r e h a b i l i t a t e and treat s p e c i f i c diseases, ailments or handicaps. As i n d u s t r i a l i z a t i o n became entrenched, s o c i a l problems of varying, kinds developed. Welfare services to meet these needs sprang up ' both i n the private and public spheres. In the health and welfare f i e l d s , services became sp e c i a l i z e d . S p e c i a l i z a t i o n among agencies not only gives r i s e to bureaucracy, but also creates an interdependence which ultimately requires co-ordinating mechanisms. The basic problem-becomes one of how to a t t a i n e f f e c t i v e integration of specialisms: ^ Among agencies however, the bases f o r s p e c i a l i z a t i o n are more varied and an authoratative structure f o r .1 Wilensky, Harold L. and Lebeaux, Charles N., I n d u s t r i a l  Society and S o c i a l Welfare. Russell Sage Foundation, New York, 1958, pp. 247-248. 23 exercising o v e r a l l control i s lacking. Further, the need for co-ordination among agencies i s often obscured. It i s less easy to see the community as a functional whole, with interdependence among a l l i t s parts, than i t i s to see the e s s e n t i a l unity of a single agency. Nevertheless, the d i v i s i o n of labor which binds us a l l together i n a web of mutual dependency * though sometimes obscure, i s a basic f a c t of community l i f e . This has great significance f o r both s o c i a l work and medicine. Specialism and the creation of interdependence demands a form of r e c i p r o c a l r e l a t i o n s h i p between the two professions. It i s the purpose of the present study to examine t h i s r e l a t i o n s h i p i n d e t a i l i n one c i t y and the r e s u l t s are presented i n Chapter two and three. Related to the problem of inter-agency co-ordination i s the problem of delineating s p e c i f i c s k i l l s and services and co-ordin-ating them into an integrated treatment plan f o r the patient. The concept of medical teamwork, the co-ordination of services i n the interest of the patient and his family becomes even more important when the team members are not working i n the same setting, guided by s i m i l a r functions and purposes. Yet t h i s very teamwork i s the only v a l i d approach to the complex problem of maintaining and restoring health. The p r i n c i p l e s of r e l a t i o n s h i p , however, are i n t r i n s i c a l l y the same whether the services operate independently and c a l l for i n t e r agency co-operation or whether they comprise an administrative team. The objective of achieving a co-ordinated medical approach however, i s not altered because of differences i n organi-zational patterns, the p r i n c i p l e s of integration have equal a p p l i c a b i l i t y inside or outside a h o s p i t a l s e t t i n g . 1 Upham, Frances, A Dynamic Approach to I l l n e s s , Family Service Association of America, New York. Second Printing 1953, p. 2 ? . 24 The focus of the team approach i s . t h a t close working relationships made possible by a group of services working to-gether, and r e s u l t i n further delineation of the special functions of each helping profession comprising the team. I t should at the same time, enrich the content and s k i l l of each service, ^ The various professions have come to recognize the p r i n c i p l e of inte r a c t i o n i n the functioning of the human being. His needs, whether medical, economic, or s o c i a l , are viewed not as a series of separate e n t i t i e s that can be treated separately by a group of s p e c i a l i s t s , but as a unit. Each area s t i l l has i t s area of s p e c i a l i z a t i o n , but each accepts that the special i z e d s k i l l s should be u t i l i z e d within the framework of a co-ordinated interprofessional approach to the i n d i v i d u a l . E f f o r t s Toward Co-operation The l i t e r a t u r e of s o c i a l work, has not i n e x p l i c i t terms offered ways of co-operating with the medical profession. Nor have the writers of professional theory set down e x p l i c i t ways of co-operating with lawyers, ministers, public health nurses and other members of the helping professions. What has been sai d i m p l i c i t l y i n statements of goals and objectives of the profession offers a sound base for co-operation. Such a statement i s made i n "Goals of Public S o c i a l Policy", a publication by the National Association of Social Workers. In th i s a r t i c l e , under the heading "Co-operation and Co-ordination", the following comment i s made:' It i s recognized that many other groups and professions share these areas of s o c i a l p o l i cy and s o c i a l action. S o c i a l advances w i l l be furthered through the broadest 1 Upham, Frances, A Dynamic Approach to I l l n e s s . Family Service Association of America, New York. Second Printing 1953, p. 25. 2 Goals of Public S o c i a l Policy, National Association of S o c i a l Workers, 1959, p. 13. 25 co-operation by s o c i a l workers with a l l such groups. Moreover, i t i s basic to s o c i a l progress that means should exist f o r co-operative planning among a l l elements i n society so that each may e f f e c t i v e l y f u l f i l l i t s own role and society may make the best use of a l l i t s i n s t i t u t i o n a l resources i n advancing the welfare and meeting the needs of i t s members. S o c i a l workers can often make t h e i r most e f f e c t i v e contribution to s o c i a l progress by lending t h e i r support and knowledge to these broadly based democratic instruments f o r ef f e c t i n g s o c i a l change. This statement puts the concept of interprofessional r e l a t i o n -ships i n the proper perspective. In t h i s same a r t i c l e , the National Association of Soc i a l Workers states the professional policy concerning health and health services. In Section Six under "Co-ordination", the following statement i s made: Co-ordinating mechanisms to assure close working r e l a t i o n -ships among the various community agencies and especially between health and welfare programmes, are also v i t a l to meeting health needs. 2 The National Conference on Social Welfare has over the years published a r t i c l e s concerning the objectives and goals of 1 Goals of Public S o c i a l Policy. National Association of S o c i a l Workers, 1959, p. 13. 2 The National Conference on Soc i a l Welfare has as i t s purpose the promotion and sharing i n discussion of the problems and methods i d e n t i f i e d with the f i e l d of s o c i a l welfare and immediately related f i e l d s . The Conference i s a forum f o r such discussion. I t does not take an o f f i c i a l p o s i t i o n on controversial issues and, adopts no resolutions, except occasional resolutions of courtesy. The Conference conducts an annual National Forum as i t s p r i n c i p l e service; also regional meetings on common service subjects i n co-operation with selected state conferences. One paper, delivered at the National Conference of Social Welfare i n 1953, concerning the objectives and goals of co-oper-ation and interprofessional relationships was: C o c k e r i l l , Elanor, "Interdependency of the Professions i n Helping People", The Soc i a l Welfare Forum. National Conference of Soc i a l Welfare, Columbia University Press, New York, 1953, pp. 137-147. 26 co-operation and interprofessional r e l a t i o n s h i p s generally, and the problems or d i f f i c u l t i e s between medicine and s o c i a l work s p e c i f i c a l l y . The topic of health and comprehensive medical care has been discussed i n several a r t i c l e s published by the Conference. The Journal of S o c i a l Casework, published by the Family Service Association of America, has contained many a r t i c l e s ^ on t h i s t o p i c . Emphasis has been placed on the growing s o c i a l -medical concepts and t h e i r implications f o r s o c i a l work practice. As was previously mentioned, these shared concepts are aids i n furthering a good working relationship•between the two professions. The " S o c i a l Worker", of June-July 1962, a publication of the Canadian Association of Soc i a l Workers, states i n a B r i e f to p the Royal Commission on Health Services: Certain community welfare services are frequently related to health care and may be needed by a patient or his family regardless of t h e i r economic status. The professional organization, representative of professional Canadian s o c i a l work, has e x p l i c i t l y stated the re l a t i o n s h i p between the two professions and through i t s B r i e f has made ef f o r t s to aid the medical profession i n an area of mutual concern. 1 Margolis, H.M., M.D. "The Biodynamic Point of View i n Medicine" Journal of Soc i a l Casework. January 1949. C o c k e r i l l , Elanor, "New Emphasis on an Old Concept of Medicine", Journal of Social Casework, January, 1949. 2 "Br i e f to the Royal Commission on Health Services", The Social  Worker, June-July, 1962. Vol. 30, No. 3, p. 7. 27 Professional publications i n the f i e l d of medicine are so numerous and varied that i t is now impossible to make an adequate resume of the l i t e r a t u r e . Various journals have contained a r t i c l e s such as "Man, Disease and So c i a l Environment", ^ by E.H. Vokhart. The B r i t i s h Columbia Medical Association, i n i t s publication, has presented two a r t i c l e s on s o c i a l work and medicine. One of these a r t i c l e s was written by a Vancouver s o c i a l worker and the other by a medical p r a c t i t i o n e r . In "Medical Education and the Changing 2 Order", R.B. Allen states: Any well educated and experienced physician r e a l i z e s that the professional services of lawyers, ministers, teachers, s o c i a l workers and personnel counsellors are e s s e n t i a l This has been a rather b r i e f description of the e f f o r t s taken by both professions to promote co-operations and understanding. The questions arise as to whether these p r i n c i p l e s are fin d i n g expression i n the practice of the i n d i v i d u a l doctor and s o c i a l worker. For i t i s actually on t h i s l e v e l that p r i n c i p l e s and concepts, come into r e a l i t y and practi c e . The i n d i v i d u a l s o c i a l worker has the r e s p o n s i b i l i t y f o r having her facts well i n hand . and using her knowledge and s k i l l i n in t e r p r e t a t i o n to promote co-operation. The doctor on the other hand has a s i m i l a r responsi-b i l i t y - to be aware of welfare services and the s k i l l s of s o c i a l workers, so that when necessary, he can r e f e r a patient to an agency, and co-operate with the s o c i a l worker, to further his patient's well-beings 1 Vokhart, E.H. "Man, Disease and Soc i a l Environment", Postgraduate  Medicine. Feb. I960, V o l . 27, No. 2, pp. 257-260. 2$ Whether these p r i n c i p l e s are fi n d i n g t h e i r way i n practice I i s a d i f f i c u l t question to answer as a resu l t of a lack of published evidence. Therefore, one assumes either one of two alter n a t i v e s : j 1 1. Nothing i s being done 2. Some e f f o r t s are frequently carried out and the in d i v i d u a l p r a c t i t i o n e r i s reluctant to make these known. The l a t t e r a l t e r n a t i v e i s speculated to be more descriptive of the actual s i t u a t i o n . Thus the reason f o r t h i s study. Methodology - Description and D e f i n i t i o n This study included the health and welfare services i n Vancouver. The survey included questionnaires f o r and selected interviews with, both the representatives of health services, the doctors, and the representatives of the Welfare services, the s o c i a l workers. According to a count made of the doctors l i s t e d i n the Medical Directory, 1 9 6 2 - 6 3 , College of Physicians and Surgeons of B r i t i s h Columbia, (November 1 9 6 2 ) , there are an estimated 9#2 doctors p r a c t i c i n g i n Vancouver, excluding North and South yBur.naby.jr. This includes doctors i n private practice as well as sal a r i e d medical p r a c t i t i o n e r s . Of the 9#2, an estimated 5 4 1 are q u a l i f i e d s p e c i a l i s t s and 441 general p r a c t i t i o n e r s . Of the 4 4 1 , 128 are sala r i e d and 3 1 3 i n private practice. The decision to use general p r a c t i t i o n e r s , as participants in t h i s survey was based on three factors: 29 1. The t o t a l number of doctors p r a c t i c i n g i n the survey area was too large to include i n the confines of t h i s study. 2. General p r a c t i t i o n e r s were selected as they do not spe c i a l i z e i n the treatment of one disease or handicap and therefore see many people with a vari e t y of i l l n e s s e s . 3. The general p r a c t i t i o n e r i s considered a "family doctor." Every t h i r d general p r a c t i t i o n e r i n private practice was chosen to answer a questionnaire, thus r e a l i z i n g a control group of one hundred doctors. D e f i n i t i o n of doctor, to be used i n t h i s study w i l l r e f e r to the men and women representing the general p r a c t i t i o n e r s included i n the survey. A general p r a c t i t i o n e r for purposes of t h i s survey i s a doctor who i s not a c e r t i f i e d " s p e c i a l i s t " of The Royal College of Physicians and Surgeons. For the purposes of t h i s study, health services, are defined as those i n s t i t u t i o n s and t h e i r representatives whose function i t i s to treat i n d i v i d u a l s and groups suffering from disease or handicap, with the purpose of restoring them to as complete a state of physical, emotional and s o c i a l well being as possible. Welfare services, as defined i n t h i s study, are those i n s t i t u t i o n s and. t h e i r representatives who aid individuals and groups to a t t a i n s a t i s f y i n g standards of l i f e by helping them achieve personal and s o c i a l r e l a t i o n s h i p s which permit individuals the development of t h e i r f u l l capacities and the promotion of t h e i r well being i n harmony with the needs of the community. In Vancouver there are an estimated ^ two hundred and seven health and welfare agencies. There are one hundred and twenty-nine 1 Count made from the: Community Chest and Councils of Greater Vancouver, Basic Pattern of Community Agencies. P r i o r i t i e s Programme, Master L i s t of Agencies. June 1963. 30 welfare agencies, sixty-nine health agencies and nine other agencies which could not be s a t i s f a c t o r i l y c l a s s i f i e d as health o or welfare agencies. An estimated four hundred s o c i a l workers are employed i n these agencies. One hundred and f i f t y - t h r e e . agencies are p r i v a t e l y sponsored and f i f t y - f o u r are p u b l i c l y or government sponsored. Three agencies, representing public and private welfare were included i n t h i s survey: 1. Vancouver C i t y S o c i a l Service Department, supported by municipal and p r o v i n c i a l funds, is an example of a public welfare agency which provides dir e c t welfare services to those l i v i n g i n the Greater Vancouver area. 2. The Family Service Agency of Greater Vancouver, supported by funds from the Community Chest and Council, provides a family welfare service, encompassing counselling services to family members and in d i v i d u a l s , as well as homemaker services and emergency f i n a n c i a l assistance. 3. The Childrens' Aid Society of Greater Vancouver, supported by p r o v i n c i a l and Community Chest and Council funds, provides c h i l d welfare services including adoptions, f o s t e r home find i n g and placement, i n addition to, protective services to c h i l d r e n . 1 Those agencies which could not be c l a s s i f i e d according to the above d e f i n i t i o n s are: a. The B r i t i s h Columbia Association f o r Retarded Children (4 branches) b. The B r i t i s h Columbia Safety Council c. The B r i t i s h Columbia Childrens' Foundation d. The Columbia Coast Mission e. Citizenship Branch f . The Junior League. 2 Estimate compiled on the basis of the Membership of the B r i t i s h Columbia Association of S o c i a l Workers, and the estimate given by Mr. Ron Hawkes, President of the B r i t i s h Columbia Association of S o c i a l Workers, of s o c i a l workers not belonging to the B r i t i s h Columbia Association of S o c i a l Workers. 31 The three agencies provide welfare services to the community with s t a f f members carrying a caseload of Vancouver residents. *. One of the concepts followed i n t h i s study i s to consider welfare services and not s p e c i f i c agencies. Too frequently the term "agency" i s used synonymously with "welfare services". Therefore an attempt has been made to include the main agencies and consider them as a part of welfare services. "Social worker" i s defined as the representative of the agency performing a welfare service i n the survey area. Methodology - Questionnaire The questionnaire f o r the doctors was intended to contribute information that would o f f e r an o v e r a l l perspective of the resources and work of the doctors i n t h i s community. The questionnaire was structured to include the following two general areas of information: 1. Understanding the doctors and the work they are doing. This was included i n questionnaire A under two groupings: Counselling and General, questions 4, 5, and 6. 2. Understanding the doctor's awareness and u t i l i z a t i o n of community resources. This was included i n questionnaire A under the groupings: Referrals, Welfare and Health Agencies, S o c i a l Workers and General, questions 1, 2, and 3. * The questionnaires were sent to the doctors under a covering l e t t e r ' explaining the purpose of the survey. A s l i p was placed at the bottom, that the doctors were asked to f i l l i n and return, so 1 The questionnaire f o r doctors can be found i n Appendix A.. 2 The l e t t e r can be found i n Appendix A. 3 2 t h a t the sample c o u l d be v a l i d a t e d . This s l i p o f f e r e d the d o c t o r an i n t e r v i e w , i f he so wished or the o p p o r t u n i t y not to p a r t i c i p a t e , because: a. Contacts with s o c i a l workers or w e l f a r e agencies were e x c e p t i o n a l i n p r a c t i c e b. The d o c t o r , had no o p i n i o n s , f a v o u r a b l e or unfavourable about s o c i a l work. c. Other reasons t h a t the d o c t o r wished to s t a t e f o r not p a r t i c i p a t i n g . E x c e l l e n t c o - o p e r a t i o n was r e a l i z e d from t h i s method and a 53 percent r e t u r n was r e a l i z e d ; twenty-nine percent o f the question-,,, n a i r e s Were r e t u r n e d , completed. I t was thought t h a t only 25 q u e s t i o n n a i r e s would be r e t u r n e d . f The q u e s t i o n n a i r e f o r the s o c i a l workers, Q u e s t i o n n a i r e B, was intended t o c o n t r i b u t e i n f o r m a t i o n t h a t would o f f e r a p e r s p e c t i v e of the r e s o u r c e s and s e r v i c e s o f f e r e d by the w e l f a r e agencies s e r v i n g the community i n r e l a t i o n t o i l n e s s and problems w i t h such. Q u e s t i o n n a i r e B, i n c l u d e d the f o l l o w i n g g e n e r a l areas of i n f o r m a t i o n : 1. Understanding s o c i a l workers and the work they are doing. T h i s was i n c l u d e d i n q u e s t i o n n a i r e B under the two groupings: C o u n s e l l i n g and Your Own Background and Experience. 2. Understanding the s o c i a l workers' awareness and u t i l i z a t i o n o f the r e s o u r c e s of the d o c t o r s . T h i s was obtained i n the two groupings: R e f e r r a l s and Doctors a n d - S o c i a l Workers. Phone c a l l s were made to the r e s p e c t i v e agency d i r e c t o r s , e x p l a i n i n g the purpose of the survey and r e q u e s t i n g t h e i r c o - o p e r a t i o n . Two agencies requested samples of the q u e s t i o n n a i r e to peruse, b e f o r e 1 The q u e s t i o n n a i r e f o r s o c i a l workers can be found i n Appendix B 33 agreeing to p a r t i c i p a t e . One agency agreed to f u l l s t a f f p a r t i c i -pation. Another agency was c r i t i c a l of the questionnaire but allowed six of t h e i r s t a f f members to p a r t i c i p a t e i f they could be interviewed. This was done using the questionnaire as an interview schedule. City S o c i a l Service Department, although more than w i l l i n g to co-operate, could only o f f e r seven s o c i a l workers as contact with doctors are made by the Public Health Nurses i n the medical section. The only time that s o c i a l workers t a l k d i r e c t l y with doctors, i s when the casework plan deems t h i s advisable. Twenty-six completed questionnaires were r e a l i z e d . Three interviews were made as part of t h i s survey. The f i r s t was with Miss A. Pumphrey, Director of S o c i a l Service, Vancouver General Hospital. The purpose of the interview was to discover the role of the S o c i a l Service Department i n medical education. A seminar f o r medical students was attended as well. The l a t t e r two interviews were arranged with the Executive Director of the Family Service Agency, Mr. D. Thompson and the Welfare Director of the City S o c i a l Service .Department, Miss M. Gourlay. The purpose of these interviews was to discover the role of the agency i n increasing r e c i p r o c a l awareness and u t i l i z a t i o n between medicine and s o c i a l welfare. Chapter 2 The General P r a c t i t i o n e r and the U t i l i z a t i o n  of Welfare Services The Doctors: Education and Experience Professional education has become the guide or indicator of the competence of individuals i n most of the professions. In Canada, two years of pre-medical studies, four years of medicine and a minimum of one year's internship i s required before a doctor can enter private prac t i c e . Those doctors who choose to become s p e c i a l i s t s are required to continue t h e i r studies f o r several years a f t e r t h e i r internship. The present survey ^ asked f o r the decade i n which profes-s i o n a l t r a i n i n g was taken. Emphasis on comprehensive medical care became most pronounced following World War II and the 2 declaration of the World Health Organization i n 1943. Those doctors who studied medicine i n the l a s t two decades, w i l l have received more formalized i n s t r u c t i o n i n the u t i l i z a t i o n of the s k i l l s and resources of other helping professions, of which s o c i a l work i s one. When t h i s t r a i n i n g was introduced; the amount of emphasis placed on i t ; and the form i t took such as lectures or seminars, w i l l vary from medical school to medical school. 1 See questionnaire f o r doctors i n Appendix A. 2 Chisolm, Brock, "Organization f o r World Health", Mental Hygiene. July 1948. Volume 3 2 . pp. 364-371. "Health i s a state of complete physical, mental and s o c i a l well being and not merely the absence of disease or i n f i r m i t y . " 35 Of the doctors who took part i n t h i s survey, one graduated i n the 1910's, seven i n the 1930's, f i v e i n the 1940's and one i n the 1960ts. Fift e e n of the twenty-nine participants graduated i n the 1950's. Thus, over half of the doctors p a r t i c i p a t i n g i n ^ t h i s survey, graduated a f t e r World War I I . It was determined^ that twenty of the doctors were educated i n Canadian U n i v e r s i t i e s , f i v e i n English u n i v e r s i t i e s , two i n Scottish u n i v e r s i t i e s and one i n continental Europe. In many schools of medicine, courses i n community resources or s o c i a l services are taught. With the philosophy of comprehensive care becoming more widespread, these courses are offered; so that the doctor w i l l be knowledgeable of the resources i n the, community to meet his patients' varied needs. Fif t e e n of the twenty-nine doctors did take courses concerning the s o c i a l services. Of the f i f t e e n , f i v e evaluated t h i s education as adequate and ten of the doctors evaluated i t as inadequate. Fourteen doctors did not take such courses. Often included i n the s o c i a l service course, i s information about s o c i a l work as a profession. This i s included, because s o c i a l workers not only administer welfare services, but also are important members of the treatment team. Knowledge about the p a r t i c u l a r configuration of s k i l l s to which s o c i a l workers lay claim, can a i d the doctor i n knowning when to c a l l upon the s o c i a l 1 Medical Directory. College of Physicians and Surgeons of B r i t i s h Columbia, November 1962. 36 worker and how to work with her. Seven of the twenty-nine doctors took courses about s o c i a l work, as a profession. Four evaluated t h i s education as adequate and three as inadequate. Twenty-one doctors did not take t h i s education. One doctor did not answer t h i s question. A comment on the nature of the education concerning the s o c i a l services and s o c i a l work was: "In my opinion the doctor i s not s u f f i c i e n t l y educated to the value and services provided by the s o c i a l worker. This I hope w i l l improve i n time." Medical education i s only one of the factors which contributes to the doctor's awareness of welfare services. Other contributing factors are the length of time a doctor has been i n practice, as well as the geographic locale i n which he practices. The longer a doctor practices and the more patients that he • t r e a t s , 2 the more acute his diagnostic and treatment s k i l l s become. Ideally, t h i s means that a doctor w i l l become increasingly aware of the physical, as well as the psycho-social factors associated with i l l n e s s . As experience i s gained, he may r e a l i z e that for the treatment of some i l l n e s s e s , r e f e r r a l to other helping professions i s needed. Therefore i f the doctor i s to administer the bes& medical care, he w i l l become increasingly aware of community resources and u t i l i z e them as the case demands. 1 For the purposes of t h i s study the pronoun "her" w i l l be used i n reference to s o c i a l workers and the pronoun "him" i n reference to doctors. 2 Somers, Herman and Somers, Anne, R., Doctors.Patients and Health  Insurance. Doubleday and Co., Inc., New York, 19&3, pp. 118-168. The authprs point out that medical care, once a luxery has now become*a" c i v i c r i g h t . More people than ever before are receiving medical treatment and a larger part of the nation's income and the average family.budget i s going for health than ever before. This demand i s f i r m l y based on many related s c i e n t i f i c , demographic and s o c i a l developments. 37 The geographic locale i n which a doctor practices has a dire c t bearing on the doctor's awareness of community resources. Geographic locale w i l l d i c t a t e the socio-economic status of patients and to some degree the i l l n e s s e s which they manifest. Also the a v a i l a b i l i t y of community resources w i l l vary from locale to l o c a l e , as well as the s k i l l s of the other helping professions. Thus what a doctor comprehends as welfare services and the s k i l l s of a s o c i a l worker, w i l l depend on the nature of the welfare services i n a p a r t i c u l a r l o c a l e . For the purposes of this study i t was important to determine the length of time that the doctors had been i n practice and how long they had been p r a c t i c i n g i n the survey area. The doctors were asked to indicate the number of years they had been i n practice i n (a) Canada and (b) Vancouver. Table one, indicates that the majority of the doctors have practiced medicine both i n Canada and Vancouver f o r a period of one to ten years. Five have practiced medicine i n Canada from eleven to twenty years and six from twenty-one to t h i r t y years. Seven of the doctors have practiced medicine i n Canada from eleven to twenty years and six from twenty-one to t h i r t y years. Seven of the doctors have practiced medicine i n Vancouver f o r a period of eleven to twenty years and one from twenty-one to t h i r t y years. 1 Somers, Herman and Somers, Anne, R., Doctors. Patients and  Health Insurance. Doubleday and Co., Inc., New York, 1963, pp. 113-16S; 38 Table A. Doctors: Length of Time i n Private Practice Number of years practice: Canada. Number of Responses Number of years practice: j Vancouver Number of Responses 0 - 1 0 18 0 - 1 0 21 11 - 20 5 11 - 20 7 215- 30 6 21 - 30 1 Tot a l 29 j Total 29 Understanding the Doctor's Role - Diagnosis and Treatment. Comprehensive medical care involves a " t o t a l " approach by the doctor to the in d i v i d u a l patient. Organic pathology as well as the patient's psycho-social problems are encompassed i n such. The doctor i n recognizing s o c i a l and emotional problems which may cause i l l n e s s or which may be caused by i l l n e s s , may choose to treat these problems himself or r e f e r h is patients to s k i l l e d professionals, who are s p e c i a l i s t s i n these areas. S o c i a l workers, as one group of s p e c i a l i s t s , are s k i l l e d i n handling s o c i a l problems, p a r t i c u l a r l y those related to s o c i a l functioning. Thus several questions were asked to determine the extent to which s o c i a l problems were recognized as associated with i l l n e s s ; the nature of the problems; and how the doctors treated them. Diagnosis In Chapter 1 reference was made to the fac t that a l l i l l n e s s e s have psycho-social components, as well as organic components. The in t e r a c t i o n of the three i s highly complex and one factor may be more prevalent than the others. Thus the assessment of s o c i a l or family factors as part of the diagnostic procedure, may lead to a 39 greater understanding of the patient's i l l n e s s . Twenty of the doctors usually include such factors i n t h e i r diagnosis and eight do so occasionally. One doctor did not answer t h i s question. Often the medical diagnosis reveals that the physical symptoms manifested by patients have no organic basis. This, then, can lead the doctor to a closer examination of the psycho-social complex. Twenty-eight of the doctors have patients with complaints of physical i l l n e s s f o r which there appears to be no organic basis. Twenty-five of the doctors estimated that they treated ten or more such i l l n e s s e s t h i s year. Three of the doctors estimated that they treated between six and ten patients with i l l n e s s e s f o r which no organic basis could be found, i n one year, and one doctor estimated that he treated between zero to f i v e patients i n one year. Several of the doctors added comments which indicated that the number of patients who manifest i l l n e s s e s for which no organic basis can be found i s large. Estimates were given that ranged from f i v e patients i n a day to a hundred or more i n one year. Some of the doctors crossed out "year" and replaced i t with "day" or "week." Soc i a l problems associated with i l l n e s s are often multiple and complex, as they are so cl o s e l y inter-twined with the bio-psycho problems. When s o c i a l problems are the strongesst apparent factors i n i l l n e s s they may often underlie both psychic and physical dysfunctioning. The doctors were asked to indicate the main s o c i a l problems underlying the i l l n e s s e s they encountered i n practice. Their responses, as lis.ted i n the following table, indicate that the three main s o c i a l problems which are causative factors i n 40 i l l n e s s are family problems, personality disturbances, such as neuroses or mild psychoses and problems of the aging. Financial problems were mentioned by twenty-one of the doctors, employment problems by nineteen of the doctors and d i f f i c u l t i e s i n adjusting to d i s a b i l i t y by twelve of the doctors. Three of the doctors indicated "Other" problems. Table B. Doctors: S o c i a l Problems Which Cause Functional Illnesses S o c i a l Problems Number of Times Mentioned Problems with members of the family 2 7 ; Financial problems: debt or inadequate income 2 1 Personality disturbances: neuroses or mild psychoses 2 6 v Problems of the Aging: Loneliness, boredom or feelings of being useless D i f f i c u l t i e s i n adjusting to d i s a b i l i t y ! ' . . . . . •• I 2 Problems centering around employment: boredom with job or job too demanding = 19 Others 3 Total 1 1 3 2 The s o c i a l problems included under "Others" are: 1 . sex and alcohol 2 . unemployment f 3 . Immigrants unable to adjust to l i f e ip Canada The answers returned by the doctors regarding medical diagnosis with p a r t i c u l a r reference to s o c i a l problems, indicate 41 three important points. As the doctors are assessing psycho-s o c i a l components as well as the b i o l o g i c a l ones, they are aware of the complex interactions of such and are thus pr a c t i c i n g one facet of comprehensive medical care. The responses regarding i l l n e s s e s which have no organic basis and the problems underlying such i l l n e s s e s , validate to some extent the t r i - i n t e r a c t i o n a l theory of i l l n e s s . The fact that so many patients have s o c i a l problems, as associated with i l l n e s s , indicates the need of s o c i a l workers as part of the treatment team. Treatment The treatment of i l l n e s s , i n which the psycho-social problems are strongest, i s complex. More often than not i t means involving members of the other helping professions. Social workers, i n par t i c u l a r , become involved, i f the i l l n e s s has i t s roots i n a network of s o c i a l problems. The involvement of other helping professions presupposes an acceptance of teamwork by the doctor and ultimately the patient, who must be consulted and prepared for such. Whether the doctors are tr e a t i n g these s p e c i a l problems themselves or r e f e r r i n g t h e i r patients to other s k i l l e d professionals, i s a question of primary importance to t h i s study. It appears, from the following table, that a l l but one of the doctors either discusses the problems with the patient or counsels him about i t . Twenty-two of the doctors, at the same time, r e f e r the patient to a resource that w i l l further meet his needs. Two of the doctors administer treatment for physical manifestations of i l l n e s s and f i v e use other treatment methods. 42 Three of the treatment methods l i s t e d under "Others" encompass s k i l l e d counselling which should involve a thorough knowledge of personality dynamics and a high degree of i n t e r -viewing s k i l l . The purpose i s to help the patient develop i n -sight into his i l l n e s s . Although doctors receive formalized t r a i n i n g i n interview-ing, counselling and personality dynamics, the question arises as to t h e i r specialized s k i l l i n t h i s area and to the amount of time ^ they have to give to t h i s counselling. The proper i n v e s t i -gation that i s needed i n these forms of i l l n e s s involves time f o r interviewing the patient and members of his family. It i s impossible to treat one person i n i s o l a t i o n , i f t h e i r dysfunctioning i s created by d i f f i c u l t i e s i n r e l a t i o n s h i p . As doctors often do not treat a l l the members of one family, the question a r i s e s as to who takes the r e s p o n s i b i l i t y for interviewing family members. This i s one of the primary s k i l l s of the s o c i a l workers and an important c o n t r i -bution which she can make i f called upon. Table C. Treatment Methods Administered i n Cases of  I l l n e s s With No Organic Basis Treatment Number of Times Mentioned Discuss problem with patient and/or counsel him about i t 28 Refer patient to a resource that w i l l further meet his need 22 Treat i l l n e s s as i f i t had organic basis 2 Others 5 Total 57 1 Somers and Somers, op. c i t . . pp. 413-438. The authors discuss the doctor-patient r e l a t i o n s h i p as i t has changed to meet new demands and state that the brisk impersonal atmosphere of the hospital combined with the t y p i c a l f i v e to ten minute con-. -L*. -: ~v, joj^o__ojif_o_e±..^^ i a 1 i nt e r c our s e. 43 The treatment methods included under "Others" are: 1. Method depends on the patient - no set routine. 2. Often I wait u n t i l the patient gets a better idea about his problem. 3 . Reassurance, often mild sedation, and discussion with family i f required. 4 . Reassurance that the i l l n e s s has no organic basis i s necessary. This may involve considerable i n t e r p r e t a t i o n . 5. W i l l r e f e r patient to another resource only i f I f e e l I am making no headway. Awareness and U t i l i z a t i o n Determining the awareness the doctors have of welfare services and the s k i l l s of the s o c i a l workers, involved questioning the nature of t h e i r r e f e r r a l s , t h e i r contacts with welfare agencies and t h e i r knowledge of the s k i l l s of s o c i a l workers and t h e i r experience i n working with s o c i a l workers. Attitudes/and opinions. about such are further indicators of the degree of awareness and 1 u t i l i z a t i o n . The questions under Referrals", Health and Welfare Agencies, S o c i a l Workers and General, questions one, two and three, w i l l afford such information. Referrals The team approach to medical care, involves awareness and u t i l i z a t i o n of the s k i l l s and resources, of not only s o c i a l workers but of the many other helping professions. The r e f e r r a l of a patient to other professional people varies according to the patient's i l l n e s s and needs, as well as the doctor's awareness of. resources a v a i l a b l e and his wish to u t i l i z e , such.The•number of 1 See Appendix A. 44 r e f e r r a l s that the doctors made to resources in the community i n a two week period, as l i s t e d in. the following table, indicates that r e f e r r a l s to p s y c h i a t r i s t s f a r outnumber those made to any other resource. Of those resources mentioned under "Others", two doctors indicated that they referred patients to associates of other medical consultants. Therefore the doctors are r e f e r r i n g patients to members of t h e i r own profession, f a r more than to members of the other helping professions. The question on r e f e r r a l s , i s only an i n d i c a t i o n of the pattern established by the doctors. A l l figures represent estimates of the community resources used most frequently i n a two week period. Exact numbers were not c a l l e d f o r as i t was f e l t that the search f o r such would be too time consuming. As a result of the pattern of r e f e r r a l s established i n thi s study, several pertinent questions have arisen. Further research is needed to answer them. They are as follows: 1. What psycho-social problems associated with i l l n e s s do the doctors f e e l competent to handle themselves? 2. What degree of symptomology must a patient exhibit i n order for the doctor to r e f e r him to other s k i l l e d professionals? 3. What i s the doctor's understanding of a p s y c h i a t r i s t ' s s k i l l s and the nature of the i l l n e s s e s which a ps y c h i a t r i s t i s prepared to treat? 4. Are doctors r e f e r r i n g patients to p s y c h i a t r i s t s who should be referred to s o c i a l workers or welfare agencies? 1 R e f e r r a l was defined as giving information or telephoning d i r e c t l y or contacting on a patient's behalf. 45 5. I f so, are the p s y c h i a t r i s t s , once having examined these patients, then r e f e r r i n g them to s o c i a l workers or welfare agencies? 6. The doctors stated that the three main s o c i a l problems they encounter, as associated with i l l n e s s , are family problems, personality disturbances and problems of the aging. S k i l l e d counselling and interviewing i s often required i n the t r e a t -• ment of such disturbances. A s o c i a l worker i s competent to treat such, yet doctors are evidently not r e f e r r i n g as many patients to welfare agencies. Is t h i s due to the fact that doctors do not consider s o c i a l workers have an important role to play i n the treatment team or i s i t because doctors are not as aware of the counselling s k i l l s of a s o c i a l worker as they are of her s k i l l s i n finding community resources and arranging f i n a n c i a l assistance? (see Table J ) . Table D. Referrals Made by Doctors to Community Resources i n a Two Week Period Resource Number of times Mentioned Ps y c h i a t r i s t 20 j Welfare Agency 11 j Minister 5 I Lawyer 1 | Others 3 j Total 40 Those resources mentioned under "Others" are: 1. Family 2. Associates or Medical Consultants Of the resources l i s t e d ^ welfare agencies, ranked second to those of p s y c h i a t r i s t s . Thus, the doctors were asked which of the many welfare agencies they dealt with most often. Their answers, as l i s t e d i n the following table, indicate that the resources of the City S o c i a l Service Department are u t i l i z e d , f o r patients unable to meet t h e i r medical needs through t h e i r own resources, f a r more often than the other twelve agencies. Nine 46 of the t h i r t e e n agencies l i s t e d are health agencies and the use of such appears to be more frequent than welfare agencies. Thus, the s k i l l s and resources of medical personnel appear to be u t i l i z e d f a r more often than those of the other helping professions. Table E. Welfare Agencies Used Most Often by Doctors (Rank and Frequency of Use) Rankf and Use of Resources Welfare Agencies F i r s t ' Second Thirc City S o c i a l Service Department 13 1 0 Childrens' Aid Society 4 5 3 Family Service Agency 2 3 1 Canadian A r t h r i t i s and Rheumatism Society 2 "•• 2 2 B r i t i s h Columbia Cancer I n s t i t u t e 0 3 3 V i c t o r i a n Order of Nurses 1 1 1 G.F. Strong Rehab i l i t a t i o n Centre 1 2 0 Alcoholism Foundations 0 0 1 Multiple Sclerosis Society 0 o 1 Vancouver General Hospital S o c i a l Service Department 1 1 1 Old Age Assistance and Old Age Pensions Board 0 1 1 Child Guidance C l i n i c 0 2 0 Canadian Mental Health Association 0 o 1 Total 24„.._„ 22 15 The fact that healths agencies would be used more often by doctors than welfare agencies, was indicated early i n t h i s study. 1 The p o s s i b i l i t y that health agencies might be used more frequently arose a f t e r informal discussion with the doctors who 4pji advised on certa i n technical aspects of t h i s study. . • 47 Therefore i t was important to discover whether doctors were.: aware of the fact that s o c i a l workers were part of the treatment team i n most health agencies, and i f so, whether they considered the f a c t that the s k i l l s of the s o c i a l workers, are available when r e f e r r i n g a patient to a health agency. The responses, im the following table, were recorded under the headings, "Yes", "No", and "Occasionally". "Yes", indicates that the doctors do consider the avail a b l e s k i l l s of the s o c i a l worker when making a r e f e r r a l to the l i s t e d agency, and "No", indicates that they do not consider the s k i l l s of the s o c i a l worker when making a r e f e r r a l . The column marked "Occasionally", indicates that the doctors, on occasion, do consider such s k i l l s when making a r e f e r r a l . It can be inferred from the doctors *,responses that the s k i l l s of the s o c i a l worker are more often not considered when a r e f e r r a l i s made to a health agency. The s k i l l s of the s o c i a l workers at the Alcoholism Foundation are taken into consideration most often and those available at the B r i t i s h Columbia Cancer I n s t i t u t e , least often. Why a s o c i a l worker's s k i l l s are considered more often i n making r e f e r r a l s to one agency than to another, i s not known. Further research i s indicated here. It may be that certain i l l n e s s e s , such as alcoholism are considered to have more s o c i a l and emotional components than others. It does appear, however, that the s k i l l s of the s o c i a l worker, are considered by . the doctor to be of lesser import than those of the other team members i n treatment of certain diseases and handicaps. As a re s u l t of the doctors' responses to this question, three further questions are raised: 48 1. Do doctors consider that the s k i l l s of a s o c i a l worker are necessary i n the treatment of certain diseases and handicaps, or do they consider them as unnecessary f r i l l s ? 2. I f a d i s t i n c t i o n i s so made, then i n the treatment of which i l l n e s s e s , do the doctors consider s o c i a l workers as important team members and i n the treatment of which i l l n e s s e s do they f e e l s o c i a l workers have no contributions to make? 3 . Why did the doctors state that adjustment to d i s a b i l i t y was one of the minor s o c i a l problems encountered i n practice, when u t i l i z a t i o n of health agencies by doctors, is much greater than u t i l i z a t i o n of welfare agencies? Table F. The Doctors' Consideration of Available Social Work S k i l l s  When Referring Patients to Health Agencies. Agency Number of 1 'imps Mentioned Yes No Occasionally G.F. Strong Rehabilitation Centre 9 14 4 Alcoholism Foundation 14 11 3 Canadian A r t h r i t i s and Rheumatism Society 11 13 5 B r i t i s h Columbia Cancer Institute 10 15 4 Cerebral Palsy Foundation 6 14 5 Others 1 0 0 Total 51 67 21 The "Other" agency.listed was the Epilepsy Society. The answers to t h i s question were not at a l l s a t i s f a c t o r y . This may be due to the fac t that the question was poorly worded. As a result two doctors did not answer concerning the G.F. Strong Rehabilitation Centre; one did not answer concerning the Alcoholism Foundation, and f i v e did not answer concerning the Cerebral Palsy Foundation. Some doctors checked o f f "Others", but did not state the name of the agency. 49 At t h i s point i n the study the p o s s i b i l i t y a r ises that the doctors consider s k i l l s as related to agency function, Thus, i f a patient indicated the need f o r marital counselling, a doctor might refer him to an agency whose function i s such. The patient at the same time may be referred to a health agency f o r treatment of a s p e c i f i c disease. The doctor, although he may or may not r e a l i z e s o c i a l work counselling i s avail a b l e , ' and i f he does, he may think the s o c i a l worker's s k i l l s are d i r e c t l y related to counselling about health problems and not f o r marital counselling. This would then indicate the doctors' lack of awareness of the generic quality of the s k i l l s of a s o c i a l worker. Certain of the answers returned by the doctors indicate that t h i s theory has some v a l i d i t y . The City S o c i a l Service Department was the agency most u t i l i z e d by doctors f o r t h e i r patients. This agency has as i t s function the provision of public assistance to those people, who f o r reasons beyond t h e i r control are not able to be s e l f supporting. S o c i a l workers determine, e l i g i b i l i t y as well as provide casework services. The doctors not only u t i l i z e t h i s agency more frequently than others but they also indicated (See Table J) that the s k i l l s of the s o c i a l workers thay they recognize more than any others are arranging f i n a n c i a l assistance and knowledge of community resources. These are two of the primary s o c i a l work s k i l l s u t i l i z e d i n Public Assistance agencies. This theory i s further supported by the fact that doctors, i n r e f e r r i n g patients to health agencies, do not, primarily, consider the s o c i a l worker's s k i l l s . I f s k i l l i s seen as related to agency function, the doctors would f i r s t of a l l consider those of the 50 medical personnel when making a r e f e r r a l to a health agency. I f the s o c i a l worker i s considered, she may be thought of as having s k i l l s related primarily to the treatment of i l l n e s s . Further research i s indicated here. I f this theory does prove v a l i d , i t may be discovered that patients are being " s p l i t " . . between various agencies, when i t need not be so. , A doctor may be aware of the resources of a welfare agency that w i l l meet a patient's need, but, for various reasons he w i l l not u t i l i z e these resources. The reasons w i l l vary from doctor to doctor and from patient to patient. In t h i s study i t was most important to discover the most common reasons f o r not using the resources of a welfare agency to meet a patient's need, so that some of the problems involved i n awareness and u t i l i z a t i o n would be understood. The answers to t h i s question, as l i s t e d i n the following table, reveal that ten of the doctors do not u t i l i z e the resources of a welfare agency as t h e i r patients have negative or mixed feelings about being referred. I t could be that i n the eyes of the lay public, that u t i l i z a t i o n of the resources of a welfare agency s t i l l has some stigma attached to i t . Although doctors know d i f f e r e n t l y , the experience of most s o c i a l workers has been that many c l i e n t s and the lay public, think that the stigma of 1 For further discussion of the problem of " s p l i t t i n g the c l i e n t " r e f e r to: Wilensky, Harold, L., and Lebeaux, Charles, N., In d u s t r i a l Society  and S o c i a l Welfare. Russell Sage Foundation, New York, 1958, p. 252. 51 "lesser e l i g i b i l i t y " , exists f o r those who u t i l i z e welfare services. Six of the doctors do not u t i l i z e the resources of a welfare agency as they f e e l that the pressures and demands on the agency are so great that the patient would not receive enough .time or attention. Four of the doctors do not u t i l i z e the re-sources of a welfare agency as, i n t h e i r opinions, the inadequacies of the s o c i a l workers are so great that the doctors can handle the problem much better. Four of the doctors have "Other" reasons for not u t i l i z i n g welfare resources and f i v e doctors did not answer th i s question. Several comments which were added indicated that either none of the reasons l i s t e d were applicable or that they presented no problem. One doctor stated that his experience i n t h i s f i e l d was too limited f o r him to be s p e c i f i c and one doctor stated that he referred regardless of the reasons l i s t e d . Table G. Reasons that the Doctors Do Not Refer a Patient to a Welfare Agency Reasons f o r not Referring Number of Times Mentioned Patient has negative or mixed feelings about being referred 10 Pressures and demands on the agency are so great that the patient would not re-ceive enough time or attention 6 The inadequacies of the s o c i a l workers are so great that the doctor could handle the problem much better 4 Others 4 Total 24 1 The concept of "lesser e l i g i b i l i t y " which developed as a r e s u l t of the Elizabethan Poor Law, encompasses the b e l i e f that anyone who.needs welfare services i s of lesser character and worth than the i n d i v i d u a l who manages on his own resources. 52 The reasons included under "Others" are: 1. Language problems. 2. Unemployment can only be met by adequate work p o s s i b i l i t i e s . 3 . Not r e a l l y aware of a l l the services a patient can draw on - not introduced to these services since being i n practi c e . 4. The inadequacies of s o c i a l workers i s not a common problem but can be a r e a l one. This seems more related to policy than i n d i v i d u a l workers. Contacts with Welfare Agencies When a doctor has a patient who i s a c l i e n t of a l o c a l * welfare agency, the outcome i s apt to be increased awareness on the part of the doctor, of the function and modus operandi of the agency. This may res u l t i n increased u t i l i z a t i o n . Often a s o c i a l worker w i l l contact the doctor to discuss the patient's health and s o c i a l problems or the doctor may f i n d i t necessary to contact the s o c i a l worker or agency administrator f o r a variety of reasons. As a r e s u l t communication i s established, teamwork i n i t i a t e d and a clearer understanding of the agency and the role of the s o c i a l worker developed. Twenty-eight of the doctors have patients who have had contact with a l o c a l welfare agency. Twenty-seven have talked to a s o c i a l worker about a case and two have not. One added the comment that-hec."never saw.a s o c i a l worker". Seventeen of the doctors have talked with a d i r e c t o r or administrator of an agency; twelve have not. Several of the doctors added comments which indicated that they only spoke to an administrator when the problem was acute and needed immediate action; and where the . 53 s o c i a l worker i n such cases was hindered by administrative procedures. One doctor commented that he spoke to an adminis-t r a t o r about an adoption problem and one doctor indicated that he found the administrator co-operative. Maintenance of contact with a welfare agency, a f t e r r e f e r r i n g a patient, indicates the doctor's desire to co-operate with the s o c i a l worker and establish a team approach i n t r e a t i n g his patient's i l l n e s s . The contact w i l l also increase awareness; and u t i l i z a t i o n , as each team member defines t h e i r role according to s k i l l and resources, and discusses treatment plans. Eleven of the doctors t r y to maintain contact with a welfare agency, a f t e r r e f e r r i n g a patient and f i v e do so occasionally. Ten doctors did not answer t h i s question. Two s p e c i f i c comments were added: "I have rarely had occasion to r e f e r to an agency n(this varies with locale of p r a c t i c e ) . "After r e f e r r i n g a patient to a welfare agency, do t h e y maintain contact with me? Nol" The second comment made in r e l a t i o n to maintenance of contact between the two professions, r a i s e s a most important issue. In 1 the h o s p i t a l , where team rel a t i o n s h i p s are structured and roles defined, the r e s p o n s i b i l i t y f o r maintaining contact between s o c i a l workers and doctors, l i e s with the s o c i a l workers. A problem a r i s e s , when team, members work in d i f f e r e n t i n s t i t u t i o n s and are administering varying p o l i c i e s . The questions as to who has the r e s p o n s i b i l i t y for maintaining contact i s most pertinent. The d i f f i c u l t y here may be due to the lack of c l a r i f i c a t i o n of team structure and the problem of whether comprehensive care may 54 need to be more structured w i l l have to be examined most cl o s e l y . Although a doctor or any other member of the helping professions may wish to r e f e r a patient to a resource that w i l l further meet his need, he may not know i f the resource i s a v a i l -« able. In order to solve t h i s problem, the Community Chest and Councils of Greater Vancouver, has prepared a Directory of Health, Welfare and Recreational Services i n Metropolitan Vancouver. The Directory i s organized into nine categories of service f o r meeting the health, welfare and recreation needs of the community. Within each category are subdivisions related to s p e c i f i c v a r i e t i e s of service. A b r i e f statement of functions and program i s offered fo r each organization, This publication i s available to a l l pro-f e s s i o n a l and lay people i n the community. Eighteen of the doctors were f a m i l i a r with the publication, eleven were not. Two desig-nated that they had some other form of welfare services directory, these being t h e i r own private l i s t s of agencies and the Canadian Medical Association Information Manual. Nine of the doctors i n d i -cated no other form of welfare services d i r e c t o r y . A question was asked to discover what resources the doctors u t i l i z e when wishing to know more about welfare services i n the community. The following table indicates that the s t a f f of the . C i t y Social Service Department and. Medical colleagues are most often consulted, followed by the Community Chest and Council and the Vancouver General Hospital, S o c i a l Service Department. One doctor consults the Family Service Agency, one the V i c t o r i a n Order 55 of Nurses and one doctor answered none. Three doctors did not answer t h i s question and one added the comment, "It depends on the type of case." Table H. Resources U t i l i z e d By Doctors to Increase Their  Knowledge of Welfare Services Resource Number of Times Mentioned City S o c i a l Service Department 10 Community Chest and Council 4 S o c i a l Service Department Vancouver General Hospital 4 Colleagues 6 Family Service Agency 1 V i c t o r i a n Order of Nurses 1 None 1 Total 27 Doctors' View of the S o c i a l Workers • The questions concerning what the doctors knew and thought about s o c i a l workers applied to the awareness and u t i l i z a t i o n they have of welfare services. U t i l i z a t i o n of welfare services w i l l depend on whether the doctors recognize s o c i a l workers as educated i n d i v i d u a l s , adequately trained to "carry out the job demands placed on them by v i r t u e of t h e i r r o l e and function. Reluctant use of welfare services w i l l r e s u l t i f the doctors f e e l that s o c i a l workers are not trained or s k i l l e d enough to contribute to the highly specialized medical team. The doctors were asked what they understood as the educational q u a l i f i c a t i o n s needed by s o c i a l workers i n order to practice. Seventeen of the responses, l i s t e d 56 i n the following table, indicated that the doctors understood that s o c i a l workers needed a Social Work Diploma i n order to practice. Eleven of the responses indicated that post-graduate t r a i n i n g beyond the Bachelor of Arts l e v e l was needed; eight of these stating that two years of postgraduate t r a i n i n g i s required and three of these, s t a t i n g that one year of postgraduate work i s necessary. Five of the responses indicated a Bachelor of Arts as the q u a l i f i c a t i o n f o r practice and one, senior matriculation. The majority of the doctors recognize that specialized t r a i n i n g i s necessary. However, the responses do not indicate whether the doctors are aware of the l e v e l on which s o c i a l work training begins. Whether i t i s understood by the doctors that an undergraduate degree i s a pre-requisite to admission into a school of s o c i a l work, i s not known. It i s surely s i g n i f i c a n t that h a l f of the doctors interviewed s p e c i f i e d a Social Work Diploma. This has been superseded since 1 9 4 6 . To be e l i g i b l e for such, notably at the University of B r i t i s h Columbia, a student was required to have an undergraduate degree and complete fourteen months of study at the school of s o c i a l work. Table I. Opinions of the Doctors as to the Education Required f o r Social Work Practice 1 Education Number of Times Mentioned Senior M a t r i c u l a t i o n 1 Bachelor of Arts • 5 S o c i a l Work Diploma 17 Post Graduate Training - One Year 3 Post Graduate Training - Two Years 8 Total 57 Doctors' Opinions About Socral Workers When a doctor considers the treatment team necessary to insure comprehensive medical care f o r his patient, he must be aware of the nature of the spec i a l i z e d s k i l l s which team members can contribute. Therefore, what the doctor understands to be the s k i l l s of the s o c i a l worker, w i l l a f f e c t t h e i r u t i l i z a t i o n . In order to determine what the doctors understand to be the s k i l l s of a s o c i a l worker, they were asked to check off those s k i l l s they are aware of, as l i s t e d i n the questionnaire. An opportunity to express t h e i r own opinions was also given (under the heading of "Others"). The responses to the question, con-cerning the doctors' opinions as to the p a r t i c u l a r s k i l l s of the s o c i a l worker, reveal, i n the following table, that the three s k i l l s of the s o c i a l worker of which the doctors are most aware are knowledge of community resources; the arranging of f i n a n c i a l assistance; and securing shelter f o r homeless and unattached persons. The s k i l l s of the s o c i a l group worker such as guiding members of groups i n various programme a c t i v i t i e s , and conducting group therapy sessions in medical settings, are the s k i l l s that the doctors are least aware of, and are i n a l l p r o b a b i l i t y , l e a s t u t i l i z e d . Eighteen of the doctors indicated that the s k i l l s of a s o c i a l worker included planning f o r the provision and maintenance' of welfare services; seventeen noted specialized counselling s k i l l s ; and eleven understood e f f e c t i n g environmental changes to be a s k i l l possessed by s o c i a l workers. The s k i l l s of s o c i a l workers, recognized most by the doctors, are those that have t h e i r roots i n the early days of s o c i a l work. 58 The s k i l l s , more recently developed, such as group work and casework, have been given less recognition. It may be that s o c i a l workers are not as e f f i c i e n t and e f f e c t i v e i n the adminis-t r a t i o n of such s k i l l s . Yet the lack of recognition given to group work, i n p a r t i c u l a r , i s somewhat puzzling i n t h i s era of g e r i a t r i c medicine. The doctors presented problems of the aging as one of the major s o c i a l problems encountered i n practice and much of the g e r i a t r i c l i t e r a t u r e has emphasized group a c t i v i t i e s for the aging to aid i n overcoming loneliness and boredom. Table J . The Doctors' Understanding of S o c i a l Workers 1 S k i l l s S k i l l s Number * of Times Mentioned Arranging of f i n a n c i a l or material assistance 21 Securing shelter and care for homeless or unattached persons 19 Knowledge of Community Resources to meet a varied number of needs 25 E f f e c t i n g environmental changes 11 Specialized counselling s k i l l s 17 Guiding members of groups i n various programme a c t i v i t i e s 7 Conducting group therapy sessions i n medical settings 5 Planning for the provision and maintenance of welfare services i n the community 18 Others 2 Total 125 The two s k i l l s mentioned under "Others" were: 1. Explanation and guidance to the needy i n making the most of the resources they have, be i t physical, mental or material. 2. Maintenance of contact with the lonely and frightened. 5 9 The nature of the co-operation experienced by doctors when working with s o c i a l workers, w i l l , to some extent a f f e c t awareness and u t i l i z a t i o n . The doctors w i l l be more w i l l i n g to involve the s o c i a l worker as part of the team, i f past working experiences have been productive and n o n - i r r i t a t i n g . The opposite i s also true. D i f f i c u l t i e s i n working with s o c i a l workers w i l l tend to prejudice the nature of the doctor's awareness and hence h i s u t i l i z a t i o n of the s k i l l s of the s o c i a l worker. The doctors were asked to indicate what d i f f i c u l t i e s they had experienced in working with s o c i a l workers i n (a) hospitals, (b) health agencies and (c) welfare agencies. Their complaints, as l i s t e d i n the following table, have been c l a s s i f i e d under four headings: Professional S k i l l s , Attitude, Competency, and Others. Profes-s i o n a l S k i l l s are those to which s o c i a l workers lay claim by virtu e of t h e i r t r a i n i n g ; r o l e ; and function. The manner i n which a s o c i a l worker approaches her c l i e n t s , professional peers, and team members i s referred to, as a t t i t u d e . Competency i s defined as the accuracy and e f f i c i e n c y with which the s o c i a l worker carries out the administrative aspects of her job. The t o t a l number of responses indicate that the most d i f f i -c u l t i e s experienced have been with s o c i a l workers i n welfare agencies; followed by s o c i a l workers i n hospitals and then i n health agencies. The major d i f f i c u l t i e s met i n both health and welfare agencies have been too much red tape; not enough resources; s o c i a l workers over worked; and caseloads too high. The d i f f i -c u l t i e s experienced here, r e s u l t from agency policy as adminis-tered by s o c i a l workers. Subsequently, the doctors indicated, that i n a l l settings, the d i f f i c u l t i e s they have encountered 6 0 are due to the fact that s o c i a l workers are: too t h e o r e t i c a l ; V not r e a l i s t i c ; upset the patient; t r y to make medical decisions and give medical advice; i n s u f f i c i e n t l y trained; poorly informed about the patient; and breaching the p r i n c i p l e of c o n f i d e n t i a l i t y . The s o c i a l worker's lack of e f f i c i e n c y and competency, i n hospitals and health and welfare agencies, i s creating f r i c t i o n i n the working re l a t i o n s h i p s ; as we l l as t h e i r a t t i t u d e . Table K. D i f f i c u l t i e s Encountered by Doctors i n Working With S o c i a l Workers Problem 1 1 .Number of Res snonses -lospitall Health Agency Welfare Professional S k i l l s 1 Too t h e o r e t i c a l , not r e a l i s t i c , upset the patient, try to make medical decisions and give medical advice, i n s u f f i c i e n t t r a i n i n g , poor information about patient, lack of c o n f i d e n t i a l i t y . 4 3 4 Attitude Unapproachable, f e e l superior to patient and doctor, too interested. i n cutting costs, dogmatic, r i g i d 0 1 2 Competency Lack of i n d i v i d u a l continuity and follow-up, slow, delay, not report back to doctor, waste time on phone 4 1 2 Others • S o c i a l problem i s a d i r e c t r e f l e c -t i o n of an inadequate government, too much red tape and riot enough resources, caseload too high and workers overworked, co-operative not too much contact or experience here 4 6 9 Total 1 2 1 1 1 7 61 This question was d i f f i c u l t to tabulate, due to the ways in which the doctors chose to answer. Nine doctors indicated no problems i n hospitals; seven i n health agencies; and f i v e i n welfare agencies. Six d i d not answer the t o t a l question; two did not answer the question regarding hospitals; f i v e did not answer the question regarding health agencies; and one did not answer regarding welfare agencies. Thus the f i n a l tabulation of the d i f f i c u l t i e s encountered i s not comprehensive and i s some-what unsatisfactory. Several of the s o c i a l workers' s k i l l s , c r i t i c i z e d by the doctors, may indicate that they f e e l that the s o c i a l worker i s a threat to the doctor-patient r e l a t i o n s h i p . What the doctor understands as probing may be the s o c i a l worker's attempt to discover the f a c t s about the patient i n order to make an assess-1 ment and to establish a casework r e l a t i o n s h i p . Also, what the doctor sees as lack of c o n f i d e n t i a l i t y , may be the s o c i a l worker's e f f o r t s to discuss the patient's i l l n e s s with him and help him to make further plans. The doctor may f e e l that t h i s i s the essence of the doctor-patient r e l a t i o n s h i p . He would then see the s o c i a l worker as i n t e r f e r i n g and threatening. I f t h i s i s the case, i t may mean that team roles w i l l have to be more e x p l i c i t l y defined fo r both doctors and s o c i a l workers. 1 For a discussion of the casework rela t i o n s h i p r e f e r to: Perlman, H.H., S o c i a l Casework. University of Chicago Press, Chicago, 1957, pp. 64-84. 62 Next, the doctors were asked to indicate which complaints, most often heard about s o c i a l workers from doctors, they thought to have the most substance. Their answers, as l i s t e d i n the following table, indicate that, mainly, s o c i a l workers are using too much jargon and are upsetting the patients by too much probing. Five of the doctors have complaints about the s o c i a l workers' t r a i n i n g ; four complained about s o c i a l workers not taking s u f f i c i e n t account of medical f a c t s ; and four of the doctors complained about the fact that s o c i a l workers are unable to carry out t h e i r re-quests. What the nature of these requests are and why the s o c i a l worker cannot carry them out i s not known. The r e s u l t s of t h i s question were d i f f i c u l t to interpret, as only a minority of the doctors answered i t . Eleven doctors who stated the l a t t e r did not of f e r t h e i r own c r i t i c i s m s . Neverthe-les s , c e r t a i n things did stand out although a d e f i n i t e pattern could not be established due to the minority answers. Table L. Doctors' Complaints About Social Workers Complaints Number of Times Mentioned They are i n s u f f i c i e n t l y trained 5 They take i n s u f f i c i e n t account of medical facts 4 Upset patients by too much probing 7 Use too much "jargon" 7 Usually unable to carry out your requests 4 Total 27 The comments accompanying th i s question were varied. One doctor f e l t that s o c i a l workers are most h e l p f u l , while others 63 complained about s o c i a l workers upsetting the patient by being i n d i f f e r e n t ; and s o c i a l workers assuming f a r too much responsi-b i l i t y i n o f f e r i n g medical advice. One doctor stated/that he-had no complaints about s o c i a l workers, only with the. sbclb-r economic-legal-religious system allowing these conditions to exist and another doctor made a comment to the effect that there i s too much red tape about s o c i a l work routine which engenders, a. great deal of antagonism. Just as f r i c t i o n between doctors and s o c i a l , workers,; w i l l a f f e c t awareness and u t i l i z a t i o n , so w i l l favourable working 1 relationships with s o c i a l workers. What the doctor considers : as the s o c i a l worker's best contribution to the team w i l l be taken into consideration when making a r e f e r r a l and involving her as part of the medical team. The doctors were questioned about what they consider as the best contributions of s o c i a l workers. Their opinions, as l i s t e d i n the following table, have been c l a s s i f i e d under three headings: Professional S k i l l s , Attitude and Others. Seven of the doctors did not answer. Twelve of the doctors f e l t that the s o c i a l worker's best contributions consisted i n determining points at which help may be most productively given; arranging for material and environ-mental assistance; providing a good s o c i a l h istory; knowledge' of : resources; and maintenance of welfare services i n the community. Six of the doctors indicated that the s o c i a l worker's supportive', reassuring, personalized attitude was the major contribution and four doctors l i s t e d "Other" contributions. 64 Table M. The Doctors' Opinions as to the S o c i a l Worker's Best Contributions r Contributions Number of Responses Professional S k i l l s Determining points at which help may be most productively given, arranging for material and environmental assistance, maintenance of welfare services i n the community, provide good s o c i a l history, knowledge of resources and placements. 12 Attitude Have time to help, fr i e n d and counsellor to the needy, t r e a t i n g g e r i a t r i c patients as human beings, understanding rapport, reassuring, maintain contact with the lonely ana frightened 6 Others Ease the doctor's load and co-operative 4 4 Total 22 Chapter 3 S o c i a l Workers and the U t i l i z a t i o n of Medical Services The S o c i a l Workers: Education and Experience Professional education i s regarded as an in d i c a t i o n of competence i n the profession of S o c i a l Work, Emphasis i s also placed on experience i n s o c i a l work practice.; Frequently the length of experience an in d i v i d u a l worker has, may acquire equal importance with the nature and length of professional education. It i s in t h i s context that the discussion of education should be considered. The following table indicates that eighteen of the s o c i a l workers who participated i n t h i s survey have a Bachelor of Arts; thirteen have a Bachelor of S o c i a l Work, ^ and eleven have a Masters of S o c i a l Work. Four of the s o c i a l workers possess the e.quivalent to one year of graduate s o c i a l work education and four, the equivalent to two years of graduate s o c i a l work education. Two of the s o c i a l workers had just senior matricu-l a t i o n . Thus, seventeen of the s o c i a l workers had attended a school of s o c i a l work f o r one year of sp e c i a l i z e d t r a i n i n g and f i f t e e n for two years of spe c i a l i z e d t r a i n i n g . The majority of the s o c i a l workers, therefore, appear to have a Bachelor of So c i a l Work or i t s equivalent. Whether t h i s i s i n d i c a t i v e of 1 Bachelor of Soc i a l Work i s granted to candidates who have a Bachelor of Arts and one year of s o c i a l work education. 2 Master of S o c i a l Work i s granted to candidates who have a Bachelor of Arts and two years of s o c i a l work education. o6 the q u a l i f i c a t i o n s of most s o c i a l workers i n Vancouver i s not known. The Council orl S o c i a l Work Education has stated that the minimum q u a l i f i c a t i o n f o r a beginning Social Worker i s a Masters of S o c i a l Work, yet a minority of the s o c i a l workers have a Bachelor of S o c i a l Work or l e s s . Four of the s o c i a l workers ; received t h e i r education i n the United States and the others attended Canadian Schools of Social Work. Table N. S o c i a l Workers: Educational Degrees Degrees Number of Times Mentioned Equivalent to one year of graduate s o c i a l work education Equivalent to two years of graduate s o c i a l work education Bachelor of Arts Bachelor of S o c i a l Work Masters of S o c i a l Work : \ • \ k\\ 18 " ' 13 ' . • •: 11 v ) I Total S o c i a l work education has changed considerably i n emphasis and content over the l a s t f i f t e e n years. The decade i n which 1 s o c i a l workers received t h e i r education w i l l a f f e c t , to some ; extent, the degree of awareness and u t i l i z a t i o n they have of"] general p r a c t i t i o n e r s . U n t i l the 1 9$0 Ts s o c i a l work students' were given courses i n medical information, i n addition to e x p l i c i t i n s t r u c t i o n concerning the roles of the doctor and s o c i a l worker on the treatment team. Courses i n medical s o c i a l work were offered to those second year students who wished to s p e c i a l i z e i n t h i s f i e l d . Since 1956, emphasis has been placed, not on s p e c i a l i z a t i o n by se t t i n g , but rather on s p e c i a l i z a t i o n 67 by method. The course on "medical information" has been re-developed into an integrated course on "human growth and behavior." Although the importance of teamwork i s stressed, i n s t r u c t i o n regarding the role of the, s o c i a l worker i n the treatment team i s less e x p l i c i t . Three of the s o c i a l workers graduated i n the 1940's; thi r t e e n in the 1950*s and nine in the 1960's. Two of the s o c i a l workers did not graduate from a school of s o c i a l work. Thus, twenty-two of the s o c i a l workers graduated in the/decades, i n which a generic approach to team work was being taught. The " t o t a l " approach to the patient which i s emphasized i n -medicine, i s also a tenet of s o c i a l work education and practice. Thus, i n s o c i a l work education emphasis i s placed on the under-standing and use of community resources and the s p e c i a l i z e d s k i l l s of other professions. In the table following, the responses to the questions determining whether courses i n s o c i a l work education mentioned the role of the doctor i n the treatment of i l l n e s s or suggested ways of working with doctors, are as follows: Twenty-four of the s o c i a l workers took courses which offered an understanding of the doctor's role i n the treatment of i l l n e s s . . The comment " l i m i t e d " was added, by one of the s o c i a l workers. Fourteen of the s o c i a l workers took courses which suggested ways of working with doctors who r e f e r patients. One s o c i a l worker commented that she had learned t h i s by experience and several s o c i a l workers stated that t h i s was implied, p a r t i c u l a r l y 68 i n the casework sequence. Another s o c i a l worker commented on the fact that t h i s was taught i n several courses, including, community organization, f i e l d work, medical information, medical s o c i a l work and s o c i a l psychiatry. The courses here mentioned were offered i n the early 1950's, when s p e c i a l i z a t i o n by s e t t i n g rather than by method was emphasized. Twenty-two of the s o c i a l workers took a course which sugges-ted ways of working with a sick c l i e n t , not referred by a doctor. One commented that she learned t h i s from practice and another stated that i t was implied rather than d i r e c t l y taught. Another comment was that t h i s was learned i n casework seminars, i n the course on medical information and i n a s p e c i a l i z e d reading course. One s o c i a l worker did not answe t h i s question. Table 0. Social Workers: Education Related to the Under  Standing of the Doctor Nature of the Question Number of Responses Yes Mo 1 Total Course material offered i n increasing understanding of the doctors' role i n the treatment of i l l n e s s . 24 2 26 Course material suggesting ways of working with doctors who r e f e r patients. 14 12 26 Course material suggesting ways of working with a sick c l i e n t , not referred bv a doctor 22 23 25 A S o c i a l workers' awareness of community resources, \vhich leads to u t i l i z a t i o n , more often depends upon the number of years she has been i n practice i n the w e l f a r e ' f i e l d , rather than professional . 69 education. As a s o c i a l worker's caseload grows, she finds the need to be increasingly aware of community resources and to u t i l i z e them s e l e c t i v e l y , i n order to aid her c l i e n t in his s o c i a l functioning. Thus, the longer a s o c i a l worker i s i n practice, the more aware she usually becomes of available resources and s k i l l s i n a p a r t i c u l a r community. The table following indicates that nine of the s o c i a l workers have been i n practice from one to f i v e years; four from six to ten years and s i x , from eleven to f i f t e e n years. Five s o c i a l workers have had from sixteen to twenty years experience and one from twenty-one to twenty-five years experience. One s o c i a l worker did not answer t h i s question. For the purpose of t h i s study i t was important to determine the number of years that the s o c i a l workers had been working i n the agency where they are now presently employed. F a m i l i a r i t y with agency policy and procedure develops over a period of time and with experience. Interpretation to the doctors of agency policy and the role of the s o c i a l worker within the agency i s partly dependent on such. The table following indicates that eighteen of the s o c i a l workers have been, employed i n the agency i n which the.y are now working, from one to f i v e years; three, from six to ten years and three, from eleven to f i f t e e n years. Two s o c i a l workers have been employed from sixteen to twenty years, i n the agency i n which they are now working. 70 Table P. Social Workers: Number of Years i n Practice i n  the Welfare F i e l d and i n Their Present Employ-ing Agency. Number of Years Number of Number of Years Number of in Practice Responses Employed i n Agency Responses 0 - 5 9 0 - 5 13 6 -110 > 6 - 1 0 3 1 1 - 1 5 6 1 1 - 1 5 3 16 - 20 5 1 6 - 2 0 2 21 - 25 1 2 1 - 2 5 0 Total 25 Total 26 ; Counselling The r o l e of the s o c i a l worker, i n any agency, i s to enhance, maintain or restore s o c i a l functioning. ^ The nature of a c l i e n t ' s health or any health problems being experienced by a • 2 c l i e n t w i l l a f f e c t his role performance. Therefore, i t i s advisable to explore t h i s area with a c l i e n t i n making a s o c i a l assessment. ^ Twenty-six of the s o c i a l workers stated that they did inquire into the nature of health problems being experienced by a c l i e n t . Health problems were defined as i l l n e s s , the meaning of i l l n e s s to a c l i e n t , d i f f i c u l t i e s i n paying doctors' b i l l s and d i f f i c u l t i e s i n following the doctor's treatment programme. 1 Soc i a l functioning refers to the sum t o t a l bf an indiv i d u a l ' s i n t e r a c t i o n which indivi d u a l s or groups i n his environment. /i-2 Role performance i s the enactment of the s o c i a l requirements of the status held.by the i n d i v i d u a l . 3 A s o c i a l assessment i s a combination of theory plus, facts gathered by the s o c i a l worker about the c l i e n t ' s .problems i n s o c i a l functioning. From t h i s a hypothesis about the person-problems complex i s formed. 71 Eleven of the s o c i a l workers do t h i s routinely, seven, occasion-a l l y and eight inquire only when the c l i e n t presents t h i s as a problem. The r o l e of the s o c i a l worker i n the treatment of i l l n e s s i s to help her c l i e n t cope with s o c i a l or emotional problems associated with i l l n e s s . Twenty-six of the s o c i a l workers stated that they counselled c l i e n t s about the s o c i a l aspects of a health problem. One added the comment "when applicable". Counselling c l i e n t s about the s o c i a l aspects of i l l n e s s , appears to be an inherent part of every caseworker's job. The s o c i a l worker, while counselling c l i e n t s about health problems, should at a l l times be i n contact with the c l i e n t ' s doctor i n order that an integrated team approach i s established. Of the twenty-six participants i n t h i s survey, twenty-five do contact the c l i e n t ' s doctor and one does not. The l a t t e r , added the comment: •/ "In t h i s agency t h i s i s the job of the medical section, although, on a rare case I have phoned the doctor a f t e r receiving permission from the medical section." Three of the s o c i a l workers who replied i n the affirmative, in.di cated that t h e i r contact was made through the .medical section of the agency. -Comments added to t h i s question indicate that one worker contacts the doctor only i f the need i s indicated. Need i s determined by the nature of. the.problem and the ro l e of the s o c i a l worker. Another worker contacts the doctor only i f she has the c l i e n t ' s permission to do so. 72 Reasons f o r contacting the doctor may vary according to the needs of the c l i e n t and the problems associated with the c l i e n t ! s i l l n e s s . Reasons f o r contact should stem from a competent s o c i a l assessment and the s o c i a l worker*s desire to co-operate with the doctor. It appears, i n the table following, that one of the main purposes for contacting the c l i e n t ' s doctor i s to discuss with the doctor the fact that his patient i s being '. counselled at the agency. Twenty-two of the responses indicate that the c l i e n t ' s doctor i s contacted i n order to discover the treatment recommended; twenty of the responses indicate that the purpose f o r contact i s to ascertain the nature of the c l i e n t ' s i l l n e s s ; and eighteen, to discover how well the c l i e n t i s following treatment. Of the twenty-two reasons l i s t e d under "Others", ten indicated that the purpose for contact was to establish an i n t e -grated team approach. Table Q. The Social Workers TPurposes f o r Contacting the Client's Doctor Purpose Number of Times Mentioned To ascertain the nature of the i l l n e s s 20 To discover the treatment recommended 22 To discover how well the c l i e n t i s following treatment 18 To discuss with the doctor the f a c t L ' that h i s patient i s being counselled at the agency 23 Others 22 Total 105 73 Those purposes mentioned under "Others" were: 1. To discuss with the doctor how we may best work together and co-operate f o r the good of the c l i e n t , which involves, defining professional r o l e s , discovering how the doctor f e e l s the s o c i a l worker can help, and involving the doctor i n the s o c i a l work treatment plan. (10 responses) 2. To arrange for resources and r e f e r r a l s and in doing so co-ordinate physical and emotional help to the c l i e n t . This involves arranging f o r appliances, payment f o r drugs and r e f e r r a l s to a p s y c h i a t r i s t . (4 responses) 3. To discover how the i l l n e s s w i l l a f f e c t the s o c i a l functioning of the c l i e n t and his family, now and i n the future. (3 responses) 4. To request c o l l a t e r a l information which w i l l a i d i n a psycho-social assessment. This involves the medical-diagnosis and prognosis. (2 responses) 5. To discover the nature of the counselling done by the doctor. (2 responses) Comments, added to t h i s question indicate that.purposes f o r contact depended on the nature of the case. One s o c i a l worker stated that t h i s must be done with the c l i e n t whenever possible, i n order to insure the c l i e n t ' s s e l f d i g n i t y and r i g h t to s e l f determination. This statement i s i n d i c a t i v e of the s o c i a l worker's r e a l i s t i c a p p l i c a t i o n of two basic tenets of the s o c i a l work philosophy. The majority of the responses to t h i s question indicate two important and related f a c t o r s . Most of the s o c i a l workers, when working with a c l i e n t whose problems are those associated with i l l n e s s , are taking the i n i t i a t i v e i n contacting the c l i e n t ' s doctor. This i n i t s e l f i s the f i r s t step.towards establishing rapport between the two helping professions. Secondly, the majority of the s o c i a l workers indicated that the purpose f o r a contact was to establish an integrated team approach, by discussing 74 with the doctor the fact that his patient i s being counselled at the agency and discussing with him, how the doctor and the s o c i a l worker may best work together and co-operate for the good of the c l i e n t . The other purposes f o r contacting the doctor, that were l i s t e d , also are limited facets of the team approach and indicate the emphasis and importance that the s o c i a l workers place on such. Awareness and U t i l i z a t i o n One of the best indicators of the degree of r e c i p r o c a l awareness and u t i l i z a t i o n i s the number of r e f e r r a l s made to doctors and received from doctors i n a certain period of time. In response to the question asking how many of t h e i r c l i e n t s were referred to the agency i n the la s t month by a doctor', the following responses were made: Three did not answer the question, and seven replied that they did.not know. Ten had received no r e f e r r a l s from doctors i n the l a s t month. One s o c i a l worker received two r e f e r r a l s , one received three r e f e r r a l s , one received s i x r e f e r r a l s and one received seven r e f e r r a l s . Thus of the six reporting workers, a sum t o t a l of eighteen r e f e r r a l s were received. In estimating the number of r e f e r r a l s made to doctors i n the l a s t month the responses were as follows. Three s o c i a l . workers did not answer t h i s question and four stated that they did not know. Eight reported no r e f e r r a l s to. doctors i n the l a s t month. The remaining eleven reported a t o t a l of twenty-nine r e f e r r a l s to doctors i n the l a s t month. Six of the s o c i a l 75 workers referred one c l i e n t each, three referred two, one referred f i v e and one referred ten. Unfortunately, the number of s o c i a l workers who answered the questions on r e f e r r a l s , represent le s s than half of the group. The number of r e f e r r a l s to doctors was weighted by one reply of ten and the number of r e f e r r a l s from doctors was weighted by a reply of seven. Further research which would indicate the number of r e f e r r a l s to and from a doctor annually may indicate more c l e a r l y the degree of r e c i p r o c a l awareness and u t i l i z a t i o n between the two professions. This i s due to the fac t that the r e f e r r a l i n i t s e l f , i n some cases, i s i n d i c a t i v e of a great deal of time and e f f o r t of the part of the s o c i a l worker and the doctor. Although a s o c i a l worker or a doctor may recognize the c l i e n t ' s need for such, i t may take time before a r e f e r r a l can expedited. In the interum, the c l i e n t or patient may need to be helped to recognize the need himself, be prepared 9or the new experience and be emotionally or physically able to continue in treatment. Permission must be granted by the c l i e n t or patient to release c o n f i d e n t i a l information and i n the case of a s o c i a l work r e f e r r a l , agency policy and procedure must be adhered to. Twenty-three of the s o c i a l workers indicated that they made an e f f o r t to contact the doctor f o r c o l l a t e r a l information when the doctor referred a c l i e n t . Two did not answer the question and one repl i e d i n the negative. 76 Maintenance of contact with a doctor, a f t e r r e f e r r i n g a c l i e n t , indicates the s o c i a l worker's desire to' co-operate with the doctor as a member of the treatment team. In response to the- question about maintaining contact with the doctor, aft e r r e f e r r i n g a c l i e n t to him, twenty-three indicated they did such. Three s o c i a l workers did not answer the question. Of the twenty-three who indicated they maintained contact with the doctor, ten replied that they did t h i s on a routine basis and thirteen did t h i s occasionally. One s o c i a l worker commented that her contacts, depended on the nature of her s o c i a l assess-ment and one maintained contact "more or l e s s " on a routine basis with a doctor. The question as to who has the responsi-b i l i t y f o r maintaining contact appears to be of less concern to the s o c i a l workers than to the doctors. I t may be that the non-medical s o c i a l worker f e e l s that t h i s i s as much her responsi-b i l i t y as that of the medical s o c i a l worker. Proble'rhs encountered by s o c i a l workers i n working with doctors, w i l l a f f e c t awareness and u t i l i z a t i o n . The opposite i s also true. I f co-operation and good working relationships have been the s o c i a l worker's experience, then she w i l l be more c l e a r l y aware of the doctor's s k i l l s and his role i n the treatment team. She h e r s e l f w i l l also be more w i l l i n g to become involved i n the team. In response to the question r e l a t i n g to problems i n t r y i n g to work with doctors on a case, seventeen indicated that they had encountered problems and six indicated they had not. Three of the s o c i a l workers did not answer t h i s question. 77 The two major problems apparently encountered i n working with doctors are that the doctors underestimate s o c i a l and emotional problems as factors i n i l l n e s s , and that doctors do not understand the role of the s o c i a l worker and the agency pol i c y which she administers. Three of the responses indicate that problems are encountered as a r e s u l t of the doctors counselling patients without an adequate understanding of personality dynamics or the patient's complex s o c i a l s i t u a t i o n . This reply i s somewhat in contradiction to those made by the doctors. The majority of the doctors claim to assess psycho-s o c i a l factors when diagnosing i l l n e s s s . Yet the s o c i a l workers f e e l that these factors are underestimated by the doctors. What i s meant by "underestimated" may have some re l a t i o n s h i p to the .. team role confusion, i n that the s o c i a l workers are not clear about the doctor's role i n the treatment of i l l n e s s or on the treatment team, as well as her own role on the team. Indications are that the doctors do not f u l l y comprehend the s o c i a l worker's r o l e . Further.research into t h i s problem i s necessary. Two s o c i a l workers have met problems i n the working re l a t i o n s h i p as doctors have refused to share c o l l a t e r a l i n f o r -mation and two indicated that doctors are d i f f i c u l t to contact or do not respond quickly enough to requests f o r medical infor-: mation. One s o c i a l worker fe e l s that doctors treat c l i e n t s with disrespect and eight s o c i a l workers did not answer t h i s question. Table R. Problems Encountered by S o c i a l Workers in Individual Contacts with Doctors. D i f f i c u l t i e s Encountered Number of Times Mentioned Doctors underestimated s o c i a l and erriotional problems as factors i n i l l n e s s Doctors do not understand the role of the s o c i a l worker and the agency policy which she administers 7 Doctors counsel patients without an ade-quate understanding of personality dynamics or the patient's complex s o c i a l s i t u a t i o n Doctors refuse to share c o l l a t e r a l information 2 ' Doctors are d i f f i c u l t to contact or do not respond quickly enough to requests for medical information . .2 Doctors treat c l i e n t s with disrespect l ' Total 23 Doctors and S o c i a l Workers The s o c i a l workers' understanding of the tr a i n i n g provided in medical schools concerning s o c i a l work and the s o c i a l services, i s a p a r t i a l i n d i c a t i o n of the s o c i a l workers' awareness of the s k i l l s and knowledge that a doctor contributes to the medical team. Fi f t e e n of the s o c i a l workers indicated (see following table) that they understand, that doctors do take courses i n interviewing and counselling and eighp indicated that t h i s was not t h e i r understanding. Two s o c i a l workers did not answer t h i s question and two r e p l i e d that they did not know. The comment "more emphasis i s needed on t h i s " , was added to t h i s question. 1 79 This comment can be d i r e c t l y related to the c r i t i c i s m s that the doctors underestimate the psycho-social factors related to i l l n e s s and that they are counselling without an adequate under-standing of personality dynamics or the patient's complex s o c i a l s i t u a t i o n . Thirteen of the s o c i a l workers do not think that doctors are offered course material about the profession of S o c i a l Work and nine do. Two so c i a l workers did not answer t h i s question and two indicated that they did not know. "A minimal smattering", was the comment added. Fourteen of the socia-T workers understand that doctors do receive i n s t r u c t i o n about the s o c i a l services and eight r e p l i e d to the negative. One s o c i a l worker did not answer t h i s question and three do not know whether doctors are educated about such. One s o c i a l worker commented that the information about the s o c i a l services given to doctors i s limited and one s o c i a l worker f e l t ' that the orientation depends on the approach of the p a r t i c u l a r medical school and the acceptance of the medical professor of s o c i a l work. Table S. The Social Workers' Understanding of Medical  Education Concerning Social Work and the S o c i a l Services Doctors' Education . Yes No Total Interviewing and Counselling 15 8 23 S o c i a l V/ork, as a Profession 9 1 3 22 S o c i a l .Services '•' '•< 1 4 S 22 80 What the s o c i a l worker believes are her main contributions to the doctor, w i l l a f f e c t the way i n which she performs her duties and works with other team members. To a great degree, t h i s w i l l influence the doctor's awareness and u t i l i z a t i o n of s o c i a l work s k i l l s . Seventeen of the s o c i a l workers, who responded" tp the question about s o c i a l work contributions rendered to doctors i n (a) health agencies (b) hospitals and (c) welfare agencies, answered the three part question with one answer f o r a l l three parts. This can be^ seen i n the follow-ing table. Fourteen of the s o c i a l workers indicated that the main contribution rendered to doctors, i n a l l settings, i s to integrate the psycho-social assessment with medical findings into a co-ordinated plan f o r the patient. Two s o c i a l workers stated the main contribution was acting as l i a s o n between team members and two, the i n t e r p r e t a t i o n of welfare resources and the role of the s o c i a l worker. Table T. The S o c i a l Workers' Opinions as to the Main Contri-butions Which Can Be Rendered to Doctors i n Health  Agencies. Hospitals and Welfare Agencies Contribution Number of Times Mentioned Health Agency Hospital Welfare Agency Integrated psycho-social assess-ment with medical findings, into a co-ordinated plan for the patient. Liason among team members. Interpret the r o l e of s o c i a l work and s o c i a l welfare resources i n the community  1 ; ' ' ' " i •• "i m II i Total 14 2 2 18 14 2 2 18 14 2 2 18 81 Although d i f f i c u l t i e s i n working with doctors have been met by i n d i v i d u a l s o c i a l workers; i t was most important to t h i s study to ascertain whether these d i f f i c u l t i e s are being met by most s o c i a l workers. I f such Is the case, then both doctors and s o c i a l workers must take the r e s p o n s i b i l i t y f o r examining these d i f f i -c u l t i e s and make some e f f o r t to overcome them.' Team roles are t h e o r e t i c a l l y complementary and i f practice proves t h i s to be d i f f e r e n t , then e f f o r t s must be taken to make t h i s a r e a l i t y i n t h i s era of s p e c i a l i z a t i o n . Thirteen of the s o c i a l workers are of the opinion, as i n d i -cated i n the following table, that most s o c i a l workers experience d i f f i c u l t i e s i n working with doctors, as the doctors do not under-stand the role of the s o c i a l worker and the agency policy within which she works. Mine of the s o c i a l workers indicated that d i f f i -c u l t i e s are met due to the f a c t that doctors underestimate s o c i a l and emotional problems as factors i n i l l n e s s and f i v e f e e l that doctors are reluctant to share t h e i r s p e c i a l i z e d knowledge with s o c i a l workers. The question raised i n Chapter 2 regarding the time and specialized s k i l l s that doctors have i n order to counsel patients about emotional or s o c i a l problems appears to be of im-portance, as the s o c i a l workers are fin d i n g t h i s counselling some-what inadequate and f r i c t i o n producing. Two s o c i a l workers f e e l that d i f f i c u l t i e s i n the working r e l a t i o n s h i p , come as a resu l t of doctors counselling patients without an adequate understanding of personality dynamics or the patient's s o c i a l s i t u a t i o n , and . two s o c i a l workers stated that d i f f i c u l t i e s arose as doctors are 32 reluctant to consider s o c i a l work contributions. When doctors make private adoption placements and when they do not ref e r unmarried mothers to the proper resources, f r i c t i o n i s created i n the professional r e l a t i o n s h i p . This was the opinion of two s o c i a l workers. Two of the s o c i a l workers f e e l that d i f f i c u l t i e s a r i s e as doctors are reluctant to ref e r a patient to a p s y c h i a t r i s t , when the need i s indicated and one pointed out that d i f f i c u l t i e s are due to the doctor's lack of time and interest i n explaining i l l n e s s to a patient. Three of the s o c i a l workers did not answer the question, one claimed that no problems existed, and one did not know, as the medical section of the agency made the contacts with the doctors. i n Working with Doctors D i f f i c u l t i e s Encountered umber of Times Mentioned Doctors do not understand the role of the s o c i a l worker and the agency policy within which she works 13 Doctors underestimate s o c i a l and emo-t i o n a l problems as factors i n i l l n e s s 9 Doctors' are reluctant to share t h e i r s p e c i a l i z e d knowledge with s o c i a l workers 5 Doctors counsel patients without an ade-quate understanding of personality dynamics or the patient's s o c i a l situatior 2 Doctors are reluctant to consider* s o c i a l work contributions 2 Doctors make private adoption place-ments and do not r e f e r unmarried mothers to the proper resources 2 Doctors are reluctant to r e f e r a patient to a p s y c h i a t r i s t , when the need i s indicated [ .- 2 ••' Doctors lack time and interest i n ex-plaining i l l n e s s to a patient Total 36 C e r t a i n i n s u f f i c i e n c i e s e x h i b i t e d i n the p r o f e s s i o n a l r o l e performance o f s o c i a l workers are c r e a t i n g f r i c t i o n between the two p r o f e s s i o n s . I f s o c i a l workers are w i l l i n g t o make a r e a l -i s t i c assessment of such and then d e v i s e ways o f overcoming them; not only w i l l t h e standards o f p r o f e s s i o n a l p r a c t i c e improve, but a l s o i n c r e a s e d u t i l i z a t i o n of s o c i a l work s k i l l s b y 'doctors and members of the o t h e r h e l p i n g p r o f e s s i o n s , may r e s u l t . T h e r e f o r e , f o r the purposes of t h i s study, the s o c i a l workers were asked f o r t h e i r o p i n i o n s as to the d i f f i c u l t i e s encountered by d o c t o r s i n working with s o c i a l workers. E i g h t of the s o c i a l workers suggested, as i n d i c a t e d i n the f o l l o w i n g t a b l e , t h a t d o c t o r s have d i f f i c u l t i e s i n working with s o c i a l workers, because the l a t t e r a re unsure of t h e i r f a c t s . The r e s u l t o f such i s i n e f f i c i e n c y , i n d e c i s i v e n e s s , slowness and too much t a l k i n g . An equal number of the s o c i a l workers agreed to the f a c t t h a t s o c i a l workers do not understand t h e i r team r o l e as w e l l as t h a t of the d o c t o r s . Three of the s o c i a l workers i n d i c a t e d t h a t the use o f too much jargon la c o n t r i b u t i n g t o i n t e r - p r o -f e s s i o n a l f r i c t i o n . Two of the s o c i a l workers claimed t h a t d o c t o r s f i n d agency p o l i c i e s to be i r r i t a t i n g . The q u e s t i o n a r i s e s as to whether the s o c i a l workers who must a d m i n i s t e r these p o l i c i e s and govern t h e i r a c t i o n s a c c o r d i n g t o the d i c t a t e s of such, are f i n d i n g them e q u a l l y i r r i t a t i n g ^ 34 Table V. Opinions o f the S o c i a l Workers Concerning T h e i r  C o n t r i b u t i o n s t o I n t e r - P r o f e s s i o n a l D i s c o r d D i f f i c u l t i e s Number o f Times Mentioned S o c i a l Workers are i n e f f i c i e n t , l a c k of c l a r i t y about g o a l s , t h i n k i n g , i s d i f f u s e , too v e r b a l , unsure o f f a c t s , unable t o get t h i n g s done q u i c k l y and d e c i s i v e l y 3 S o c i a l Workers do not understand t h e i r r o l e on the team a s w e l l as t h a t o f the d o c t o r 3 S o c i a l Workers use too much jar g o n 3 S o c i a l Workers do not have s u f f i c i e n t m edical knowledge t o understand the medical a s p e c t s of i l l n e s s 3 P r o f e s s i o n a l j e a l o u s y , S o c i a l Workers are h o s t i l e and d e f e n s i v e due to h i g h e r s t a t u s accorded medicine 2 Agency p o l i c y i s f r u s t r a t i n g t o d o c t o r s . 2 T o t a l 26 There seems t o be some agreement between the d o c t o r s and s o c i a l workers as t o t h e d i f f i c u l t i e s encountered by d o c t o r s i n working w i t h s o c i a l workers. In Chapter 2, the d o c t o r s i n d i -cated t h a t s o c i a l workers were unsure o f t h e i r £aets, used too much jargon and have i n s u f f i c i e n t knowledge o f medi c a l f a c t s . I r r i t a t i o n w i t h agency p o l i c i e s was c l e a r l y s t a t e d . B e i n g aware of the d i f f i c u l t i e s encountered between team members i s one st e p toward s o l v i n g the complex problem. The next step, i s t o formulate suggestions as to how the f r i c t i o n might be reduced. Thus the s o c i a l workers were asked t o suggest I 85 what they might do to improve working relationships in their role of caseworker and in any other role in which they might function. Table W indicates that nine of the caseworke'rs f e l t that they must be more explicit in their interpretation of agency policy and the role of the social worker; Six of the caseworkers stated that improvement of social work s k i l l s and standards might improve working relationships and three f e l t that caseworkers need to extend more respect to the medical profession. Three of the social workers indicated that social agencies should establish a continuous public relations programme. They failed to state what role the caseworker might play in public relations as a staff member. One social worker f e l t caseworkers should take a inter-pretative role in medical education and four social workers did not answer the question. One stated she did not know. Ten of the social workers seem to agree that explicit interpretation is needed both to practicing doctors and to medical students. What should be involved in this interpretation was not clearly, outlined. The problem also arises, that in spite of the fact that interpretation to medical students i s indicated, the medical schools have to indicate their desire for such and even i f this i s the case, the content of course material may be limited due to the demanding medical curriculum. 86 Table W. Social Workers: Suggestions as to the Role Professional Discord Suggestions Number of Times Mentioned E x p l i c i t i n t e r p r e t a t i o n of the role ,of the, s o c i a l worker and agency po l i c y 9 Improve s o c i a l work s k i l l s and standards 6 S o c i a l workers need to extend more respect to the medical profession 3 S o c i a l agencies should establish a continuous public r e l a t i o n s programme 3 Social workers should take an i n t e r -pretative role i n medical education * 1 Total 22 S o c i a l workers, and i n t h i s p a r t i c u l a r instance, caseworkers, function i n many roles that do not s p e c i f i c a l l y involve c l i e n t s , but which are professionally oriented. As members of agency boards or community planning groups, they are concerned with the welfare of large numbers of people. As members of the professional organization, they devote,their' energies to helping the profession grow and develop. Concern with s o c i a l problems may lead s o c i a l workers to membership i n p o l i t i c a l parties and pressure groups. In t h e i r many roles , they have chances to interpret s o c i a l work, by deed and action. I t appears, i n the table following, that s i x of the s o c i a l • *r . workers f e e l that i n t e r p r e t a t i o n , whenever possible, i s one method of overcoming f r i c t i o n between s o c i a l workers and doctors, 87 The question arises as to the nature, content and presentation of the inter p r e t a t i o n . Three of the s o c i a l workers would encourage joint discussions between the professions at meetings of both professional organizations or at conferences, and three would involve doctors as members of agency boards and community plan-ning groups. One of the s o c i a l workers thinks that some d i f f i -c u l t i e s might be overcome i f the B r i t i s h Columbia Association of Soci a l Workers was more active i n public r e l a t i o n s and one sugges-ted that s o c i a l workers, assume the role of teachers, i n medical education. The answers to t h i s question are not too sati s f a c t o r y . Twelve s o c i a l workers did not answer t h i s question. The question, there-fore a r i s e s , as to whether caseworkers are l i m i t i n g t h e i r profes-sional problem solving role to one area of t h e i r functioning and by doing so, l i m i t i n g the solutions available to t h i s problem. Further research i s needed to determine what s o c i a l workers under-stand to be the expectations and r e s p o n s i b i l i t i e s inherent in t h e i r professional r o l e . Table X. Suggestions as to the Ways So c i a l Workers f i n  Other Professional Roles. Can Ameliorate, Inter-Pro-f e s s i o n a l Discord Suggestions Number of Times ^entioned_ Interpret S o c i a l Work wherever possible 6 Encourage joint discussion between the professions at meetings of the professional 3 . , organizations or at conferences Involve doctors as members of agency boards and community planning groups 3 The B r i t i s h Columbia Association of Soc i a l Workers must be more active i n public 1 relations Social Workers should participate i n ...medical—educati on _! S3 The s o c i a l workers were not only asked what could be done to a l l e v i a t e some of the d i f f i c u l t i e s between doctors and s o c i a l workers, but also where they thought the most e f f e c t i v e job. could be done to promote better working r e l a t i o n s h i p s . I t appears, from the following table that an equal number of the s o c i a l workers . f e e l that the r e s p o n s i b i l i t y l i e s at the administrative l e v e l as well as at the caseworker-doctor l e v e l , f o r promoting Co-oper-ation and co-ordination between doctors and s o c i a l workers. The B r i t i s h Columbia Association of S o c i a l Workers was designated by eleven s o c i a l workers, followed by public discussion and the univ e r s i t y as a body generally take the r e s p o n s i b i l i t y . Seven of the s o c i a l workers indicated that the r e s p o n s i b i l i t y l i e s at the supervisory l e v e l ; six with the school of s o c i a l work and f i v e with the Community Chest and Council. Four levels of responsi-b i l i t y were indicated under "Other", i n addition to the: above mentioned th i r t e e n . Two s o c i a l workers said they d i d not know. One comment added to t h i s question, indicated, that unless there i s adequate professional practice based on a firm grounding i n theory, a l l the other e f f o r t s would be useless. One s o c i a l . worker commented that more co-operation i s needed between the University of B r i t i s h Columbia School of S c o a i l Work and the University of B r i t i s h Columbia Faculty of Medicine, and another would recommend more jo i n t meetings between the B r i t i s h Columbia Association of S o c i a l Workers and The B r i t i s h Columbia Medical Association. 89 Table Y. The Social Workers' Opinions as to the Level at Which Most Can Be Done to Promote Co-operation and Co-ordination Level Number of Times If Mentioned t Supervisory Level 7 Administrative Level x3 Chest and Council 5 B r i t i s h Columbia Association of So c i a l Workers 11 The School of Social Work 6 The University Generally , 8 Public Dis cussion 10 Others 17 Total 77 Included under "Others" were: 1. Demonstrated e f f i c i e n c y , desire to co-operate, and sensi-t i v i t y to each other's needs at the caseworker-doctor l e v e l . (13 responses) 2; In the School of S o c i a l Work and Faculty of Medicine. (1 response) 3. In the ho s p i t a l setting where interns can learn by many contacts with s o c i a l workers. (1 response) 4. Doctors l e c t u r i n g at s t a f f meetings. (1 response) 5. Increase government rates paid to doctors f o r patients i n recept of Public Assistance, (1 response) An attempt was made to discover i f the agencies made'any attempt to promote r e c i p r o c a l awareness and u t i l i z a t i o n . A question was asked about the s t a f f development programme being devoted to increasing the professional s t a f f ' s knowledge of the ways private p r a c t i t i o n e r s and s o c i a l workers can work together. 90 Seventeen of the s o c i a l workers indicated that t h i s had not occurred, eight indicated i t had and one did not answer. Thirteen of the s o c i a l workers stated that t h e i r agency did not have-a l i s t of doctors from which the c l i e n t may choose, i f r e f e r r a l to a doctor i s indicated, nine stated i t did and four did not answer. The responses.to t h i s question are not s a t i s f a c t o r y . Contradictory r e p l i e s were returned from workers in the same agency. Some indicated they had t h e i r own l i s t s . One raises the question as to whether agency p o l i c y and procedure has been c l a r i f i e d on t h i s matter. Chapter k Relations Between Doctors and Social Workers: Some Provisional Conclusions The occurrence of specialized health and welfare services has not only given r i s e to large bureaucracies, but has also created interdependency between the two professions. The need then a r i s e s f o r int e r - p r o f e s s i o n a l relatedness and co-ordination of services, i n order to provide the means available to the population f o r the meeting of health and welfare needs. The objective of t h i s study was to assess the nature of the i n t e r -professional relatedness e x i s t i n g between doctors and s o c i a l workers i n one c i t y and the main concept evaluated was re c i p r o c a l awareness and u t i l i z a t i o n . Abstracting the two e n t i t i e s , health and welfare services, may seem to imply that they are the most important or most i n need of study and change. But the two e n t i t i e s must not be considered out of context and viewed as only phenomena e x i s t i n g and functioning i n a geographical area. They are much more. When combined with the other helping professions, they provide the populations' means of meeting health, educational, s o c i a l personal and s p i r i t u a l needs. Reciprocal Awareness and U t i l i z a t i o n As a frame of reference f o r the evaluation of r e c i p r o c a l awareness and u t i l i z a t i o n , f i v e questions were raised that 9 2 applied to the two professions, medicine and s o c i a l work. They are: 1. What contribution has been made by professional education to r e c i p r o c a l awareness and u t i l i z a t i o n between the pro-fessions of medicine and s o c i a l worker? 2. As doctors and s o c i a l workers encounter s i m i l a r problems in d a i l y practice, how does each profession manage those problems not considered to f a l l within t h e i r area of sp e c i a l i z a t i o n ? 3. What does each profession consider to be the s k i l l s and resources of the other? 4. What problems have been encountered i n trying to establish an integrated team approach? 5. What solutions may be offered to overcome barri e r s toward co-operation and understanding? In the community sampled the profession of medicine was represented by twenty-nine general p r a c t i t i o n e r s . The doctors, by t h e i r co-operation in the survey, indicated a d e f i n i t e i n t e r e s t i n discussing the r e l a t i o n s h i p of health to welfare services. The majority of the doctors took courses which offered information about the s o c i a l services and most of them rated t h i s education as inadequate. A small minority of the doctors were offered course material concerning s o c i a l work, as a profession. It appears that the majority of those who were offered t h i s information found i t adequate. Most of the doctors have had several years of experience i n the practice of medicine as well as residence i n the community. A great number of the doctors include a psycho-social assess-ment as part of t h e i r medical diagnosis and a l l of the doctors have patients whose i l l n e s s e s have no organic basis. The major 93 s o c i a l problems associated with such cases of i l l n e s s are family-problems, personality problems and problems of the aging. The doctors are doing a-considerable amount of counselling i n r e l a t i o n to these problems, as well as r e f e r r i n g t h e i r patients to a re-source that w i l l further meet t h e i r need. Of the resources u t i l i z e d by doctors, welfare agencies, follow p s y c h i a t r i s t s and health agencies, i n frequency of use. The resources of the City S o c i a l Service Department are u t i l i z e d more often than those of any other welfare agency. The main reasons f o r not u t i l i z i n g the resources of a welfare agency, although the doctors are aware of i t s function, are that patients have negative or mixed feelings about being referred, as well as, the fact that doctors believe the pressures and demands on the agency are so great that patients w i l l not receive enough time or attention. When r e f e r r i n g patients to a health agency, doctors, more often do not consider the available s k i l l s of the s o c i a l workers on s t a f f . Most of the doctors have been i n touch with the personnel of welfare agencies and most of them t r y to maintain contact with the agency a f t e r r e f e r r i n g a patient. A high percentage of the doctors have a Community Chest and Council Directory or other l i s t s of agencies and most of them consult the City Social Service Department i f they wish to learn more about available welfare services. The majority of the doctors recognized the fact that specialized t r a i n i n g was needed for s o c i a l work practice,: but 94 t h e i r understanding of the prerequisites for t h i s and the length of contemporary t r a i n i n g was not clear and somewhat outdated. The three s k i l l s of the s o c i a l worker of which the doctors are most aware are knowledge of community resources, arranging of f i n a n c i a l assistance, and securing shelter f o r homeless and unattached persons. The doctors are more aware of the pioneer s k i l l s of the s o c i a l worker but less cogent of the s k i l l s and methods developed i n the l a s t f i f t e e n years. Of p a r a l l e l consideration to the preceding information are the f a c t s , opinions and attitudes expressed by the s o c i a l workers about the doctors, as based on general knowledge and actual personal contact. The twenty-six s o c i a l workers who participated i n this survey represented three welfare agencies i n the community. The majority had received one year of postgraduate t r a i n i n g or i t s equivalent and a minority had attained the maximum standard of a Master of S o c i a l Work degree. A high percentage of the s o c i a l workers took courses which offered an understanding of the role of the doctor i n the treatment of i l l n e s s or suggested ways of working with doctors. However, opinions seemed to c o n f l i c t as to the adequacy of such course material, and most of the comments indicated that the material was taught i n d i r e c t l y rather than e x p l i c i t l y . Most of the s o c i a l workers have had a number of years of p r a c t i c a l experience both i n the welfare f i e l d generally, and i n the agency i n which they are now employed. 95 A l l the s o c i a l workers include an inquiry about the c l i e n t ' s state of health as part of t h e i r s o c i a l assessment and a l l counsel c l i e n t s about the s o c i a l aspects of health problems. A majority of the s o c i a l workers, while, counselling c l i e n t s about health problems, contact the c l i e n t ' s doctor i n order to esta b l i s h an integrated team approach. When r e f e r r a l s are made by doctors, most of the s o c i a l workers make an e f f o r t to contact the doctor f o r c o l l a t e r a l information. Indications are that the s o c i a l workers f e e l i t to be t h e i r r e s p o n s i b i l i t y for maintaining contact. Most of the s o c i a l workers have a good understanding of the doctors* education regarding counselling, the s o c i a l services and s o c i a l work as a profession. The majority of the s o c i a l workers indicate that the main contributions, rendered to doctors in a l l settings, i s to integrate the psycho-s o c i a l assessment with medical findings into a co-ordinated plan for the patient. Problems Encountered i n the Team Approach The most d i f f i c u l t i e s experienced by doctors, i n working relationships have been with s o c i a l workers i n welfare agencies, followed by s o c i a l workers i n hospitals and then i n health agencies. The major d i f f i c u l t i e s met i n both health and welfare agencies res u l t from agency p o l i c y as administered by s o c i a l workers. These include too much red tape, not enough resources, ' s o c i a l workers overworked and caseloads too high. Subsequently, the doctors indicated, that the d i f f i c u l t i e s they have encountered are due to the fa c t that s o c i a l workers are too t h e o r e t i c a l ; not r e a l i s t i c ; upset the patient; t r y to make medical decisions and 96 give medical advice; are i n s u f f i c i e n t l y trained; are poorly informed about the patient and breach the p r i n c i p l e of c o n f i -d e n t i a l i t y . In addition, the doctors c r i t i c i z e d the s o c i a l workers' lack of e f f i c i e n c y and competency as well as t h e i r a t t i t u d e . On the other hand the doctors f e l t that the s o c i a l workers' best contributions consisted of determining points at which help may be most productively given; arranging f o r material and environmental assistance; providing a good s o c i a l history; knowledge of resources; and maintenance of welfare services i n the community. D i f f i c u l t i e s met by most s o c i a l workers, i n working with doctors, are due to the fact that doctors do not understand the role of the s o c i a l worker and the agency policy within which she works; as well as, the fact that the doctors seem to underestimate s o c i a l and emotional problems i n i l l n e s s . The s o c i a l workers claim that the two main d i f f i c u l t i e s that doctors encounter i n working with s o c i a l workers are due to the fact that s o c i a l workers do not understand t h e i r role on the team nor that of the doctor. Also, s o c i a l workers are i n e f f i c i e n t , lack c l a r i t y about t h e i r goals, think d i f f u s e l y ; are too verbal; unsure of facts and are unable to get things done quickly and d e c i s i v e l y . Solutions to Overcome Barriers Toward Co-oper-ation and Understanding The discussion of solution depends upon c l a r i f i c a t i o n of the d i f f i c u l t i e s that both recognize as impeding co-operation. These have been outlined i n the preceding section. Both the 97 doctors and the s o c i a l workers agree that the i n e f f i c i e n t adminis-t r a t i o n of s o c i a l work s k i l l s i s creating f r i c t i o n . The doctors f e e l that agency policy and procedure i s contributing to i n t e r -professional dissention; and the s o c i a l workers indicated that the doctors' lack of understanding of the r o l e of the s o c i a l worker within the agency, as well as, t h e i r underestimation of the s o c i a l and emotional factors associated with i l l n e s s are factors which contribute to poor working re l a t i o n s h i p s . The doctors were not asked for t h e i r opinions on how the d i f f i c u l t i e s i n co-operation might be overcome. However, i n d i -cations of what these might be are inherent i n t h e i r c r i t i c i s m s of tvelfare services and s o c i a l workers. These would be an improvement of s o c i a l work standards and s k i l l s as well as a r e v i s i o n and review of the policy and procedure of some-welfare agencies. The s o c i a l workers suggested more int e r p r e t a t i o n on a case-worker-doctor l e v e l about the role of the s o c i a l worker and the policy she administers, as well as improving s o c i a l work s k i l l and standards. A few mentioned the need fo r s o c i a l agencies to establish a continuous public relations programme and the d e s i r -a b i l i t y of s o c i a l workers taking an interpretative role i n medical education. They indicated that the i n d i v i d u a l worker and the administrative s t a f f i n the agency, have an equal r e s p o n s i b i l i t y for carrying out such. Joint meetings between the professional organizations were suggested. The question arises as to whether these solutions o f f e r an a l l i n c l u s i v e answer to the stated problems. Reflection on the 98 material from the survey and impressions gained during the interviews, suggest that any e f f o r t s to increase co-operation w i l l not suddenly evolve from application of any or a l l these solutions. Rather the solutions w i l l come from within each pro-fession a f t e r a more detailed evaluation of t h e i r respective roles i n the community. The recommendations f o r the doctors and s o c i a l workers have been arrived at a f t e r reviewing not only the findings of the survey, but also l o c a l and national e f f o r t s at promoting co-operation and the l i m i t s inherent i n such programmes. The findings of the survey have been summarized i n the preceding paragraphs and a summary of e f f o r t s i n promoting co-operation w i l l precede the f i n a l recommendations. E f f o r t s at Co-operation: Medicine Because of the changes i n our c i v i l i z a t i o n and way of l i v i n g , which s i g n i f i c a n t l y a f f e c t the nature of i l l n e s s and i t s care, there has been an increasing awareness among medical educators of the need to give medical students an understanding of the s o c i a l and environmental problems of th e i r patients as related to the practice of medicine today. In 1941 the Association of American Medical Colleges appointed a sub-committee to explore the subject under the chairmanship of Dr. Jean Alonzo Curran, President and Dean of the Long Island College of Medicine. Using data from questionnaires which had been answered by sixty-eight, out of seventy-six medical schools, Dr. Curran compiled a progress report i n the teaching of s o c i a l and environmental factors by medical f a c u l t i e s and departments 99 of s o c i a l work i n teaching hospitals. In 1943 at Dr. Curran's i n v i t a t i o n the American Association of Medical S o c i a l Workers ^ appointed a committee to work with hi s committee. The d e l i b e r a t i o n of the committee c l e a r l y estab-li s h e d the p r i n c i p l e that the subject matter taught by a s o c i a l worker i s not " s o c i a l work" but c e r t a i n selected aspects f o r 2 the medical curriculum: The Study made by the American Association of Medical Social Workers in 1939 of this area of educational a c t i v i t y helped to c l a r i f y the fact that we should not be teaching s o c i a l work but rather the s o c i a l i m p l i -cations of i l l n e s s and medical care which the physician needs to understand for the practice of his own profession. The following recommendations were proposed by the Joint 3 Committee on Medical Education: 1. It was recommended that consideration of the three major aspects of i l l n e s s - physical, psychological and s o c i a l -are e s s e n t i a l in the practice of medical diagnosis and treatment. This concept implies that the exclusion of any one of these aspects i n the exploration and t r e a t -ment of medical problems, means that the study of the patient has been incomplete. 2 . • The medical student should learn to recognize these factors i n every case, to evaluate them i n r e l a t i o n to the medical problem and to assume r e s p o n s i b i l i t y (him-s e l f or through others) for the relevant problems, as a part of diagnosis and treatment. 1 The American Association of Medical S o c i a l Workers, o r i g i n a l l y a separate professional organization representing medical s o c i a l workers, became a part of the National Association of Social Workers i n 1955. 2 C o c k e r i l l , Elanor, "Widening Horizons i n Medical Education", Journal of Social. Casework. January 1 9 4 3 . Vol. 2 9 , p. 4 . 3 Ibid., pp. 5-6; 100 3. In order to assume t h i s r e s p o n s i b i l i t y the medical student must be helped to acquire the s k i l l of interviewing since t h i s i s the means through which he achieves understanding of a l l these facets of his patients' problems. The s k i l l s of interviewing, are based upon an understanding of the nature of the doctor-patient rel a t i o n s h i p and a d i s c i p l i n e d use of t h i s r e l a t i o n s h i p . Social casework has experience to share with the physician i n t h i s area of teaching of interviewing s k i l l s , 4. The capacity to work with other professional persons compromising the medical team i n the hos p i t a l or c l i n i c i s something that has to be acquired. Medical students need to learn about the various resources within the community upon which he might draw i n the care of his patient and that he should develop the capacity to make eff e c t i v e use of them. The composition and purpose of the Joint Committee established a precedent in furthering the relationship between the two pro-fessions. Each profession recognized the nature of th e i r i n t e r -dependence and made recommendations to co-ordinate t h e i r a c t i v i t i e s i n r e l a t i o n to medical education. S o c i a l work, represented by medical s o c i a l work, was designated an important role i n medical education. I f positive relationships can be established between the two professions i n the very early years of medical education, then l a t e r , vihen the student becomes a doctor, the effects of such w i l l benefit patients and pra c t i t i o n e r s i n both professions. The medical s o c i a l workers and the medical s o c i a l service depart-ments i n teaching hospitals are i n a position whereby they repre-sent s o c i a l work i n toto, to the medical student. How they carry out t h e i r role and function w i l l color the physician's attitude to and use of s o c i a l work and s o c i a l welfare services i n l a t e r years. 1 The Committee's recommendations affirmed the trend to the broadening and deepening of the concept of medical treatment 101 which inevitably means a more appropriate and meaningful use of s o c i a l work s k i l l s . This trend towards courses i n comprehensive medical care has been on the increase since the 1940's. Although by no means universal, an increasing number of medical f a c u l t i e s are expanding t h e i r medical curriculum to include such. Various methods of teaching have developed, such as lectures, seminars, case conferences, r e f e r r a l and consultation. Any one or a combination of these methods may be used. Medical educators, medical students and a member or members of the medical s o c i a l service departments work together, each bringing t h e i r unique professional c o n t r i -butions to bear on a p a r t i c u l a r case. Although the medical student may have gathered the s o c i a l data as part of his medical history, i t i s the s o c i a l worker's job to demonstrate how these p a r t i c u l a r f a c t s may be co-ordinated and interpreted, so that they form a conscise and meaningful s o c i a l assessment and a s o c i a l treatment plan. In t h i s p a r t i c u l a r way the medical student becomes aware of the s k i l l s of the s o c i a l worker and the deeper meaning of the s o c i a l h i s t o r y he has taken. In Vancouver, the University of B r i t i s h Columbia, Faculty of Medicine, and the Vancouver General Hospital Social Service Department, are working together i n t h i s area. The programme, ^ i n i t i a t e d by the Faculty of Medicine, f a l l s i n l i n e with the general p o l i c y that the medical students receive a modern and 1 Information obtained from interview with Miss A. Pumphrey, Director of Social Services, Vancouver General Hospital. 102 comprehensive medical education. Due to the increasing emphasis on the s o c i a l aspects of medical care, i t was f e l t advisable to i n i t i a t e such a teaching programme. The Director of the Soc i a l Service Department was requested by the Faculty of Medicine to work i n co-operation with members of the medical teaching s t a f f , to formulate and present the course. Course presentation has changed i t s form over the years. They have ranged from d i d a c t i c lectures, to seminars including medical students and members of the medical and s o c i a l service s t a f f s . At t h i s point i n time the seminar, "Use of Community Resources" has taken a new form. Each fourth year medical student must attend two out of four seminars, while on Outpatient Department r o t a t i o n . Cases active with the Soc i a l Service department are discussed i n the seminars. A medical hi s t o r y i s presented by a member of the medical f a c u l t y , which includes any s o c i a l data that the doctor has col l e c t e d . The medical students then discuss the implications of the history, why they would r e f e r the case to the s o c i a l service department and what s p e c i f i c request would be made. The s o c i a l worker, active on the case, then presents her assessment, plan and implementation of the plan. The l a s t minutes of the seminar are a question and answer period. Whenever possible emphasis i s placed on s o c i a l services outside the h o s p i t a l . The medical students are made, aware of the Community Chest and Council Directory of Welfare Services. A second teaching programme has been i n i t i a t e d recently by the Faculty of Medicine. Every f i r s t year medical student i s assigned a healthy family, which he carries i n sickness or health 103 f o r at least one year. He v i s i t s the family with a Public Health Nurse from the Metropolitan Health Unit. The s o c i a l work consul-tant, attached to the Metropolitan Health Unit i s available to the nurse and i f necessary to the student. This learning experience i s aimed at exposing medical undergraduates to a human group so that he may be i n a position to observe human in t e r a c t i o n . Obser-ving a family over a period of time enables a student to experience the hopes, aspirations and fr u s t r a t i o n s to which a l l people are exposed and which greatly af f e c t i l l n e s s . During the past two years the University of Alberta, Medical School, has also been involved i n designing and establishing such a programme. 1 Twenty family physicians are active p a r t i c i p a n t s . Each t h i r d year student i s assigned a family belonging to the practice of one of the p a r t i c i p a t i n g doctors. The student under-takes a detailed psycho-social medical assessment of the entire family. The significance of his observations and t h e i r i n t e r -pretation are then discussed at informal seminars. Attending the seminars are the family physician, a student group and a psychiatric s o c i a l worker. Spe c i f i c topics are assigned to the student; topics dealing with p a r t i c u l a r aspects of family and community health. The student draws on his observations of his pa r t i c u l a r family and uses them as the basis of his presentation. Following t h i s b r i e f presentation, an open and non-directive discussion i s held. 1 Green h i l l , Stanley. M.D. "Teaching the Undergraduate Mental Health and Family Care", Canada's Mental Health. March I963, Vol. XI, No. 3, pp. 20-25. 104 The medical s o c i a l worker i s playing an important role i n the education of medical students. She, representing her pro-fession, indicates the s k i l l s of a s o c i a l worker as well as her contribution to the medical team. The establishment of such teaching programmes, i n themselves, indicate medicine's increasing awareness and u t i l i z a t i o n of the s k i l l s and resources of s o c i a l workers. Whether these teaching programmes are achieving t h e i r t h e o r e t i c a l goals i s questionable. The undergraduate medical student, i s r i g h t f u l l y more concerned about the physical aspect of i l l n e s s and disease and may tend to f e e l that these seminars are time consuming and superfluous. As the seminars occur i n the same sequence with courses i n medicine, which are more demanding, and which may be more time or interest consuming, then the former i s l i k e l y to su f f e r . The nature of the rela t i o n s h i p between the medical and s o c i a l service s t a f f s w i l l greatly a f f e c t the seminars. I f the teaching members of the medical f a c u l t y are doubtful about the contribution made by s o c i a l workers, they may have some d i f f i c u l t y i n wholeheartedly p a r t i c i p a t i n g i n the seminars. Interns and residents are further exposed to s o c i a l work s k i l l s as they carry out t h e i r duties i n the teaching hospitals. In most large hospitals s o c i a l v/orkers are assigned to a s p e c i f i c ward or wards. They are available for consultation at a l l times as well as acting on r e f e r r a l s made by the doctors. Conferences may be held concerning a s p e c i f i c patient and his family. Occasionally these conferences w i l l include s o c i a l workers from agencies outside the h o s p i t a l as well as concerned members of 1 0 5 other helping professions,, Further seminars or classes may-be avai l a b l e , as well as the emphasis placed on the values of the s o c i a l workers 1 s k i l l s by the teaching doctors in ward rounds,, In the Vancouver General Hospital, the framework f o r i n -creasing the young doctor's awareness and u t i l i z a t i o n has been established. An orientation lecture provided at the beginning of the year i s attended by a medical s o c i a l worker, as well as the chiefs of the numerous medical services. Once a week s o c i a l work rounds are undertaken with residents, interns, nurses, and students i n attendance. These rounds are conducted by the s o c i a l worker attached to the ward and i n ef f e c t i t i s her report to the doctors and s t a f f personnel who have made r e f e r r a l s to her. St a f f seminars are held i n the Outpatient's Department with the s o c i a l worker i n attendance. A yearly seminar i s provided for residents and interns with the s o c i a l worker attached to the service. The focus of the seminar i s s o c i a l work and the s o c i a l services. The problems presented i n increasing the residents' and interns' awareness and u t i l i z a t i o n are manifold. The education received i n t h i s area by the interns and residents varies accord-ing to the medical school from which they graduated and the experiences that they have had. fcAttitudes, desire to learn and co-operate, and knowledge w i l l vary with each i n d i v i d u a l . Too, we again f i n d t h e i r focus on physical medicine and the degree to which they.are w i l l i n g to enlarge t h e i r focus xtfill depend on many factors. The relationship of the in d i v i d u a l worker v/ith the intern or resident, then becomes most important. What gaps i n 106 knowledge, any change i n attitude that cannot be dealt with on a formal learning basis, can be dealt with by the in d i v i d u a l worker. Her ro l e then, w i l l be p a r t i a l l y educational and accord-ing to her knowledge, interest and s k i l l , she w i l l be able to increase the physician's knowledge of medical s o c i a l work i n pa r t i c u l a r , and s o c i a l work and welfare services i n general. Recommendations for the Doctors The following recommendations for the doctors o f f e r a gradual approach to at t a i n i n g the desired solutions: 1 . There should be detailed consideration of the impact of s p e c i a l i z a t i o n of functions and''bureaucratization of the practice of medicine. * 2 . The doctors should review the concept of comprehensive medical care and i n doing so determine t h e i r responsi-b i l i t y f o r meeting the s o c i a l and personal needs of t h e i r patients. 3. Medical educators should determine the various helping professions with whom doctors must co-operate in' order . to give patients the best medical care and i n doing so, prepare the medical student f o r his role i n these teams. This w i l l mean r e v i s i o n or expansion of some course materials, which w i l l i n p a r t i c u l a r , give the medical student an understanding of contemporary s o c i a l work s k i l l s and the role of the s o c i a l worker in the agency. 4. Consideration should be made of the role of the profession of medicine as an instrument of s o c i a l change and in s o c i a l policy formation. It i s anticipated that the preceding l i s t of recommendations have been considered i n part or i n t o t a l by the various medical organizations. But It seems advantageous in t h i s community that the doctors reconsider t h e i r role and function i n order to f a c i l i -tate co-operation and understanding with a l l the helping professions, p a r t i c u l a r l y s o c i a l work. » 107 E f f o r t s at Co-operation: • So c i a l Work and Social Welfare Social work education has changed i n length, content and emphasis over the years. As s o c i a l work received more recog-n i t i o n by society, as a profession, the need for two years, rather than one year, of postgraduate t r a i n i n g , became evident. Some schools of s o c i a l work have i n i t i a t e d post-Master of Social Work programmes as well as Doctoral programmes. The adaptation of p s y c h i a t r i c , medical and s o c i o l o g i c a l concepts into the theory of s o c i a l work, gave depth and new emphasis to the course material. The emphasis on "s p e c i a l i z e d " s o c i a l work practice, resulted i n course material which prepared s o c i a l workers for work i n one pa r t i c u l a r f i e l d such as medical, psychiatric and school s o c i a l work. Recent developments are leading to another approach. The increasing interest i n a comprehensive view of s o c i a l work practice, and the determination to i d e n t i f y the common elements of practice, made i t possible for s o c i a l work educators to start further back; to teach theory which w i l l provide a frame of reference r e l a t i n g to the basic core of s o c i a l work. This i s known as the generic approach and i t emphasizes s p e c i a l i z a t i o n by method rather than by setting. Thus .social work students, are not e x p l i c i t l y taught how to work with doctors or ether members of the helping professions. Rather the;emphasis i s on the importance of u t i l i z i n g the team approach, s e l e c t i v e l y , regard-less of the agency i n which the s o c i a l worker i s employed. Whether or not the s o c i a l work student needs e x p l i c i t i n s t r u c t i o n concerning the s k i l l s of the doctor and the role of the s o c i a l 103 worker on the medical team, i s a question that was partially-studied i n Chapter 3 . The educational opportunities whereby the s o c i a l work student may increase her awareness and u t i l i z a t i o n of medical s k i l l and resources f a l l into two main c l a s s i f i c a t i o n s : (a) class room lectures (b) f i e l d work experience. The s o c i a l worker's role i s to maintain, restore or enhance s o c i a l functioning. An important part of s o c i a l functionings i s physical functioning. In the Human Growth and Behavior sequence, both at the University of B r i t i s h Columbia, School of Social Work, and at other schools of s o c i a l work, the student i s taught about the meaning of i l l n e s s and the importance of adequate and immediate medical care f o r the c l i e n t who i s i n need of i t . Members of the Faculty of Medicine l e c t u r e to students on the normal pattern of physical growth and development. Student s o c i a l workers are taught that physiological causes may underly many cases of s o c i a l dysfunctioning and that i n most cases i t i s wise to obtain a medical report of the state of the c l i e n t ' s health. In cases where c l i e n t s do not have a doctor, or cannot afford medical services, i t i s the s o c i a l worker's role to d i r e c t him to the proper resources. In the methods courses, p a r t i c u l a r l y casework, the emphasis i s placed on developing knowledge and s k i l l in the use of community resources; The s o c i a l worker must have a thorough grounding of knowledge as to the socio-economic factors i n the community which have an influence upon indiv i d u a l s ; population make-up and trends, I n d u s t r i a l and health conditions; history of the community, p o l i t i c a l or 1 0 9 government structure; educational provisions and standards; r e l i g i o u s influences; e t h i c a l standards and so f o r t h , -j. Because of t h i s knowledge, the s o c i a l worker w i l l come to under-stand s o c i a l needs and comprehend the resources for meeting such needs. The s o c i a l work student i s taught to see the agency as a part of a c o n s t e l l a t i o n of community resources. Knowledge of the various community resources includes understanding the personal, s o c i a l and group needs which the agency or professional p r a c t i t i o n e r s are set up to meet, t h e i r diverse origins and auspices, t h e i r varying structures, functions and concepts of service and the degree and quality of t h e i r i n t e r r e l a t i o n s h i p . Co-operation with educational and r e l i g i o u s organizations has been a long standing accepted obligation of s o c i a l work. In addition, r e f e r r a l to medical, nursing, dental and s i m i l a r resources as well as employment and legal f a c i l i t i e s has increas-ingly been refined as a c h a r a c t e r i s t i c form of service based on established practices of inter-agency or inter-professional collaboration. Health needs are seen i n t h e i r relationship to the c l i e n t ' s requests and to other problems and treatment i s geared to foster the t o t a l well being of the i n d i v i d u a l and family. The student s o c i a l worker learns to appreciate and to interpret 1 Hamilton, Gordon, Theory and Practice of Social Casework, Columbia University Press, New York, p. # 4 . 110 not only his own agency but also other agencies i n the f i e l d of s o c i a l welfare and health. This emphasis on co-operation i s derived from the fact that the t y p i c a l s o c i a l case i s complex and has many facets. Every s o c i a l work student at the University of B r i t i s h Columbia, spends two days a week i n a welfare agency, under a qu a l i f i e d supervisor. It i s here that theory i s put into practice. Depending on the function of the agency and the nature of the caseload, the student comes into contact with other-agencies and professional p r a c t i t i o n e r s such as doctors. I f a l l i s favourable he w i l l learn to use medical resources i n such a way as to benefit his agency, c l i e n t and the doctor. The students placed i n medical or psychiatric settings w i l l gain more knowledge and experience i n t h e i r working relationships with medical p r a c t i t i o n e r s . Nonetheless, students i n welfare agencies can acquire valuable s k i l l s , increase t h e i r awareness and u t i l i z a t i o n of medical resources. There i s no doubt that the s k i l l s acquired vary greatly from student to student and from school to school, depending on the varying curriculum and f i e l d placements. Also, there are s o c i a l workers who have not graduated from schools of s o c i a l work. This complex si t u a t i o n and many variables w i l l a f f e c t the relati o n s h i p between the two professions. The role of the agency i n increasing r e c i p r o c a l awareness and u t i l i z a t i o n i s an important one. There i s a dearth of I l l l i t e r a t u r e or s t a t i s t i c s i n t h i s . f i e l d and i t appears that t h i s role i s underestimated or overlooked. Members of the medical profession are becoming more important i n the role of policy formation, p a r t i c u l a r l y i n private agencies: The business e l i t e coupled with high status lawyers and doctors play a prominent role i n the control of these bureaucracies. Working out a s a t i s f a c t o r y r e l a t i o n s h i p with these men in the formulation of welfare p o l i c y . i s a major problem f o r welfare professionals.^ The nature of the presentations, and reports made by executive directors and members of the s o c i a l work s t a f f w i l l a f f e c t the doctor's impressions of the s o c i a l work profession. This w i l l l a t e r be transmitted to working colleagues. Many public and private agencies have doctors attached to t h e i r s t a f f . P s y c h i a t r i s t s and other s p e c i a l i s t s are often hired as consultants. Staff development and i n - t r a i n i n g programmes may be dedicated to enlightening the s o c i a l work s t a f f on how to improve working r e l a t i o n s h i p s . The Family Service Agency of Greater Vancouver i s just one example of the role an agency can assume i n heightening r e c i p r o c a l awareness and u t i l i z a t i o n . In the l a s t three years greater e f f o r t s have been made by the Family Service Agency i n t h i s d i r e c t i o n . These e f f o r t s take the following forms: 1 Wilensky, Harold, L. and Lebeaux, Charles, N. I n d u s t r i a l  Society and S o c i a l Welfare. Russell Sage Foundation, New York, 1958. 2 Information was obtained from an interview with Mr. D. Thomson, Executive Director, Family Service Agency of Greater Vancouver. 112 1. The agency credo i s that the most e f f e c t i v e way to improve relationships i s on the basis of a personal, face to face consultation. Thus selected s p e c i a l i s t s , chosen on the basis of previous interest or treatment of Family Service c l i e n t s , are paid to act as consultants either at s t a f f meetings or for i n d i v i d u a l workers. 2. There has been d i s t r i b u t i o n of explanatory or interpretive material to the medical profession of Vancouver. This material has included personal l e t t e r s which include b r i e f descriptions of the services offered, how to r e f e r , and brochures f o r the doctor's use, when r e f e r r i n g patients. 3. Attempts to gain access to medical publications have been made. Agency personnel have written a r t i c l e s f o r the B r i t i s h Columbia Medical Association publication. These a r t i c l e s have emphasized the Hornemaker services ad adminis-tered by the Family Service Agency. Hornemaker services are stressed as any application f o r such, i n order to be accepted, must have a medical opinion attached to i t . ^ 4 . The agency has made i t known that s t a f f members are available to speak at medical conferences or on panels. 5 . The Board membership of the Family Service Agency represents a cross section of the community. The medical profession i s always included* E f f o r t s are made to insure that the repre-sentative of the medical profession i s a s t a f f doctor at one of the Vancouver h o s p i t a l s . This doctor i s then used as 113 l i a s o n , p a r t i c u l a r l y when the agency s t a f f are seeking information about hosp i t a l i z e d c l i e n t s . Recommendations for So c i a l Workers The following recommendations for the s o c i a l workers o f f e r a gradual approach to at t a i n i n g the desired solutions: 1. So c i a l work educators should re-evaluate the preparation that s o c i a l work students receive for a r o l e i n the medical team, both inside and outside the h o s p i t a l , as well as teams consisting of members of the other helping professions. 2. Standards of employment and the quality of the s o c i a l work s k i l l s practiced, should be reviewed by some welfare agencies with a view to improving such. 3 . The welfare agencies most u t i l i z e d by doctors should examine the important role they have i n promoting co-operation and co-ordination. 4. Some welfare agencies should consider the p o s s i b i l i t y of establishing a public r e l a t i o n s programme as well as i n i t i a t i n g a s t a f f development programme directed at increasing r e c i p r o c a l awareness and u t i l i z a t i o n between doctors and welfare agencies as well as the other helping professions. 5. The s o c i a l and personal needs of the population should be studied i n r e l a t i o n to the available welfare services and the v i t a l role of the caseworkers i n providing information about unmet needs should be considered and emphasized. 6. P r i o r i t i e s i n welfare services should be established that w i l l provide d i r e c t i o n to the appropriate a l l o c a t i o n of funds and personnel. 7. Consideration of the preventitive r o l e , that should be inherent i n s o c i a l work and how other helping professions, such as medicine, may contribute to t h i s role, should be made. As i n the case of the recommendations f o r the doctors, i t i s anticipated that the above have been considered i n part or i n toto by the various national welfare bodies. However, consider-ations of these recommendations should provide a framework for 114 taking i n i t i a l steps toward resolving the basic problems i n interprofessional r e l a t i o n s h i p s . Conclusion This project, a f i r s t study with small samples, surveyed the health and welfare services- i n one community on a general, pragmatic l e v e l . This approach offered a p r a c t i c a l understanding of the circumstances that made assessment possible. The advan-tages and re s u l t s of t h i s approach w i l l be amplified only as simi l a r research projects are completed. Suggested areas for further research include. 1. Repetition of a sim i l a r study including other samples of general p r a c t i t i o n e r s and s o c i a l workers. 2. Repetition of a si m i l a r study, l i m i t i n g i t to doctors and s o c i a l workers p r a c t i c i n g i n a smaller geographic locale in order to determine the relat i o n s h i p between geographic proximity and the nature of the exis t i n g co-operation and co-ordination of services. 3. Repetition of a s i m i l a r study to determine the degree of r e c i p r o c i t y e x i s t i n g between other medical s p e c i a l i s t s and so c i a l workers such as nurses, obstetricians or i n t e r n i s t s . 4. A survey of the l i t e r a t u r e and research related to unstruc-tured team r o l e s , with a view to compiling a t h e o r e t i c a l body of knowledge which would be available to members of the helping professions. The conclusion that can be reached, as a re s u l t of thi s study, i s that although r e c i p r o c a l awareness and u t i l i z a t i o n between doctors and s o c i a l workers does exist, to some extent, i t i s hampered by f a u l t y and h o s t i l e communication. Thus the problems encountered are multiple and of major proportion. Medical education intended to increase the doctors' aware-•;. 115 ness, has been deemed inadequate. The doctors are unaware of recent developments i n s o c i a l work education, s k i l l s and methods. Indications are that doctors are not u t i l i z i n g welfare services, although they are aware of t h e i r purpose and function; and that they are counselling patients about s o c i a l problems without a comprehensive understanding of personality dynamics and the necessary time that t h i s form of counselling demands. Doctors are u t i l i z i n g the s k i l l s and resources of health personnel more than those of welfare personnel. The s o c i a l workers, on the other hand, appeared to be more aware of the s k i l l s and resources of medicine, although t h e i r expectations of the doctors were somewhat high and u n r e a l i s t i c . S o c i a l work education, i n preparation f o r such, was somewhat nebulous and i t appears that experience i n the welfare f i e l d was responsible f o r heightened awareness. The s o c i a l workers indicated t h e i r willingness to establish an integrated team approach and take the r e s p o n s i b i l i t y f o r t h i s , although there seems to be some confusion as to the role they play on the team. An understanding of the problems encountered by both professions i n working with each other was evident, but the solutions offered appeared limited and there was l i t t l e agreement on which approach was most f e a s i b l e . As mutual awareness between the two professions i s limited, i t i s important to indicate why more would be desirable. Increased awareness would insure the most e f f i c i e n t and adequate care f o r individuals and groups. However i t does not stop at that but 116 continues as a means to the larger and more constructive end of creating a well informed professional community. I f th i s were not attained s o c i a l progress would be hindered and the many groups and professions sharing the concern of s o c i a l work would not be able to f u l f i l l t h e i r own r o l e s . The three .general gains from more mutual awareness among the helping professions are: 1. Maximum use of community resources to meet e x i s t i n g needs. 2. Increased a b i l i t y to detect unmet needs. 3o Potential to bring about change to meet unmet needs. APPENDIX A L e t t e r to the Doctors and  Q u e s t i o n n a i r e f o r the Doctors THE U1UV2RSITY OF BRITISH COLUMBIA. School of Social Work Dear Dr. RE; CONTACTS WITH SOCIAL WORK As part of ray post-graduate course in Social Work, I an conducting an exploratory survey of tho use of welfare service*] by general practitioners in Vancouver. I can only get infornation vith sufficient coverage by canvassing a large number of doctors, and I realize that this means making demands on busy men. But the questionnaire has been cut down to essentialsj and I am hopeful -it w ill not take up too much of your ti a e 0 If you would sooner have me make an appointment to cone for an interview with you for half-an-hour, please let me know, and I will telephone your office. Otherwise, please return the completed form, i f possible, within the next tyro weeks. The returns w i l l be analyzed statistically only, i.e., there w i l l be no mention  of any individual doctor by name. YThether or not you feel able t6 participate, it,would be nuch appreciated i f you would f i l l up and return the slip at the bottom of xnis letter,,so that 1 shall be able to validate my sample. • . With many thanks, (Miss) Shirley Moscovich, B.A., B.S.W., (M.S.W. Student) 1. I am willing to participate; and your questionnaire will be returned shortly...« .•». 2. I would prefer you to arrange an interview*. 3, I am unable to help you because $ a. Contacts with social workers or welfare agencies are exceptional in my practice.,,, b. I have no opinions, favourable or unfavourable, about social work....• c. Other (please state).*-»*'*'««.'..»..•««.*»*•.•«..*.«.».»«»...«',»..«•««.,««.«.,»..,, Doctor's Contact? with Welfare 4 g e g s i e s A 1 0 Bo you hava aooo patients with complaints of physical illness, fox which there appears to bo oo organic basis? Yess.o« No<jo*o If mYQS w, how many would you estimate you treated in a representative this year? 0-3ooooo 6-10,oooo 10 or oore 0 0»oo If "Tea" would you indicatD idiich of the factors listed below, night bo causative in such cases of illness. a Q Problem with members of the family. <MO</* t>. Financial problens such as debt or inadequate incooe.-...»» c 0 Personality disturbances, 3uch a3 neuroses or nild psycho3e80..»»» d 6 Problens of the aging, such as loneliness, boredom, or feelings of being U UQOleSSoe.evo e 0 Difficulties in adjusting to disability*..... f o. Problens centering around employment, such as boredom with job or job too dooanding for various reasons....,, ' g 0 Others (oxplain),..,.. ...»•.-....•••«••••.••••••....•••••.•.••'.••••••••••••»••• If "Yes", how do you treat such illness? &„ Discuss problem with patient and/or counsel hin about i t . . . . . . be. Refer patient to a resource'that will further noet his need...... c. Treat illness as i f i t had organic basis...... d. Others (explain. .-.......... e... »o.............. . 2.. Do you include any assessment of social or family factors as part of your diagnosis 1 9 Usually 0*.. 2 , occasionally.-.3. never.... Referrals 1. V:-.ich" 6 f the following rosources did you use nost frequently in the last two weeks? (i.e. "refer" a patient, by giving information or telephoning directly or contacting on a patient's behalf) lo Psychiatrist.,,. 2 . Lawyer.,.. 3. Minister.... 4. "Jelfaro Agency. 5 0 Others (please state).......,.,,».,.»,... • • 2 . After referring a patient to a Welfare Agency, do ycu maintain contact (either by telephone or lottor) with the Agency? Yes.... No.,.. 3 0 List the three Welfare Agencies that you deal with most often, in order of frequency, l . o . . . . . . . a . . . . • • « . » . - 2 . , * > « O B » * » • » & • . . • . • . 3 o . . . . . » « » » • » . o . « » » » . « If you know of a Welfare Agency that night meet a pationt's noed and you do not uso i t p what are your most common reasons? a 0. Patient has nogative er mixod feelings about being referred...... b. Iressuros and demands on the A g e n c y are so great that you feel your patient would not receive enough time or attention.«... . Co. The inadequacies of the social workers are such that you feel you could 'batter handle the problem...».,-do. Other(oxplain)........» . . . , , 0 .«4»».»...**..*......o..«.o.»..,.. »«««• - 2 -C . W o l f a r e arid H e a l t h A g e n c i e s 1. H a v e a n y o f y o u r p a t i e n t s h a d c o n t a c t w i t h a W e l f a r e A g e n c y ? Y e s . . . . N o . . . . ( C o o n e n t ; i f n e c e s s a r y , . . . . . ) 2. H a v e y o u e v e r t a l k e d w i t h a s o c i a l w o r k e r a b o u t a n y c a s e s ? Y e s . . . . N o . , . . ( C o o n e n t ; i f n e c e s s a r y . . . . . . . « . . . . . . • • • . • « . . ) 3. H a v o y o u o v e r t a l k e d w i t h a d i r e c t o r or* a d m i n i s t r a t o r o f a W e l f a r e A g e n c y , a b o u t a c a s e ( s ) ? Y e s . . . . N o . , . . C o m o n t . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. A r e y o u a c q u a i n t e d w i t h t h e C o u n u n i t y C h o s t D i r e c t o r y o f M a j o r W e l f a r e S o i r v i c e s ? Y e s . . , . N o , . . . I f " H o " , d o y o u h a v o a n o t h e r d i r e c t o r y o r l i s t f n g o f - f o l f a r e S e r v i c e s ? Y o s 0 . . . N o , . . . C o c m o n t . , . • 5 . W h a t s o u r c e d o y o u c o n t a c t i f y o u w i s h t o k n o w n o r c a b o u t W e l f a r e S o r v i c c s i n y o u r c o a n u n i t y ? 6, D o e s . t h e f a c t t h a t s o c i a l w o r k c o u n s e l l i n g i s p r o v i d e d i n t h e a g e n c i e s l i s t e d b e l o w , o v e r o n t e r i n t o y o u r d e c i s i o n i n m a k i n g a r e f e r r a l t o t h e n ? Y e s . . , . N o . . . . O c c a s i o n a l l y . . . . . . A G E N C Y Y N .0 A G E N C Y Y N 0 _ G . F . S t r o n g R e h a b i l i t a t i o n C e n t r e . A l c o h o l i s m F o u n d a t i o n A r t h r i t i s a n d R h e u n a t i s n S o c i e t y C a n c e r I n s t i t u t o C e r e b r a l P a l s y F o u n d a t i o n O t h e r Y : Y e s N : No 0 : O c c a s i o n a l l y D , S o c i a l W o r k e r s 1. W h a t i s y o u r u n d e r s t a n d i n g o f t h o q u a l i f i c a t i o n s n e e d e d b y S o c i a l W o r k e r s i n o r d e r t o p r a c t i c e ? 1, S e n i o r m a t r i c u l a t i o n . . . . 2. B a c h e l o r o f A r t s . . . . 3. S o c i a l W o r k D i p l o m a 4 0 P e s t g r a d u a t e t r a i n i n g - o n e y e a r . . . . 5. P o s t g r a d u a t e - t w o y e a r s . . . . 2 0 W h a t , i n y o u r o p i n i o n , a r e t h e p a r t i c u l a r s k i l l s o f t h e s o c i a l w o r k e r ? 1. A r r a n g i n g o f f i n a n c i a l o r rate-rial a s s i s t a n c e . . . . * 2. ; S e c u r i n g s h e l t e r a n d c a r e f o r h o m e l e s s o r u n a t t a c h e d p e r s o n s , . . . . 3. K n o w l e d g e o f c o r . u n i t y r e s o u r c e s t o m e e t a v a r i e d m r . b e r c f n e o d s . . . . . 4. E f f e c t i n g e n v i r o n m e n t a l c h a n g e s 5. S p e c i a l i z e d c o u n s e l l i n g s k i l l s . . . . . . 6 . . G u i d i n g r . c r . b e r s o f - r o u p s i n v a r i o u s p r o g r a n r . e a c t i v i t i e s . . . . * 7. C o n d u c t i n g g r o u p t h e r a p y s e s s i o n s i n n o d i c a l s e t t i n g s . . . . . 8. P l a n n i n g f o r t h e p r o v i s i o n a n d m a i n t e n a n c e o f w e l f a r e s e r v i c e s i n t h e , • c o r x r u n i t y . . . . • 9. O t h e r s ( e x p l a i n ) . , -3-G^neral 1 0 What have been the nain types of difficulty you have experienced in working with social workers? (a) in hospitals, clinics,, ............. (b) in health agencies.......... • (c) in welfare agencies. • ;,...........« 2. What complaints about social workers do you think have most substance? a. They are insufficiently tr- 'n b. They take insufficient account of ........ medical facts., .c. Upset patients by to. much d Use too much "jargon"....,...... probing..,«.. .0 Usually unable to carry out your requests.o.. . 3 0 If your experiences with social workers have been favourable, what do you regard as their best contributions?.. • 4. Did your medical education include any courses concerning the social services? Tea,... No.... tfould you describe thorn as: adequate..,, or inadequate..., in tfeio aroo? 5. Did your medical education include any courses which discussed social work as a profession? Yes.... . No.... Would you describe them as: adequate.... or inadequate.... in this area? 6 . For how many years havo you been in private practice in Vancouver.......... in Canada0........ APPENDIX B. Questionnaire f o r the S o c i a l 'Workers Relations between Social Workers  and Private Practitioners Name of Agency.... Type of Service... A. Counselling A. Do you enquire into the nature of health problems being experienced by a client? (i.e. illness, the meaning of illness to a client, difficulties in paying doctor's b i l l s , difficulties in following the doctor's treatment programme) Yes.... No.,.. If "Yes", is this done: Routinely..... Occasionally..... Only when the client presents this as a problem...., B. Do you counsel clients about the social aspects of health problems? Yes No If "Yes", do you contact the client's doctor? Yes.,... No If "Yes", to the above question, what is your purpose in contacting the doctor? 1, To ascertain the nature of the illness,,,,, 2 , To discover the treatment recommended,,,,., 3, To discover how well the client is following treatment..,,. 4, To discuss with the doctor the fact that his patient is being counselled at the agency 5, Others (explain),.. .....,..•..•...,..*...,,. B. Referrals . A. How many of your clients were referred to the agency, in the last month, by a private practitioner?).,,..,,,.. B. Iftien a private practitioner refers to a client, do you make an effort to contact the doctor for collateral information? Yes.... No.,.. C. How many clients did you refer to a private practitioner in the last month?,.... D. After referring a client to a private practitioner, do you maintain contact with the doctor? Yes.... No.... / If "Yes", is this done: Routinely...,, Occasionally E. Have you encountered any problems in trying to work with private practitioners on a case? Yes,,,., No,,.., If "Yes", please explain........... ...... C, Doctors and Social Workers 1. What in your opinion are the main contributions which social workers can render doctors (a) in health agencies , (b) in hospitals, clinics etc. ........ (c) in private practice 2. What in your opinion, are the main difficulties social Workers experience in working with private practitioners? 3. What in your opinion, are the main difficulties private practitioners experience in working with social workers?,.....,.,......,........... 4. What do you think that social workers can do to alleviate some of difficulties (a) as caseworkers...... - (b) in other capacities,. ,, , 5. Is i t your understanding that medical training includes courses i n inter-viewing and counselling? Yos.... No.... 6. Is it your understanding that medical training includes courses about Social Work, as a profession? Yes.... No.... 7. Is i t your understandirgthat medical training includes courses concerning the social services? Yes.... No.,,, 8. Where do you think most can be done to promote better working relationships between private practitioners and social workers, ' (a) supervisory level.... (b) administrative level... (c) Chest and Council... (d) British Columbia Association of Social Workers... (e) The School of Social Yfork... (f) The University generally.,, (g) Public discussion... (h) Other (explain)..., , ,,, Your own Background and Experience 1. How many years have you been in practice?,........ 2. How long have you been working in the agency in which you.aro presently employed? , 3. Does the agency have a l i s t of private practitioners from which the client may chose, i f referral to a private practitioner is indicated? Yes... No... 4. Has any part of the staff development programme in your agency been devoted to increasing the professional staff's knowledge of the ways private prac-titioners and social workers can work together for the benefit of the client Yes... No... 5. Did your Social Work education include course material concerning: the doctor's role in the treatment of illness? Yes... No,., 6. Did your Social Work education include course material that helped you in understanding the role of the .social worker in working with private prac-titioners, when they referred a patient to a Welfare Agency? Yes,,, No... Comment.. • 7. Did your Social Work education include course material that helped you in understanding the role of the social worker when working with a client with a health problem, who was not referred by a private practitioner? Yes... No... Comment. • 8. Please l i s t your Diplomas or Degrees and the Institution(s) from which you received them. ,, 9. Year of graduation from School of Social Work APPENDIX C BIBLIOGRAPHY BIBLIOGRAPHY A. General References Barsky, A.N., Casework in a Veteran* Hospital. Master of Social Work Thesis, University of B r i t i s h Columbia, 1954 . Boehm, W. Curriculum Study, Volume X. Council on Social Work Education, New York, 1 9 5 9 . Canon, Ida, M., On the S o c i a l Frontier of Medicine. Harvard University Press, Cambridge, 1952. ~ Canon, Walter, B., The Wisdom of the Body. Norton, New York, 1 9 5 2 . De Schweinita, K a r l , England's Road to Soc i a l Security. University of Philadelphia Press, Philadelphia, 1 9 4 3 . Dunbar, Helen, Flanders, Mind and Body: Psychosomatic Medicine. Random House, Mew York, 1 9 4 7 . Goldstine, Dora (ed.) Expanding Horizons i n Medical Social Work. University of Chicago Press, Chicago, I l l i n o i s , 1 9 5 5 . Goldstine, Dora (ed.) Readings in the Theory and Practice of Medical Social Woriel University of Chicago Press, Chicago, I l l i n o i s , 1954 . Harrison, T.R.; Adams, D.R.; B e n e t t , J r . , I.L.; Resnik, W.H.; Thorn, G.W.; Wintrob, M.M. ; Prin c i p l e s of Internal Medicine, McGraw H i l l Book Co., Inc., Toronto, 1 9 6 2 . H o l l i s , E.V., Sr, Taylor A.L., Soc i a l Work Education i n the United States. Columbia University Press, New York, 1 9 5 1 . Kogan, L.S. (ed.) Soc i a l Science Theory and Social Work Research. National Association of Social Workers, New York, 1 9 5 9 . Perlman, H.H., Social Casework. University of Chicago Press, Chicago, 1 9 5 7 . Richardson, Henry, B . , Patients Have Families. Commonwealth Fund, New York, 1939-S e l l t i z , C ; Jahoda, H . ; Deutsch, M.; Cook, S.W.; Research Methods i n Social Relations. Henry Holt and Company, Inc., New York, 1 9 5 9 . S t i l b o r n , E.J., Social Service Referrals i n a General Hospital. Master of So c i a l Work Thesis, University of B r i t i s h Columbia, 1 9 6 1 . Treker, H., S o c i a l Group"Work. Association Press, New York, 1955. What Soc i a l Workers Should Know About I l l n e s s and Physical  Handicap. Family Service Association, New York, 1937. Wheeler, Michael, A Report on Needed Research i n Welfare i n  B r i t i s h Columbia. A survey undertaken f o r the Community Chest and Council of the Greater Vancouver Area, March l°6l. Witmer, Helen, So c i a l Work: An Analysis of a Social I n s t i t u t i o n . Farrar and Rinehart, New York, 1942. Young, Pauline', V., S c i e n t i f i c Social Surveys and Research. Prentice-Hall, Inc., Englewood C l i f f s , N.J., 1956. ' B. Spe c i f i c References A l l e n , Raymond, B., Medical Education and the Changing Order. The .Commonwealth Fund, New York, 1946. Alexander, Franz, M.D., Psychosomatic Medicine. W.W. Norton &. Co., New York. B a r t l e t t , Harriet, M., Analyzing Social Work Practice by F i e l d s . National Association of So c i a l Workers, New York, 1961. "Brief to the Royal Commission on Health Services", The Social  Worker." June-July 1962. Vol. 30. No. 3. Bruno, F. J. , Trends i n S o c i a l V/ork as Reflected in the Proceddings  of the National Conference of S o c i a l Work, 1874-1946. Columbia University Press, New York, 1948. Cabot, Richard, M.D. / S o c i a l Service and the Art of Healing. Dodd,Mead, New York, 1928. Chisolm, Brock, "Organization f o r World Health", Mental Hygiene. July 1943. V o l . 32. C o c k e r i l l , Elanor, "Interdependency of the Professions in Helping People", The S o c i a l Welfare Forum. National Conference of Soc i a l Welfare, Columbia University Press, New York, 1953. C o c k e r i l l , Elanor, "New Emphasis on an Old Concept of Medicine", Journal of Social V/ork. January 1949. C o c k e r i l l , Elanor. "Widening Horizons i n Medical Education", Journal of Social Casework. January 1943, V o l . 29 . Community Chest and Councils of Greater Vancouver, Basic Pattern of Community Agencies, P r i o r i t i e s Programme. Master of L i s t  of Agencies. June 19o3. Friedlander, Walter, A., Introduction to S o c i a l Welfare. Prentice-Hall, Inc., New York, 1955* Goals of Public S o c i a l P o l i c y . National Association of S o c i a l Workers, 1959. Green h i l l , Stanley, M.D., "Teaching the Undergraduate Mental Health and Family Care", Canada Ts Mental Health. March 1 9 6 3 . V o l . x i . No. 3. Hamilton, Gordon, Theory and Practice of Social Casework. Columbia University Press, New York, 1952. Margolis, H.M., M.D., "The Biodynamic Point of View in Medicine", Journal of Social Casework. January 1 9 4 9 . Medical Directory. College of Physicians and Surgeons of B r i t i s h Columbia, November 1962. Richmond, Mary, So c i a l Diagnosis. Russell Sage Foundation, New York, 1917. Seyle, Hans, M.D., "The Adaptation Syndrome i n C l i n i c a l Medicine", The P r a c t i t i o n e r . January 1954. Somers, Herman, S., & Somers, Anne, R., Doctors. Patients and  Health Insurance. Doubleday and Company, Inc., New York, T9021 ; Stalwick, H.N., Churches and Welfare Services i n Richmond. B r i t i s h Columbia. Master of Social Work Thesis, University of B r i t i s h Columbia, 1 9 6 2 . Upham, Francis, A Dynamic Approach to I l l n e s s . Family Service Association, New York, Second Printin g , 1953. Vokhart, E.H., "Man, Disease and S o c i a l Environment", Post-graduate Medicine. February I960. Vo l . 27. No. 2. Wilensky, Harold, L., & Lebeaux, Charles, N., I n d u s t r i a l  Society and S o c i a l Welfare. Russell Sage Foundation, New York,.1958. \ 

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