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Social service referrals in a general hospital : an evaluative survey of 23 out-patient clinics of the… Stilborn, Edwin John 1961

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SOCIAL SERVICE REFERRALS IN A GENERAL HOSPITAL An Evaluative-Survey of 23 Out-patient Clinics of the Vancouver General Hospital, i 9 6 0 . by EDWIN JOHN STILBORN Thesis submitted i n Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK in the School of Social Work. Accepted as conforming to the standard required for the degree of Master of Social Work School of Social Work 1961 The University of British Columbia 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 o f 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 my 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 . D a t e if - S — & (  i i i TABLES AND CHARTS IN THE TEXT (a) Tables Page Table 1. New referrals to clin i c s i n proportion to 29 new referrals to social service . Table 2. Sources of referral to social service, Vancouver General Hospital, November, i960 32 Table 3» Social Information considered most useful, (Analysis of 24 questionnaires, April 1961) 51 (b) Charts Figure 1. Medical social services requested for patients 40 Figure 2. Social services requested by doctors. Frequency of reasons for which referrals made to Social Services Department; 24 doctors 55 i i TABLE OF CONTENTS Chapter 1 Social Work and the Out-patient Department Page Beginnings of medical social work i n Britain and North America. The concept of medical teamwork; the social worker's role. Standards of medical social service i n institutional settings. Develop-ment of social services at Vancouver General Hospital, particularly the Out-patient Department. Referral procedure for medical social services i n the Out-patient Department. Focus of the study 1 Chapter 2 Referrals to Medical Social Services i n the Out- patient Department. Referrals to social services i n relation to admission to c l i n i c s . The sources of referral. Proportion of referrals by medical staff. The nature of these requests. Classification by services 28 Chapter 3. Social Services: The Doctor's Viewpoint. Use of questionnaire as a measurement. Scope of the f i e l d covered. Findings of the survey* methods of referral; kinds of information most useful; services requested most frequently; suggestions for improvement. Preferable methods of communication; function of medical social service. Other staff recommendations 42 Chapter 4 Can Referrals Help C l i n i c a l Services? Methods of ref e r r a l . Kinds of information most useful. Reasons for making referral. Suggestions for improvement. Conclusions 67 Appendices * A. Questionnaire used i n the Survey. B. Medical Social Service Referral Form, (M.234). C. Bibliography. i v Abstract Social Service Referrals i n a General Hospital " The purpose of the present study has been to examine the referral system used by the doctors and others i n making requests from Medical Social Services i n Vancouver General Hospital.. More specifically, the examination was confined to the present use by medical personnel of the referral form, (M 234). This pilot project has been undertaken to explore the referral system i n relation to improvement of medical social services offered i n the out-patient department. As background, the history of medical social work, standards of medical care, and a resume of Medical Social Service i n the out-patient department of Vancouver General Hospital i s reviewed. Basic information for the study was obtained through a survey of a l l requests made to medical social service from out-patient c l i n i c s during November, i960. In addition to this, twenty-four doctors of the specialty c l i n i c s were canvassed through the medium of a questionnaire, and personal interviews, to ascertain their opinions on (a) most convenient methods of referral, (b) kinds of social information, (c) reasons for referral, (d) and suggestions for improving medical social services. The findings of the study indicate that slightly less than one-third of the new patients admitted to the out-patient department cl i n i c s for November, i960, were referred for medical social services. There i s evidence that a far higher percentage than this could benefit from such services. The Social Service Department has been aware of the po s s i b i l i t i e s for some time, and the present study was undertaken i n order to gain facts, opinions, and c l a r i f i c a t i o n towards improving the referral system i n the interests of more adequate standards of medical care. V Aeknowledgement s. I should lik e to convey my sincere appreciation to the members of the Vancouver General Hospital Out-patient Department (Adult) who have made this study possible. In particular, I should l i k e to thank Dr. D.M. Whitelaw, Medical Director of the Out-patient Department, for his interest, criticisms, and suggestions as the study progressed, and the Doctors of the "Specialty" cl i n i c s for their kind; co-operation i n answering the questionnaire. Special appreciation i s due to Miss Pumphrey, Director of the Social Service Department, for her encouragement, and counsel through the various phases of this undertaking. Again, I am ever indebted to the Supervisor and Staff of the Social Service unit i n the Out-patient Department for their efforts towards making necessary information available. Furthermore, I am happy to acknowledge the inestimable help of Mrs. Mary Tadych, of the School of Social Work, University of Br i t i s h Columbia, for evaluating the material included i n this study, and for her interest, optimism, and encouragement i n the writing of the f i n a l report. Finally, I am deeply grateful to Dr. Leonard C. Marsh, of the School of Social Work, for the invaluable technical assistance, and for the support which he gave so generously throughout the planning and conduct of the study, and i n the writing of the f i n a l report. v i SOCIAL SERVICE REFERRALS IN A GENERAL HOSPITAL An Evaluative Survey of 23 Out-patient Clinics of the Vancouver General Hospital, i 9 6 0 . Chapter I Social Work and the Out-patient Department. Medical Social Work, as a specialty of the social work profession, can be traced to the work of the lady almoners i n English hospitals i n the eighteen nineties. In England, during the latter part of the eighteenth century, there was a transition from the privately-owned and maintained hospitals to the voluntary publicly supported institutions. These new institutions set up dispensaries to provide out-patient care for those i n need of such attention. The desire to prevent abuses of this free medical care resulted i n the establishment of Medical Social Services i n out-patient departments. In the year 1895» through the efforts of the London Charity Organization and i t s secretary, Charles Loch, a trained social worker was placed i n the Royal Free Hospital, London, to review applicants i n regard to financial e l i g i b i l i t y . This position gave the "Lady Almoner" as the worker was called, the opportunity to inquire into the social conditions of the patient, and soon, i n addition to the original function, the almoner made referrals, where appropriate, to the charity agencies. The services of the almoner soon became an established part of the British hospital system. Charles Loch's particular concern regarding recruitment of suitable personnel, and adequate training for this important task, led to the founding of the Institute of Hospital Almoners, which undertook to carry out these purposes. While there are differences i n problems, resources, and focus, there has been a close professional link between the Almoner and the American Medical Social Worker. On the North American continent, medical social work began i n the United States i n the year 1905, through the increasing recognition of the 2 fact that adequate medical care must take account of the social problems connected with i l l n e s s . Ida M. Cannon, f i r s t medical social worker, i n d i -cates the purpose of the social service movement i n hospital settings. "What we c a l l the Medical Social Service Movement had as i t s purpose to bridge the gap between hospital and community, to recognize their interdependence, and to determine the relation of cause and effect i n the patient's disease and his 1 environment." She goes on to suggest that, in the beginning, this was expressed i n simple practical action i n relation to the patient's needs. Since modem hospitals are to some extent identified with the organizations of public health, preventive medicine, and community social service, the i s o l a -tion of the early hospital may be forgotten. Because of this factor i t i s worthwhile reviewing the early situation. Miss Ida M. Cannon was called to serve in the Massachusetts General Hospital on October 2, i n the year 1905* This appointment was the outcome of Dr. Richard Cabot's experience in out-patient departments, when patients did not keep appointments, nor carry out the doctor's orders. These circumstances appeared to emanate from unsatisfactory home conditions, about which doctors had l i t t l e information. The success of Dr. Cabot's venture was soon followed by other leading hospitals, namely, Bellevue, i n New York, and Johns Hopkins, in Baltimore. It should be noted that medical social services were f i r s t inaugurated i n the out-patient departments of these hospitals as i n Britain. It i s interesting to note the instructions given to the f i r s t social worker: 1. Cannon, Ida M. 'On the Social Frontier of Medicine". Chapter 2. Harvard University Press, Cambridge, Mass. 1952. 3 "To investigate and report to the doctors, domestic and social conditions, bearing on diagnosis and treatment, to f i l l the gap between his orders and their fulfillment, and to join the link between the hospital and the many 1 societies, institutions, and persons whose aid could be enlisted." One of the earliest responsibilities was that of establishing e l i -g i b i l i t y of patients seeking help, which was, i n i t i a l l y , a limiting factor i n permitting the workers opportunities to deal with the social aspects of i l l n e s s . In retrospect, some of the d i f f i c u l t i e s involved seem incredible today, for instance, workers were not o f f i c i a l l y responsible to anyone, since medical social work was only partially recognized as a necessary adjunct to medical care. Sometimes, in regard to questions relating to after care plans, doctors would indicate the ending of the hospital's responsibility as the patient l e f t the door. Again, some of the doctors were too busy teaching, and running c l i n i c s , to be bothered with workers asking for more specific orders regarding particular patients. Another d i f f i c u l t y was the indifferent doctor, who did not appreciate social service data, "but of these there were few. The hospital administration kept a watchful eye upon the workers, not being con-vinced of their value to the hospital setting. Also, charity organizations did not perceive the need for social workers in the hospital, yet Dr. Cabot, in keeping with his breadth of vision regarding medical services, emphasized the necessity of social case work as part of medical care. The referral system, in regard to the request for social services, was from the doctor himself, on a form supplied by the social service depart-ment for this purpose. It i s suggested that this procedure often served as a reminder to busy doctors, and was also a convenience to them, and an authority 1. Ibid, p.48. 4 for action to the social service staff. Most of the doctors used the social services i n relation to their special c l i n i c interests. About the end of the nineteenth century, the view of workers i n American charity organizations was that of a moralistic attitude i n regard to the investigation of cases, people were classed as either worthy or unworthy. In their experience i n regard to the relation of cause and effect, they de-veloped an awareness that responsibility for dependency, poverty, and i t s resulting degradation, was closely related to the conditions i n which people lived and worked. These conditions were such that individuals had l i t t l e control over them. Scientific advances i n medicine influenced methods, and offered p o s s i b i l i t i e s of better care for the sick. Por instance, improvements i n c l i n i c a l procedures made the study of disease more exact and more searching. In relation, however, to those who sought care i n sickness, there was the problem of the remoteness of the hospital from community l i f e , and the indi-vidual's fear of the hospital setting. When dispensaries and out-patient departments were established for free treatment, many physicians protested the c l i n i c s were being used by patients who could afford to pay for the services of private physicians. Ida M. Cannon suggests that needed reform "Came not i n protest of the abuse of the dispensary by the patients, but rather i n recognition of the inadequacy of treatment of patients by the 1 doctors." Dr. Richard Clarke Cabot proposed to do something about i t . This was the environment in which medical social services were f i r s t established in the United States. Up to this point the emphasis has been placed upon the beginnings of medical social work in Britain, and particularly, the United States. 1. Ibid, p.44 5 Canada, however, was not far behind i n the appointment of a social worker to the Montreal General Hospital i n the year 1910. The function of the f i r s t worker was similar to that of American hospitals, to check the e l i g i b i l i t y requirements for admission to the out-patient department. This function was gradually extended to include inquiry into the social environment i n which the patient lived, and later, to the total social and emotional needs of the patient. It i s interesting to observe that the f i r s t social worker at the Montreal General Hospital was maintained financially by a church group, who continued to carry out this project for a period of about four years, u n t i l i t became an acknowledged fact that a social service staff was a necessary addition to hospital f a c i l i t i e s , and consequently placed under hospital manage-ment. An examination of formal beginnings of medical social services in other Canadian hospitals indicates a similar pattern, where women's groups, such as hospital auxiliaries, took responsibility for the maintenance of medical social services staffs for a period of years, u n t i l acknowledged as a department of the hospital. What has been said here does not in any way negate the fact there were doctors throughout Canada with vision and breadth of outlook to appreciate the need for competent medical social workers i n any r e a l i s t i c approach to rehabilitation of patients. I n i t i a l l y , social workers functions were limited, and confined to the out-patient departments of hospitals, and only extended as doctors and other hospital personnel became increasingly aware of the value of the medical social worker in dealing with the social and emotional needs of the patient. This trend gained momentum through the impact of the two World Wars upon hospital programs of rehabilitation. As a result of the return of veterans of the two wars, many of whom were disabled, i t was generally agreed to be a national responsibility to provide the medical services necessary to their 6 rehabilitation. Again, the experience gained from these two conflicts em-phasized the fact that manpower i s a nation's most valuable resource, and unmet health needs are a drain on the economy-. Through an appreciation of this factor, nation-wide health programs were established i n countries such as New Zealand, United States, and Britain. It was, however, more parti -cularly i n the area of veterans rehabilitation that adequate medical care programs were established at the national level. In Canada, such a program is under the administration of the Department of Veteran's Affairs. The aim of this program i s stated i n the definition of rehabilitation given at the National Conference on Rehabilitation i n the United States. In the year 1946, which states: "Rehabilitation i s the restoration of the disabled to the maxi-mum physical, mental, social, economic, and vocational capacity of which they 1 are capable." Experience of the two world wars, emphasizing manpower as a nation's most valuable asset, the consequences of unmet health needs, and the result-ing medical care programs for veterans, have given impetus to the idea that since these are established facts, why not a comparable program for the whole nation? Consequently, the department of National Health and Welfare i n con-junction with the provincial governments has given financial help to build, extend, and improve f a c i l i t i e s whereby the standard of care may be improved toward optimum health conditions for the nation. While these trends are only a beginning, they have, and are helping to give the hospitals opportunity to improve their standards of care i n the interests of the community they serve. .1.. Woods,...Walter. S.,. "Canada's Rehabilitation Program", Department of Veteran's Affairs Treatment S f trvice Bulletin, May 1948. Vol.3. No.5, PP 3-12. 7 These trends are not only viewed at the national level, but internationally, through the operation of the World Health Organization a specialized branch of the United Nations, which has defined health as "A state of complete physical, mental, and social well-being, and not merely the absence of disease 1 or infirmity." This statement implies that health can only be achieved i n response to many favourable influences and forces, such as economic, social, 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 the help-ing professions. This would tend to imply that medical care is not by any means confined to the diseased organ, but takes into consideration the total person involved, and such care requires planning on a community basis since rehabilitation requires many services. Medical care i n this sense takes into consideration the economic and social, i n addition to the physical aspects, and implies the participation of several professions. This concept of the relatedness of social, emotional and physical factors i n the cause and treat-ment of disease has been developed over a period of time. The technological and chemical discoveries of the eighteenth cen-tury made i t possible for doctors to observe the human body with more accuracy through the various stages of pathology in i l l n e s s . This in time, led to further advancement i n the knowledge of specific diseases, and to specializa-tion and precision, two important aspects of medical science. As a result of continued improvement in the tools of research and refined s k i l l s of treat-ment, new findings were brought to light which broadened the concept of 1. Chisholm, Brock, "Organization for World Health", Mental Hygiene. July 1 9 4 8 . Vol. 32 pp. 3 6 4 - 3 7 1 . i disease and medical care, the studies made by Cannon in the area of physio-2 logical stress, and by Dunbar i n the f i e l d of psychosomatic medicine, are of particular importance, since they emphasize the concept of illness as a reaction of the whole organism to i t s environment. Currently, the investiga-3 tions of such leading physicians as Professor Hans Selye have helped to crystalize some of the thinking on the subject of the relation of the mind and body in i l l n e s s . Couched in c l i n i c a l terminology, the basic ideas of the "Adaptation syndrome" and the "Stress concept" express the modern broad con-cept of disease and the significance of environmental conditions in the treatment plan. The specialist in the large modern hospital of today, with i t s complete structure of specialized departments and services, shares the responsibility of formulating a diagnosis and effecting a treatment plan with a number of other specialists, either of his own profession, or of auxiliary professions, such as nursing, dietetics, physical and occupational therapy, and social work. The problem then becomes a matter of delineating the specific services, and co-ordinating them into an integrated treatment plan. Prom such an approach has evolved the concept of medical teamwork, the co-ordination of services i n the interest of the patient and his family. This has come to be accepted as the only v a l i d approach to the complex problem of maintaining and restoring health. Frances upham, i n "A Dynamic Approach to Illness", indicates the focus of the team approach when she writes, "The close working relationships that are made possible by a group of services working together under one roof, 1. Cannon, Walter B., The Wisdom of. the. Body... Horton,. New York,1952. 2. Dunbar, Helen Flanders, Mind and Body: Psychosomatic Medicine, Random House, New York, 1947. 3 . Selye, Hans, M.D. "The Adaptation Syndrome in C l i n i c a l Medicine", The Practitioner. January, 1954- Vol. 172. No. 1027, pp. 6-15. 9 and under unified direction should result 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 principle of interaction i n the functioning of the human being. His needs - whether medical, economic, or social - are viewed, not as a series of separate entities that can be treated separately by a group of specialists, but as a unit. Each area s t i l l has i t s area of specialization but each accepts that the specialized s k i l l s should be u t i l i z e d within the framework of a co-ordinated inter-1 professional approach to the individual." The Social Worker's Role in Medical Teamwork. The role of the social worker in helping the hospital carry out i t s obligation of restoring the patient to maximal usefulness constitutes an integral part i n a comprehensive program of medical care. In keeping with this aim, the American Association of Social Workers drew up, i n the year 1949» a Statement of Standards to be met by social service departments in hospitals, c l i n i c s , and sanatoria. The Statement of Standards was approved by the American Hospital Association the same year, and continues to be an important guide in organizing and improving social service departments i n hospitals, c l i n i c s , and sanatoria. This includes five broad areas of activity: "The practice of social casework; participation i n program planning and policy formation within the medical institution; participation i n the development of social and health programs in the community; participation in the educa-2 tional program for professional personnel; and social research." 1. TJpham, Frances, A Dynamic Approach to Illness. Family Service Association of America, New York. Second printing 1953> PP» 25. 2. -The.American.Association.of Medical.Social.Workers,AJ3taj£ment of Standards to be met by Social Service Departments in Hospitals. Clinics,  and Sanatoria, 1834 K St. N.W.,Washington 6, D.C. Third revision 1949. 10 In the area of direct help to the patient and his family, the medical social worker, as part of the professional team, brings the same techniques and s k i l l s that characterize social work in general. In essence, this direct help, or social casework, i s directed towards preventing further social breakdown; restoring social functions; making l i f e experience more comfortable or compensating; creating opportunities for growth and develop-ment; and increasing the individual's capacity for self-direction and social 1 contribution. It i s based upon an understanding of the dynamics of human behaviour, upon the translation of this understanding as i t applies to the patient, and upon special competence in guiding him towards maximal adjust-ment in the light of his i l l n e s s . The f i r s t step in such a helping process i s a thorough understanding of the patient's inner and outer environment, for each person i s unique in his personality configuration, his social and economic background, and in his reaction to a given situation. The combination of these variables deter-mines the meaning illness w i l l have to the patient and the areas in which he w i l l need help. Thus, he may require assistance with concrete problems, such as financial d i f f i c u l t y , confronting him and his family during his il l n e s s , or he may be disturbed by deep emotional d i f f i c u l t i e s and interpersonal rela-tionships which may react upon his medical condition. Frequently, the patient's il l n e s s creates imbalance not only within the patient himself, but within the family unit. Anxiety created by illness and separation decreases the capacity of the remaining members to handle added responsibilities. In the process of gaining an understanding of the patient's problem, the social worker senses the strengths within the patient himself and within the family 1. Hamilton, Gordon, Social Casework, Columbia University Press, New York, 1952. p. 259* 11 group, and draws on these strengths as resources. Whenever possible, she w i l l c a l l upon additional resources within the community, as this knowledge i s part of her professional equipment. Some of the ways in which the social worker can help reduce anxiety and enable the patient and his family in a constructive handling of problems created by illness are: cla r i f y i n g medical procedures, referring to an appropriate community resource, helping modify the attitudes of relatives towards the patient, preparing the family for the patient's after care. But this individualization is only one aspect of the casework process. The manner in which the help i s given i s even of greater import-ance, and i t i s here that the social worker offers a unique service to the patient. Mrs. Field describes the casework approach as follows: "The social worker's approach differs from that of the other members of the professional team, his relatives, or his friends. While the very nature of their functions imposes upon the other members of the professional team the obligation to exercise authority, and while the attitude of the family members and friends may be coloured by their own emotional reactions, the social worker can remain free from the need to prescribe any particular line of action and from emotional entanglement. Rather, the social worker's approach i s governed by an attempt to see the problem as the patient sees i t , to allow the patient to move at his own pace, and to make his own decisions towards a goal that he i s helped to set for himself. Such an approach can be carried out only when i t is rooted i n a genuine apprecia-tion of the i n t r i n s i c worth and dignity of the human being regardless of the stage of his illness or the degree of the incapacity i f produces. For the patient, such an approach assumes particular significance i n the light of an illness that tends to undermine his feeling of usefulness and status. Exper-ience has demonstrated that this approach, removing as i t does the threat of control, compulsion, or censure, tends to minimize the patient's feeling of helplessness produced by the i l l n e s s . It enables him to view his problems more r e a l i s t i c a l l y and to feel free to ask for help i n i t s solution, convinced that he wants such help and that he w i l l not be forced into a line of action contrary to his own needs and desires!.'-'-1.. Field, Minna, "Role of the Social Worker in a Modern Hospital." Social Casework. Vol. 3 4 , No. 9 , Nov. 1 9 5 3 , p. 3 9 9 -12 In the area of interpretation to hospital personnel, the social worker has the responsibility of helping the other professions gain an increasing awareness of the patient's total needs as a functioning, l i v i n g being who has an existence and concerns beyond the hospital walls. This responsibility ban be achieved only i f the social service department i s included i n policy making and planning in the hospital. A well-rounded program of interpretation includes u t i l i z a t i o n of opportunity for day-to-day contacts with other hospital staff, supplemented by more formalized teaching. In the area of community interpretations, the social worker must assume the responsibility of calling to the attention of the community the impact of substandard social conditions upon health, and suggesting ways and means of providing remedies. In this way channels w i l l be opened for broad social policies designed to ameliorate and prevent such conditions. It i s suggested social service departments should engage in teach-ing, in line with the hospitals'responsibilities towards the training of professional personnel. This task involves a formal teaching program, such as collaboration with schools of social work to provide f i e l d work practice in carrying on the education program for students; and upon request from the hospital administration, participation in courses or conferences regarding the social aspects of illness with doctors, internes, nurses, students of hospital administration, and other professional groups within the hospital. Again, the teaching function continues on a informal basis, since each member of the staff has a responsibility to interpret the social aspects of illness in his day-to-day work demonstrating to professional personnel from practice. In the teaching program, whether formal or informal, the inter-13 change of thought regarding the contribution of each professional group helps to provide greater understanding and integration of services i n the interest of the patient. Another teaching experience i s provided through requests for the teaching of lay groups and volunteers, either by group presentation in the hospital or community, or by individual work with volunteers. Finally, since social work, like other professions, i s continually changing and increasing i t s body of knowledge, i t is essential for medical social workers to have the opportunity to improve their quality of practice through supervision, professional reading material, consultation, staff con-ferences, and the chance to attend association and related conferences. In the area of research for improved medical care, the social worker can make a contribution by promoting an understanding of the social factors in illness so that provision might be made to meet the total needs of the patient. Up to this point, the role of the social worker i n individual team-work has been indicated through standards of social service departments i n hospitals, c l i n i c s , and sanatoria. The next step is to consider the medical social worker's role i n the more specific terms of day-to-day situations. An indication of this role of the medical social worker in Psychiatric Hospital care i s given in the Mental Health Services report for B r i t i s h Columbia in i960. Although this i s specifically related to psychiatric hospital settings, the l i s t of functions i s i n many respects applicable to the social worker's role in hospital and c l i n i c a l settings in general. 14 A recent study of the components of the social work job indicated that the following functions are of major concern»-1 . Admission services which involve the evaluation of the patient and his family i n relation to* a. The patient's personality assets and l i a b i l i t i e s . b. The existence and s t a b i l i t y of the patient's family group. c. The patient's realization of his i l l n e s s . d. The family's awareness of the patient's i l l n e s s , the effect of the i l l n e s s , the response to the i l l n e s s . e. Patient's desire to regain mental health. f. The family's desire for the recovery of the patient. g. The meaning that illness has for the patient. h. The patient's place i n the family. i . Changes in the family due to the i l l n e s s . j . Vocational adjustment for the patient and his family which his hospitalization has necessitated. k. Financial problems caused by the patient's i l l n e s s . 1 . How the family i s to be maintained during the patient's treat-ment; how treatment i s to be paid for. m. Patient's rehabilitation needs. n. Patient's need for protective care. o. Patient's a b i l i t y to use and carry out medical recommendations. p. The degree to which the family understands the illness and the importance of medical recommendations. q. The need for medical or psychiatric treatment by other members of the family. r. Resources i n patient, family, and community for use i n patient's rehabilitation. 1 . Extract from Report on Mental Health Services, B r i t i s h Columbia, I 9 6 0 , pp. 43-44« 1 5 These suggestions as to the role of the medical social worker in the hospital situation are by no means inclusive, yet give an indication of the multiplicity of tasks when medical social work i s an important component of the treatment setting. Development of Social Service i n the Vancouver General Hospital Like many other hospitals across the continent, the Vancouver General Hospital found the need to establish a social service department early i n the twentieth century. Also, like many others, the increasing need became gradually apparent, and the growth of the department was consequently slow for some time. The year 1912 marked the beginning of the social service department with the engagement of a social service nurse. She was supplied with an office and telephone i n the hospital, and her salary was paid by the Women's Auxiliary. The duties involved follow-up work in the homes after the patient's discharge (a car was provided, for this purpose) and attendance at the outdoor c l i n i c s . The general purpose of the social service depart-ment i s "to investigate and to assist needy cases i n the hospital... and, whenever possible, placing the needy ones in a position to become self-1 supporting." The Annual Report of the year 1918 indicated an added responsi-b i l i t y that of placing babies for adoption. In the year 1919 another development took place, when the social service nurse was allowed to make a survey of that department, and while this migjht not have appeared to be a function of the social service depart-ment, i t was a further indication the department was becoming an integral part of the hospital. By the year 1920, the volume of work had increased to 1. Annual Report of the Vancouver General Hospital, 1916. p.20. 16 the extent that i t was necessary to reorganize the department. In order to accomplish this purpose, a Miss E. Boultbee, who had taken a special course i n social service work in New York and Boston, was placed in charge as Director of the Social Service Department. The staff now consisted of two workers and a director responsible to the Director of Nursing. The greatest expansion took place i n the out-patient department, where cl i n i c s were i n -creasing i n size to meet the growing need brought about by a period of unemployment. Up to this point, the Women's Auxiliary was paying for a l l the social services, including a secretary and a car. By the year 1 9 2 6 , the hospital had expanded to 900 beds, and because of the increased financial load, the Auxiliary exhausted i t s funds, and disbanded. At this point, social service was taken over by the hospital adminstration. Again, the volume of work in the Social Service Department increased to the point that, by the year 1 9 3 0 , the out-patient was reorganized. During this process, the social service was l e f t responsible for determining e l i g i b i l i t y for free care. This function has remained the responsibility of the Social Service Department. In the year 1 9 3 9 , a new milestone was reached when the Social Service Department was separated from the Nursing Department. Other changes involved,included placing new workers i n specific services. The social service worker i n the out-patient department s t i l l spent considerable time i n establishing the e l i g i b i l i t y of patients. On the wards, discharge planning became the foremost task of the social worker. Some time was spent i n seeking to cope with such d i f f i c u l t i e s as family problems, mental and emotional insta-b i l i t y , adjustment to i l l n e s s , but more time, and staff, was needed to deal in any adequate way with these problem .cases. In the year 1947» a casework supervisor was added to the out-patient department in order to give better 17 service through staff development. By the year 1955» the staff consisted of twelve social workers, including a director, two supervisors, and nine caseworkers, and a c l e r i c a l staff of four. The department was again reorgan-ized at this time for the purpose of meeting the standards for hospital accreditation, issued."by joint commission on Accreditation of Hospitals. One of the requirements for accreditation was that qualified medical social 1 service personnel should he employed i n an organized department. One of the important changes involved i n the reorganization was in the out-patient department. Through the increased help of the Women's Auxiliary, funds were provided to hire a clerk on January 1, 1955* This clerk took over the res-ponsibility for assisting patients to obtain appliances which doctors have requested, and for which the funds were supplied by the Women's Auxiliary, and by other community resources. Again, the applications i n regard to e l i g i b i l i t y for admission to the c l i n i c were handled through the c l e r i c a l staff, with the help of volunteers from the Auxiliary, who do accreditable work i n f a c i l i t a t i n g the movement of patients through the various c l i n i c s . This important gesture on the part of the Women's Auxiliary released time for the professional social workers i n the out-patient department to devote to professional duties. The early out-patient departments were marked with the stigma of the unworthy — the place for treatment of the sick poor. Today the out-patient department of a modern hospital i s regarded as a necessary extension of medical services into a community, and a necessary adjunct to any health program. John R. McGibony, i n a recent book on hospital administration, 1. Ibid, p.-230. 18 defines i t s functions ass the provision of curative and preventive services with emphasis on the promotion of health through diagnosis, treatment, health education, research, and after-care of patients discharged from 1 hospital. These services are usually free to patients who can qualify, and e l i g i b i l i t y i s determined by a means test, which in most instances has some degree of f l e x i b i l i t y . The services offered are varied, such as medical and surgical specialties, in addition to general medicine, optometry,dentistry, drugs, prenatal and postnatal care, and child care. Social casework services are now widely offered through many out-patient departments, and may be on an environmental level, or more intensive level, depending on the nature of the problem, and the training and confidence of the worker. For some time, i n out-patient departments, social service workers were particularly involved i n determining e l i g i b i l i t y . More recently, however, the trend has been towards this task being taken over by the c l e r i c a l staffs, allowing the workers to provide their specialized professional services for patients. Briefly, the function of an out-patient department may be summarized as follows; (a) To make possible the use of staff bed f a c i l i t i e s by having a l l possible preliminary investigations done in the out-patients' c l i n i c s prior to admission to the wards. This means that hospitalization can be delayed u n t i l actually necessary, (b) To provide free medical care of a l l types to those of limited means, (c) To offer staff patients such post dis-charge care as may be deemed necessary by the staff members under whose service they were admitted, (d) To provide a teaching experience for medical internes, social work students, nurses, dieticians, and other members of the 1. McGibony, John R., Principles of Hospital Administration. G.P. Putnams, New York. p.5» * Staff beds are those provided for patients who are financially unable to pay for hospitalization. 19 treatment team. The majority of patients i n any out-patient's department are referred to the department from various sources, such as doctors, nurses, social agencies, families and friends, and other interested persons. The provision of medical service, both in number and extent, w i l l vary i n each 1 hospital. While tbe record i s not too clear, i t would seem that when medical social services were established i n the year 1912, i n the Vancouver General Hospital, by the appointment of a social service nurse, one of her duties was attendance at the outdoor c l i n i c s . Thus, in common with many other hospitals, medical social service began i n the out-patient department. It was not, however, u n t i l the year 1919 that the social service nurse was allowed to make a survey of the out-patient department. The record does not indicate what the survey was to determine, but since i t was the f i r s t department of the hospital where social services.were employed, i t is assumed the survey was to indicate the need for social services and the desirability of i n -creasing the staff. By the year 1920 , the volume of work accelerated ap-preciably, owing to the increase i n the size of the c l i n i c s , and because of the fact that unemployment became a major concern of the city. As a result of these factors, the social service staff i n the out-patient department was increased to three workers, and a secretary to keep the records. In the year 1930, the Women's Auxiliary to the hospital was formed, and a reorganization of the out-patient department became necessary. This was partially due to the fact that the social serii ce nurse was s t i l l responsible for admitting patients to the department, establishing e l i g i b i l i t y , and setting up medical charts for them. ... -The. function, of .social, services, at -this. -time,, as stated.. 1. ...Patan, John .Robert Drury, and.Weibe, John, Medical Social Service i n a Veteran's Hospital Out-patients' Clinic.Master of Social Work thesis, University of B r i t i s h Columbia, 1954. 20 was "to supplement medical treatment of a patient with social treatment, through c l i n i c , ward, or home, and aid the physician through a knowledge of the patient's home condition, or point of view which require adjustment, to make medical treatment more effective... Other services... are included in the a c t i v i t i e s which embrace a knowledge of community and medical re-sources, and understanding of the patient's medical and social needs, and the interpretation of pertinent facts to the hospital, the patient,and the 1 community." This statement of function implies a great variety of tasks, such as boarding of children, infants, mothers, and convalescents, adoption of infants, transportation from hospital, securing of material aids, braces, crutches, wheel chairs, or c l o t h i n g — arranging blood transfusions for i n -digent patients, and supplying reports on patients to various organizations which required them. This seems a formidable task, but i t was only made possible because social services were particularly on an environmental level, and a great deal of help was received from the volunteers of the Women's Auxiliary. The tremendous increase i n patients by the year 1931 was, as in the year 1919, particularly due to the high level of unemployment. In 1933* an extra nurse was added to the social services out-patient department for the specific task of admitting, i n order to help carry out a new ruling that no.patient could be admitted without a note from a doctor requesting aid in diagnosis or treatment. This step reduced the volume of patients by one-third, and gave the workers more freedom for other matters. An important milestone was reached in the year 1943, when the f i r s t trained social worker 1. Personnel and Function of the Social Service Department Combined with Out-patient Department, Vancouver General Hospital. Mimeographed material 1930. 21 (Miss Helen Sutherland) was appointed to take over the responsibilities of the out-patient department, and to supervise the volunteers. The changing emphasis in casework by the employment of a professional practitioner i s indicated i n the following statements "To further the medical care of the patient by i t s method of social case study and treatment... so that a patient i s able to work out his own plans. Often, too close supervision and intense follow-up w i l l rob a patient of his self reliance, and make him wholly depen-dent on others. A Social Service Department should know when to be content 1 with pointing the way, and allowing the patient to develop his own iniative." The intention, from this time on, was to develop modern standards of casework, however, i n the out-patient department, the trained social service staff s t i l l continued to be involved with considerable c l e r i c a l work. This i s evident in the Annual Report of 1939 > after the Social Service Depart-ment was separated from that of nursing, when the medical director stated "There i s a tendency to forget the patience, tact and thoughtfulness they display....it must be pointed out that the quality of c l e r i c a l work performed by our trained workers prevents them from applying their special knowledge 2 to the problems at hand." During the war years, there was a determined effort made by the director and staff to c l a r i f y the function and policy of the department , particularly i n relation to referrals to social service for environmental problems of patients only, and an attempt was made to foster an awareness of the deeper potentialities of the service. This was particularly true of the out-patient department i n relation to social services, and has been a continu-ing problem of interpretation. Today, there are four out-patient departments;;^ |» Annual Report of the Vancouver General Hospital, 1 9 4 0 , p. 37-2. Ibid 22 the adult out-patient's department, the women's c l i n i c , the health centre for children, and adult psychiatry. The Policy Manual states "These depart-ments function separately i n terms of setting their own c l i n i c times, making their own appointments, and looking after their own records. A l l adult out-patient departments come under the Medical Director, Out-patient depart-1 ment." Each of these out-patient departments have their own social service staff, who are responsible to the Director of the Social Service Department. At present the social service staff i n the adult out-patient department consists of a casework supervisor, two caseworkers, one case aide, and one driver clerk. The e l i g i b i l i t y scale for admission to the out-patient department is established by the Board of Trustees on the recommendation of the Medical Board. It i s subject to revision from time to time. The scale serves only as a guide, and may be applied flexibly. Thus, when patient's income i s slightly over the designated amount, but there are extenuating circumstances, such as large medical debts, patient may be e l i g i b l e . Final decision regard-ing admission i s made by the admitting clerk. In d i f f i c u l t cases she may consult the casework supervisor. 1 person i n a family $150.00 per month 2 persons 11 " " 170.00 " " 3 4 5 6 7 " " " 2 0. 0 " " " " 1 1 225.00 " " " " " 250.00 " " " " " 275.00 " " it it tt xnn r>n » n 500.00 $25.00 may be allowed for each additional child, over $300.00 for a family of seven. $1,000.00 as a savings account does not bar admission, and exten-uating circumstances may be considered i n excess of this... If a patient has 1. Policy Manual, Social Service Department, Vancouver General Hospital, August I960, P. 3. * For purpose of this study, the out-patient department referred to w i l l be the adult, excluding women's cl i n i c s and psychiatry. 23 medical insurance coverage, he may not be seen i n the out-patient department, although financially e l i g i b l e , except for those conditions which his insurance w i l l not cover and which l i e within the policy of the c l i n i c . The kinds of patients admitted are as follows; (a) low income, (b) unemployed, (c) unemployment insurance cases, (d) workmen's compensation recipients and dependents, (e) veterans and dependents (not e l i g i b l e for D.V.A. care), (f) inmates of provincial institutions, (g) social assistance 1 recipients. When the patient has been admitted to the c l i n i c , i n order to have the benefit of medical social work help, he must be referred to the depart-ment. Referrals to the Social Service unit in the out-patient department are made primarily by c l i n i c doctors, however, referrals are also received from other hospital personnel, such as the nursing staff, as well as social agencies, friends, and by the individuals themselves, but the Policy Manual states; "Other persons referring patients should consult the doctor concerned, 2 and have his sanction for referral." Social Service personnel accept re-rerrals from a l l the out-patient department cl i n i c s and are directed to the caseworker assigned to a particular c l i n i c when possible. Referrals are made to medical social service"for people who need nursing home and boarding home care, or financial assistance, and these patients are helped with their attitude towards aging, and the need to change their way of l i f e . B r itish Columbia has a great preponderance of aging patients i n relation to the rest of Canada, and a large number find their way 3 to the out-patient department." Again, referrals are often received request-ing help for emotional- problems-affecting i l l n e s s , social histories, behaviour 1. Ibid, p. 8 and 9* 2. Loc. cit.,p. 8. 3. Weaver, JKennath,"History and Organization of a Social Service Department", Canadian Welfare. Vol. 32, 1956.(Dec.)p. 231. 24 problems, and appliances. Referral Procedure for Out-patients Department Social Service The procedure in referring patients to medical social services has been developed and changed over a period of time. Under the most recent policy, referrals to social service are to be made by the doctor on a speci-f i c referral sheet, provided for this purpose. Many doctors use this sheet, but the practice of written referrals i s not yet universal, so the depart-ment has to decide whether to accept verbal referrals as well. It i s not suggested here that this i s the only means of communica-tion between doctors and social workers i n the c l i n i c s , or that i t i s a substitute for personal contact, which i s certainly not the case. The referral form i s , however, a supplementary means of communication in addition to per-sonal contact. Whenever social services are requested for a patient i n the out-patient department, i t i s not only important, but necessary that a record of this service be maintained. This i s obvious, since i t provides continuity for further action on a basis of continuing treatment, or for a reopening of the case at a future date. The volume of work i n any out-patient department makes i t impossible to remember what action actually took place i n regard to a particular patient. The referral form, as a record of service, i s placed on the medical chart as a ready reference i n relation to the service requested, what service was rendered, and i f not, the reason given. There are, of course, other more detailed reports contained i n the social service f i l e s , but these are only for social service personnel, and, i n many instances, are only main-tained when more than one contact with a patient has been made. In instances of brief contact, the only record of the services requested and given, are those recorded on the social service referral form, 25. with its space for the worker's report attached to the medical chart just in front of the form used by the doctor. The social service referral form, then, is a useful ready reference of services requested and given, though it must be clearly understood that the referral form is not a substitute for the social service file, but is a different type of record more particularly for the doctor who rightly expects any information he needs to be included on the medical chart. Probably one of the most important uses of the social service referral form has been indicated here, but not expressed, as a source of information to both social workers and doctors, as well as other hospital personnel. The form is organized so that the following information can be given. ' The patient's name, unit number, date, clinic, and medical diagnosis. Next, the reason for referral, such as social history, family problems, emotion-al problems affecting illness, rehabilitation plan, appliance, financial assistance, and discharge; plans or some other reason. After this, there is a space for the doctor's remarks, and his signature at the bottom. On the basis of this organization, considerable information about the patient, and what appears to be his social need in relation to his medical problem, is contained in the form. Additionally, in the space for remarks, special characteristics of the patient, and the urgency of the situation may also be expressed in a few words. In actual fact, information supplied by the doctor is of real importance to the social worker in facilitating action on the problem. Actually, it is not appropriate or feasible to ask the patient directly for i t , i f it is omitted, or is insufficient, it often means trying to contact the patient's clinic doctor before action can be taken in regard to the situation. * See sample form in appendix, B. 26 On the other hand, the doctor, in his concern for the patient, as a person, has referred him to the social service unit, since he is aware of the subtle ways in which the social aspects of illness may impinge upon the physical and emotional. In doing this, he is interested in seeing the result of a teamwork approach, thus he looks for the social worker's report of what could be done, or what is being done, for the patient. This he can find out when he reviews the medical chart. He may ask further questions, give further information i f requested, or ascertain from the worker i f this should be neces-sary. Therefore, i t would seem that the social service referral form can be an excellent source of information in facilitating teamwork in the cl inical setting. Something of the purpose of the form, notice of referral to the social service department (adult) has been here indicated. This is the basis of the institution of the form. In point of fact, behind this lies the desire of the medical social services for the continued improvement of service in an effort to play its part in helping the hospital to give the highest standard of medical care possible to the community. This goal, in relation to medical social service, is expressed succinctly by Ida M. Cannon, when she indicates social care ought to be available to anyone in whose care a social problem exists. Focus of the present study The purpose of the present study is to review the day-to-day opera-tion of the social service referral procedure to evaluate its stated purpose, and more specifically, to ascertain its contribution to the facilitation of improved social services in the out-patient department. The kind of questions •2-7 which may be posed are* ( l ) What is i t s value i n relation;to the services requested and given? (2) To what extent i s the present form of referral being used? (3) What suggestions or recommendations are indicated for the future? Are these r e a l i s t i c , and what possibility i s there of their implementation? The method of the study was to examine a l l referrals to the social service unit in the out-patient department for a specified month, November, i960. The analysis of who made the referrals, why, and for what service i s set out in Chapter 2. It operated primarily between doctors and social service workers, and i n order to gain an indication of the doctor's estima-tion of the value of this form i n making referrals to social service, a questionnaire was devised, and the doctors of the specialty cl i n i c s were inter-viewed i n this regard. The reactions by the doctors to the questionnaire are set out in Chapter 3» In so doing, this section recognizes that a sample of 20$ of the medical staff i n the out-patient department must only be given a limited or indicative v a l i d i t y . The implications of this material with regard to the out-patient department staff and the community, are discussed i n the f i n a l chapter. -Chapter II A Survey of Referrals to Medical Social Service in the  Out-Patient Department To obtain a perspective of the present use made of the social service referrals, a l l the new referrals made to the social service unit in the out-patient department on the specified form M .234, were reviewed and tabulated for the sample month. In order to do this, a record was kept by the unit members, of a l l new referrals for the month, including the source of the referrals. These were then examined in regard to the following points: (a) The ratio of patients referred, i n relation to the total out-patient department patient group for the month. (b) The ratio of patients referred, in relation to the various c l i n i c s . (c) The source of the refer r a l . (d) The services requested. (e) The way in which the referrals were made. The number of referrals to the social service unit, for the month of November, was 195 out of a total patient group of 600 new patients. The latter figure used here comes from the monthly report of the out-patient department, excluding Psychiatry, Gynaecology, and Obstetrics, as these three c l i n i c s have their own social service unit. The figures give an indication of the volume of new patients referred to the social service unit from the clini c s for the month, 3 2 . 5 $ of the total patient group. This i s an approxi-mate indication of the volume of work of the social service unit, and a * Social Service Unit, Out-patient Department s t a t i s t i c s , for the month of November, I960. 29 necessary base from which to observe the present use made of the social service referral form. It must, of course, be remembered that these figures are compiled for only one month, and need not necessarily be considered as an average for the twelve month period. Again, i t must be taken into considera-tion that the new referrals to the social service unit for the month of Novem-ber might not, i n a l l instances, be new cases to medical c l i n i c s , so there could be some duplication. Table 1. New referrals to cl i n i c s i n proportion to new referrals to social service. Clinics Medicine General Medical Cardiac Dermatology Diabetic Endocrine Gastro-intestinal Haematology Hypertension Med. Allergy Med. Ar t h r i t i c Neurology Anticoagulent Surgery General Surgery Chiropody Neuro-surgery Orthopedic Peripheral Vascular Proctology Urology Total New. referrals to c l i n i c s . I l l 2 43 4 2 1 6 4 11 12 1 64 1 61 11 . . 8 _ 2 1 365 New referrals -to :M.S.S. from O.P.D. 46 1 3 2 1 1 9 3 19 1 2 97 Not referred to M.S.S. * from c l i n i c s . 65 1 40 2 2 1 5 3 2 9 1 55 1 42 10 8 21 268 * M.S.S. - Medical Social Service. .30 Table 1 - continued, New, referrals, .to cl i n i c s in proportion to new referrals to social service. Clinics Not referred New referrals New referrals .to.- .to M.S.S. * to c l i n i c s . * M.S.S.from O.P.D. from clinics. brought forward 365 97 268 Dental 84 40 44 Ear, Nose and Throat 44 2 42 Eye 59 56 3 Nutrition 42 - 42 Physical Medicine 6 - 6 Total 600 195 405 Clinics omitted - Phychiatry, Gynaecology, and Obstetrics. Several observations are indicated here. Some of the larger c l i n i c s , such as General Medicine, and Dental, referred about half their new patients, while the Eye c l i n i c referred 56 patients out of 59 new referrals to that c l i n i c . The possible reason for such a high rate of referral to social services from the Eye c l i n i c i s that, i n most instances, financial arrange-ments have to be made for the purchase of glasses, since most patients lack the financial resources. This i s also true, but to a more limited extent i n relation to payment for the dentures. General Medicine is often the f i r s t c l i n i c to be visited by a new patient, and, in many instances, enquiries are made from community agencies regarding employability, or from the c l i n i c regarding financial, and sometimes family or emotional d i f f i c u l t i e s . Other larger c l i n i c s , such as Dermatology, Ear, Nose and Throat, Nutrition, and Orthopedic referred a very small percentage of their new patient group, during the month, to social services. It would appear that, i n many of these * M.S.S. - Medical Social Service. 31 cases, such as Dermatology, there could be strong emotional and social components in relation to the disease entity. Turning to the smaller c l i n i c s , such as Neurology and Peripheral Vascular, only four out of twelve, and one out of eleven new patients appeared to need any help from medical social services. Prom the Neurology c l i n i c patients are referred to medical social services for social history i n relation to the home situation and assistance in helping the patient and his family in adjusting to the pathology caused by the ill n e s s which may mean changing employment or retraining, or possibly, more suitable accomodation. For example, epileptic patients sometimes have poor employment records, and often blame the employer for the fact they cannot hold a job. In such circumstances the medical social service helps the patient to see the pattern of continually changing employment is related to his own attitudes which need to be changed before the patient w i l l find any degree of satisfaction in:employment. In other words, the social and emotional aspects of illness continually impinge upon the physical. To what extent medical social work can help i n the rehabilitation of such patients depends on the s k i l l and competence of the worker, but how effective the rehabilitation of the patient w i l l be without this help i s an important ques-tion i n any adequate standard of medical care. From the Cardiac, Hypertension, and Diabetic c l i n i c s , half the patients were referred to medical social service. Usually such patients have difficu l t y , i n accepting the limitations i l l n e s s imposes upon their physical activity and learning to live within these limitations. Medical social service can help these patients with financial problems where necessary, or more suitable employment, i f advisable, and particularly to the physical limitations 32 imposed by the i l l n e s s . One of the most important facts indicated by Table 1, is that the referrals from the large majority of cl i n i c s to medical social service are few, in proportion to the number of new patients for the month. Sources of referral to Social Service. Vancouver General Hospital,November I960  Table 2 Source of referral New Cases  Numbers Percentages Doctors 115 58.9$ Other hospital personnel 11 5»6$ Routine by Social Service* 10 5.1$ Patient -34 17.4$ Community _25_ 12.8$ Total 195 100.00 It might be supposed that a l l referrals to medical social service are made by doctors, but such i s not the case. Many community agencies make request for the use of hospital services, and their requests are made through medical social services. In the out-patient department, community agencies were responsible for 12.8$ of the referrals to the social service unit. Quite often, patients refer themselves to medical social service, making specific requests for a particular service. During November, 34 patients referred themselves. Referrals also came from varied sources, such as other hospital personnel, particularly the nursing staff; and sometimes a patient's par t i -cular problem may be discovered by a social service worker at registration, through an examination of the form completed by the patient when registering for out-patient department services. One more comment, however, i s necessary in regard to the sources of referral to medical social services. Medical social service, in a hospital setting,, i s a part of the. medical services . * Patients' needs are sometimes discovered at registration. 33 offered, but ancillary to that given by the physician, so that a l l referrals should be made on the authority of, or with the advice of, the family, or c l i n i c doctor. ways as who makes them. In the out-patient department, in addition to the social service referral form, referrals can also be made by telephone, dis-cussion with the worker, sending the patient to medical social services, writing the information on the medical chart, or some combination of these various methods. An examination of the social service record of referrals indicates the following methods were used by doctors. When requests were made regarding appliances, i n most instances a written referral on form M .234 was made to medical social service, for dentures and glasses the request i s made by prescription. In regard to the other 33 referrals to the unit, two were given on the medical chart, seventeen were written on the requisition, two through a discussion with the worker, eleven ©ending the patient to the unit, and several of the above were a combination of these methods. Because of these variations, i t i s d i f f i c u l t to determine the frequency of a parti -cular method, when the requests for appliances, dentures, glasses, are ex-cluded. Requests made by other members of the hospital staff are usually the result of discussions with the social worker. Referral from community agencies requesting services for patients, are usually made by telephone, and later followed up with a written request i n regard to the particular situation, cleared by the attending doctor and a hospital worker. One exception to to this method of referral by community agencies i s a reciprocal arrangement between the City social service department, and medical social services i n How are these referrals made? Thii lought as important i n some 34 the out-patient department o f the Vancouver General Hospital that r e f e r r a l s can be made by telephone. (The reason being, that patients are often r e f e r r e d to the C i t y s o c i a l s e rvice department f o r s o c i a l assistance, from the out-patient department of the Vancouver General Hospital, and one of the e l i g i b i -l i t y requirements i s r e l a t e d to employability.) Up to t h i s point, nothing has been mentioned i n regard to the predominant age range of the patient popula-t i o n . As t h i s i s an adult out-patient department and the Vancouver General Hospital has a Health Centre f o r c h i l d r e n , the adult e l i g i b i l i t y age would probably range from 16 years up, however, there i s some f l e x i b i l i t y i n t h i s regard. An a r t i c l e written on the s o c i a l s e rvice department of the h o s p i t a l , by Mr. Kenneth Weaver, i n the year 1955> confirms that the age d i s t r i b u t i o n i n the out-patient department, as might be expected, r e f l e c t s a well-known trend i n t h i s part of the world. " B r i t i s h Columbia has a great preponderance of aged patients i n r e l a t i o n to the r e s t of Canada, and a large number f i n d 1 t h e i r way to the out-patient department." There i s no reason to b e l i e v e the s i t u a t i o n has changed, unless there i s a s t i l l greater preponderance of the aged coming to the out-patient department at the present time. An understand-i n g of the age d i s t r i b u t i o n i s important, i n r e l a t i o n to the requests f o r s e r v i c e s . For instance, patients r e c e i v i n g e i t h e r o l d age assistance, or old age s e c u r i t y pensions, and those who are of the pension age of 65 years, may need appliances, f i n a n c i a l help, or accomodation more frequently than other services offered by medical s o c i a l s e r v i c e s . An examination of the s o c i a l service records shows there are a 1. Weaver, Kenneth R. "History and Organization of a S o c i a l Service Department", Canadian Welfare. 1955. V o l . 32, p.231. 3.5 m u l t i p l i c i t y of requests i n the r e f e r r a l s to medical s o c i a l s e r v i c e . Because of t h i s , there was d i f f i c u l t y i n b r i n g i n g them together i n such a manner they could be shown here. Thus, i n order to do so, the focus was d e l i b e r a t e l y placed on the reason given f o r the r e f e r r a l . Even within these l i m i t s , how-ever, the v a r i a t i o n s are of a wide range. Examination of the r e f e r r a l s suggests f i v e areas as a basis of c l a s s i f i c a t i o n . 1 . Requests f o r a i d i n procuring dentures, appliances and glasses. These requests require that the patient be interviewed and h i s f i n a n c i a l status reviewed. A f t e r t h i s review, i f the patient i s found e l i g i b l e , the request i s sent to the appropriate community agency f o r f i n a n -c i a l assistance i n procuring the appliance or s u r g i c a l supplies, as the case may be. In most instances, these requests are f o r patients r e c e i v i n g s o c i a l assistance, o l d age assistance, o l d age s e c u r i t y , disabled persons allowance, or a minimal income where they cannot a f f o r d the increased expenditure. Some-times the fi n a n c i n g of these requests i s assumed by the Women's A u x i l i a r y to the h o s p i t a l . 2. Requests f o r f i n a n c i a l help. This might appear to be a r e p e t i t i o n of the f i r s t category, but a c t u a l l y i t i s not. These requests are varied, often i t i s a desire on the part of the patient to t a l k over h i s f i n a n c i a l s i t u a t i o n with a s o c i a l worker. I t may be a request from a c l i n i c doctor i n regard to a patient who i s un-employed, and who has no apparent source of income to meet the needs of h i s family. A f t e r an interview with the patient, a r e f e r r a l i s made to the proper agency. Another type of f i n a n c i a l request i s sometimes made i n regard to the f a c t that the patient has formerly incurred medical b i l l s which he cannot pay, and about which he'may: be-deeply concerned. Here, again, a discussion with the worker can help to c l a r i f y the situation. It i s only too frequently revealed that financial d i f f i c u l t i e s can become such a con-stant worry to the patient that i t can be an important contributory factor in i l l n e s s . 5. Requests regarding employ-ability. Referrals i n regard to employability come from agencies such as the City social service department, which requires this information i n re-lation to e l i g i b i l i t y . Sometimes the doctor w i l l state that because of a particular condition, a patient w i l l not be able to work for several months. It i s important this information be given to the agency to which the referral i s made. Also, i f a patient is not able to work, he should not be registered at the National Employment Office. It i s necessary for the City social ser-vice department to have this information, too, so the patient's health w i l l not be endangered by unnecessary trips to the agency. Community agencies often make requests to the medical social service i n relation to appointments for clients. The request may be that arrangements be made for a patient to come from the interior of the province for a medical assessment where a number of c l i n i c a l appointments might need to be made. Another type of request may come from the doctor, for a worker to contact a patient who is neglecting to keep c l i n i c appointments, which, needless to say, hinders the progress of the medical treatment program. 4. Liaison services, such as finding accomodation and employment. It could be maintained that the varied requests which have thus far been indicated, are a l l of a practical nature. The intention here is not to suggest otherwise, but only to differentiate between a number of similar 37 requests. Quite often, r e f e r r a l s are received i n regard to accomodation. I t may be a doctor from the cardiac c l i n i c , who f e e l s i t i s detrimental to a heart p a t i e n t to have to climb three f l i g h t s of s t a i r s to h i s room, so asks i f a room on the ground f l o o r can be found f o r h i s p a t i e n t . Again, i t may be the patient i s no longer able to look a f t e r himself, and the doctor requests a nursing home be found where the patient would receive adequate care, which may not be the s i t u a t i o n at present. Part of the involvement here i s d i s -cussing the s i t u a t i o n with the patient, and helping him to understand the need f o r proper care, then f i n d i n g a s u i t a b l e nursing home, i f a v a i l a b l e . On the other hand, the r e f e r r a l may be f o r a patient who, f o r various reasons, does not seem able to manage h i s finances i n such a way that he has regular meals and a regular place to sleep. In such instances, the request i s f o r a s u i t a b l e boarding home to be found, i f p o s s i b l e . This r e -quest, l i k e that f o r a nursing home, involves more than the l o c a t i o n of a suitable place; much more important i s the i n t e r p r e t a t i o n and encouragement to the patient, to help him to r e a l i z e the value to himself of such a change. While not exactly r e l a t e d to the requests f o r suitable accomodation f o r p a t i e n t s , and yet another p r a c t i c a l s e r v i c e , i s the r e f e r r a l f o r employment. Sometimes there are r e f e r r a l s from such c l i n i c s as the A r t h r i t i c , asking a worker to f i n d s u i t a b l e employment f o r a p a t i e n t . This often becomes neces-sary, since e f f e c t s of the a r t h r i t i s may mean the patient's legs have become a -li m i t i n g f a c t o r i n h i s being employed i n a standing job, or where he must be walking around most of the day. This often e n t a i l s r e t r a i n i n g f o r another type of employment, where advisable, or a type of sedentary work where the patient does not have to use h i s legs. The task of handling such a request often involves r e f e r r a l s f o r v o c a t i o n a l counselling, and to the s p e c i a l 38 placements "branch of the National Employment Service where the s t a f f t r y to f i n d employment f o r the i n d i v i d u a l i n keeping with h i s c a p a b i l i t i e s and ph y s i c a l l i m i t a t i o n s . Another type of request i n regard to employment may be made to the s o c i a l service u n i t regarding the young man with an asthmatic condition who may, or may not, need a s p e c i a l type of employment. Here, again, the process i s s i m i l a r to that of the above example, except i t w i l l not ne c e s s a r i l y be a matter of r e t r a i n i n g , but vocat i o n a l t r a i n i n g i n r e l a t i o n to the i n d i v i d u a l ' s p a r t i c u l a r aptitudes and c a p a b i l i t i e s . In both of these instances, the s a t i s -f a c t i o n of having and holding a s u i t a b l e job i s important to the i n d i v i d u a l i n the medical treatment program. 5. S o c i a l information. There are many kinds of s o c i a l information requested by medical per-sonnel, as an a i d i n diagnosis, and treatment planning, and i n g i v i n g a s s i s t -ance with problems of anxiety or uns a t i s f a c t o r y s o c i a l r e l a t i o n s h i p s . The f i r s t section i n t h i s category includes requests f o r s o c i a l h i s t o r i e s regarding information the doctor has neither the opportunity, or the time, to obtain. An i l l u s t r a t i o n of t h i s could be a r e f e r r a l from a doctor i n the Neurology c l i n i c requesting a s o c i a l h i s t o r y of background material i n r e l a -t i o n to the seizure pattern of an e p i l e p t i c p a t i e n t . This i s a request f o r s p e c i f i c m a t e r i a l , and the worker would interview the patient several times to gather the pertinent f a c t s . This i s an example of what might be c a l l e d a s p e c i a l s o c i a l h i s t o r y . When the material i s gathered together, i t i s placed on the medical f i l e f o r the doctor's information. At other times, a doctor may make a r e f e r r a l f o r a general s o c i a l h i s t o r y i n regard to a p a r t i c u l a r 59 patient which may involve h i s t o r y material i n r e l a t i o n to the early l i f e of the patient, family r e l a t i o n s h i p s , schooldays, employment h i s t o r y , and marriage r e l a t i o n s h i p s . This may be a l l the information required i n the r e f e r r a l , or the doctor may f e e l there i s an emotional problem involved, and request casework f o r the pa t i e n t . In such instances the worker deals with a s p e c i f i c area of the problem i n co-operation with the doctor. At other times, requests are received by the s o c i a l s e rvice u n i t from doctors i n d i c a t i n g there does not appear to be anything p h y s i c a l l y wrong with the patient, but the emotional aspect may be important i n the s i t u a t i o n . When the worker receives a r e f e r r a l of t h i s nature, the patient i s interviewed, and the s i t u a t i o n explored, to f i n d out the area i n which the d i f f i c u l t y l i e s . Sometimes i t may be a family problem, disagreement between husband and wife, d i f f i c u l t y i n care of the ch i l d r e n , or i t may be r e l a t e d to d i s s a t i s f a c t i o n i n regard to the patient's present job. On the other hand, i t may be r e l a t e d to the f a c t of a patient being unemployed, and l a c k i n g the s a t i s f a c t i o n and con-fidence that can r e s u l t from s u i t a b l e employment. Again, there are other s i t u a t i o n s where the emotional component i n i l l n e s s r e s u l t s from a patient's fear of h i s disease e n t i t y , which i s a deterrent to s a t i s f a c t o r y recovery. Another type of emotional d i f f i c u l t y i s the cardiac, or hypertension patient, who needs to be helped to f i n d some s a t i s -f a c t i o n i n le a r n i n g to l i v e within the l i m i t a t i o n s imposed by h i s medical condition. This short discussion on the v a r i e d types of requests made to the s o c i a l s e rvice u n i t i n the out-patient department, i s only intended as an i l l u s t r a t i o n , and i s not i n any way i n c l u s i v e of a l l the services requested. 40 Figure 1. . Medical Social Services Requested for Patients. Percentage of total II III IV Income inaintainance Housing, employment. Employability assessment = 1 Social information. 41 The services most often requested in relation to the five broad categories referred to within the foregoing discussion are illustrated i n figure 1, and show some facts in regard to requests from the social service unit. In the f i r s t place, the large majority of requests are for brief services, when i t may only be necessary for the worker to see the patient once or twice. Secondly, these services are of a practical nature, such as requests for financial assistance, accomodation, and employment. Thirdly, the requests for social information i n regard to diagnosis and treatment planning, together with assistance related to problems of anxiety and social relations, represent only 5*1$ of the total services given. Chapter III S o c i a l Services. The Doctor's Viewpoint What i s the degree of p a r t i c i p a t i o n of the medical s t a f f i n the s o c i a l s e r v i c e program of the out-patient department, with s p e c i a l reference to the method of r e f e r r a l ? What i s the doctor's viewpoint from personal experience i n u t i l i z i n g s o c i a l services as an a i d to medical s o c i a l t r e a t -ment? The questionnaire formulated to f i n d t h i s out, covered three areas of h o s p i t a l s o c i a l s e r v i c e , the method of r e f e r r a l preferred by the doctors, the kinds of s o c i a l information most u s e f u l to the. medical s t a f f , the kinds of s o c i a l s e r v i c e most frequently requested by the doctors. In a d d i t i o n , i t asked f o r suggestions f o r Improving the work of the s o c i a l service department, and i t a l s o asked what the doctors regard as the most important functions of s o c i a l services i n out-patient c l i n i c s , and whether, i n t h e i r judgement, enough patients are being r e f e r r e d to s o c i a l s e r v i c e s . Five of the eight questions included a check l i s t of possible ans-wers, but with space provided f o r a l t e r n a t i v e s . The three other questions were of a more subjective nature, asking d i r e c t l y f o r the doctor's opinion *•. based on h i s own experience. In preparing the questionnaire, several f a c -tors had to be taken i n t o consideration. Since i t was r e a l i z e d that the doctors were involved with c l i n i c a c t i v i t i e s , i n which there i s a great deal of "paper work", i t was necessary to prepare a questionnaire that would be b r i e f , concise, and p r a c t i c a l . Again, as f a r as can be ascertained, i t i s the f i r s t time such a project has been c a r r i e d out i n the out-patient department. For. t h i s reason, the questionnaire was constructed i n such a manner that i t * The purpose of the questionnaire was outlined i n two short para-graphs at the top of the f i r s t page. See Appendix A. 43 would not simply be a survey of the uses the medical s t a f f were making of s o c i a l s e r v i c e s , but also some i n t e r p r e t a t i o n of t h e i r conception of the function and importance of these services i n r e l a t i o n to the c l i n i c s e t t i n g . Probably one of the most important aspects of the questionnaire was the oppor-tu n i t y i t offered f o r suggestions i n regard to the improvement of s o c i a l services i n the out-patient department. Part of the d i f f i c u l t y i n the use of a questionnaire i n obtaining relevant material i s r e l a t e d to a consideration as to whether i t should be mailed to the personnel concerned, or whether i t should be used i n conjunction with a,personal interview. Mailed questionnaires frequently get a disappoint-i n g r e t u r n . On the other hand, personal interviews, i n conjunction with the questionnaire, give much better r e s u l t s . The time required f o r interviews, however, a l s o needs to be taken into consideration i n comparison with the f i r s t procedures. Another consideration i s the large number of doctors i n the out-patient department, who, i f they were a l l to be contacted, would, because of the time involved, exclude the use of the personal interview. These were some of the considerations involved i n deciding the best way i n which to use the questionnaire i n t h i s part of the pr o j e c t . As a r e s u l t , a compromise was decided upon; to check c e r t a i n c l i n i c s and interview the doctors, with the questionnaire,;' The c l i n i c s chosen f o r t h i s purpose were the " s p e c i a l t y c l i n i c s " , namely, G a s t r o - i n t e s t i n a l , Diabetes, Haemotologyj Hypertension, Endocrine, M e d i c a l - A r t h r i t i c , Neurology, Cardiac, and Dermatology. From these c l i n i c s , twenty-four out of a possible twenty-five doctors were interviewed, the pro-cedure being: the doctor was interviewed, and the purpose of the questionnaire explained. Further a m p l i f i c a t i o n or c l a r i f i c a t i o n was given i n regard to any questions, i f asked f o r , and the questionnaire then completed by the doctor, 44 or interviewer, depending on h i s or her personal wishes. The only regret i n regard to t h i s procedure, i s that i t was not possible to interview the doctors i n a l l the c l i n i c s , with the questionnaire. This may, however, become a poss-i b i l i t y at some future date. In i n t e r p r e t i n g the r e s u l t s , i t i s relevant to remember t h i s i s only a sample of the t o t a l c l i n i c group, and because of t h i s , the opinions and preferences expressed may not n e c e s s a r i l y be representative of the t o t a l medical group i n the out-patient department c l i n i c s . I t i s , nevertheless, a good cross section of medical personnel. These are a l l p r o f e s s i o n a l men with years of c l i n i c experience i n r e l a t i o n to the use of s o c i a l services as a p a r t of medical treatment programs. Method of r e f e r r a l to S o c i a l Service. A large majority of the c l i n i c doctors stated that they found the p r a c t i c e of w r i t i n g r e q u i s i t i o n s a convenient method of making r e f e r r a l s to medical s o c i a l services i n the out-patient department, only three d i d not q u a l i f y t h e i r answers by i n d i c a t i n g the use of supplementary procedures, while three doctors d i d not f i n d the w r i t i n g of r e q u i s i t i o n s a convenient method of r e f e r r a l . The answers on supplementary procedures s p e c i f i e d several a l t e r n a t i v e s . Thirteen doctors s i g n i f i e d that the written r e q u i s i t i o n should be supplemented by a discussion of the r e f e r r a l with the s o c i a l worker. The doctors who d i d not view the written r e q u i s i t i o n as a convenient method of r e f e r r a l , preferred to discuss the r e f e r r a l with the s o c i a l worker. Two doctors checked both "yes" and "no" on w r i t i n g r e q u i s i t i o n s , one q u a l i f y i n g h i s answer by suggesting that, f o r some r e f e r r a l s , the r e q u i s i t i o n was s u f f i -c i e n t , while i n other instances, a discussion with the worker would s u f f i c e . 45 The other physician who answered the question i d e n t i c a l l y , stated, i n h i s opinion, a d i s c u s s i o n with the worker was valuable only when held i n p r i v a t e . One of those who answered the question both p o s i t i v e l y and nega-t i v e l y , suggested the method of r e f e r r a l to be used depended on the nature of the problem, and the a c t u a l w r i t i n g of a r e q u i s i t i o n informs the patient of the doctor's i n t e n t , while another doctor pointed out that the w r i t t e n r e -q u i s i t i o n was the best method of r e f e r r a l f o r a single problem. I t can be seen, by the foregoing discussion that there apparently i s not, a c t u a l l y , one single method of r e f e r r a l to medical s o c i a l s e r v i c e s , but, rather, a combination of several, of which the w r i t t e n r e q u i s i t i o n , plus a discussion with the worker, seems to be most u s e f u l to the doctor. Several of the group went f u r t h e r , and offered suggestions i n regard to the improvement of the r e f e r r a l form i n present use. One doctor thought the r e f e r r a l form was too b r i e f , and d i d not ask the doctor enough questions, therefore, the present form, M.234» needs to be expanded. For instance, i n regard to r e h a b i l i t a t i o n planning, such categories as educational opportunities, and vocational t r a i n i n g , could be added under t h i s p a r t i c u l a r heading. By expanding the r e f e r r a l form i n t h i s way the doctor would be better informed as to the services o f f e r e d by the s o c i a l s e r v i c e u n i t , and, at the same time, he could be more e x p l i c i t i n h i s reasons f o r r e f e r r i n g a p a t i e n t . The suggestion here, f o r expansion i n regard to information on the form, was not only i n r e l a t i o n to r e h a b i l i t a t i o n planning, but a l l areas mentioned. Another suggested that the combination of the written r e f e r r a l and a discussion with the worker should be again supplemented by a follow-up procedure whereby the treatment plan would be c a r r i e d on i n close co-operation. 46 Again, several doctors indicated a real need for more exchange of opinions between medical social service personnel and the physicians of the out-patient department. This, i n brief, i s a summary of the answers given by the doctors to the f i r s t question regarding the method of referral to the social service unit. From the doctors' overall responses, and comments, as a group they are aware of the need for a close working relationship with the medical social services. They have found the referral form useful, i n many instances, but not entirely adequate, and needing supplementary, or alternative procedures. The form should be expanded, so that doctors could receive further information which would be helpful i n planning the referral to medical social services. The suggestion for the expansion of the referral form i s related to the need for closer co-operation with the social worker, so that his role i n the treatment process could be more clearly defined. On the other hand, medical social services would welcome the opportunity of developing procedures to improve co-operation. While the area of closer co-operation was stressed by the doctors, the procedure used during November, 1960, did not always show such co-operation, therefore, i t seems desirable to investigate this area further, through closer examination. Social information. For the purposes of this survey, the items included as social infor-mation were as follows: patient's family and social relationships* employment history; economic status; patient's plans on discharge; his reaction to his illn e s s ; and home and community resources for his use. These were to be a 47 guide i n answering the question, "What kinds of s o c i a l information do you f i n d most u s e f u l ? " The r e s u l t s suggest the doctors as a group have shown keen per-ception i n t h e i r r a t i n g of the comparative values of the d i f f e r e n t items. Out of the twenty-four doctors who answered t h i s portion of the questionnaire, eight included a l l items i n t h e i r responses, and three of these, i n d i c a t i n g the items chosen would depend on the p a r t i c u l a r patient and the problem f o r which he was being r e f e r r e d . The other f i v e were i n a group of nine doctors who s i g n i f i e d t h e i r i n d i v i d u a l preferences by p l a c i n g numbers 1-6 beside the respective items. From t h i s group using numbers, four d i d not use a l l the items mentioned. The majority checked from three to s i x items; three checked two items, four checked one item, and none f a i l e d to check any of the items. (Table 3.) There was some d i f f i c u l t y i n deciding which items of s o c i a l informa-t i o n were most frequently used, owing to the f a c t that a number of the doctors included them a l l . Taking into consideration, however, those most frequently mentioned, nineteen out of twenty-four doctors stated that home and community resources f o r the patients was one of the most u s e f u l areas looked f o r i n s o c i a l s e rvice reports. Close to t h i s area, i n frequency, on the l i s t , was s o c i a l information i n regard to the patient's family and s o c i a l r e l a t i o n s h i p s . The item appearing of l e a s t importance to the doctors, was that of the patient's r e a c t i o n to h i s i l l n e s s . Only ten of the twenty-four doctors answering the questionnaire mentioned t h i s item, and there were others who questioned the use of t h i s item as an area of s o c i a l information. This i s important and demands further a t t e n t i o n . 48 What might he c a l l e d the middle range of items, and of equal import-ance, were the two, namely, economic status, and patient's plan on discharge. In terms of preferences expressed "by the medical personnel, these two items were checked by sixteen doctors i n each instance. One of the important f a c t o r s i n an a n a l y s i s of the responses given as to the kinds of information most u s e f u l to doctors, i s that the v a r i a t i o n between the middle range of frequency, and the top preference, i s a narrow margin 16-19. In the category stated as "Other", where opportunity was given f o r suggestions as to the kinds of information not mentioned i n the questionnaire, several doctors added t h e i r comments r e s u l t i n g from t h e i r experience. One i n d i -cated that i t appeared to him about 8Cf/° o f a medical s o c i a l worker's task was i n regard to the development and f a c i l i t a t i o n of home and community resources, so they could be used by the patient to reach an optimum state of p h y s i c a l and mental health. Another doctor, t h i n k i n g i n terms of r e h a b i l i t a t i o n d i f f i c u l -t i e s f o r chronic n e u r o l o g i c a l cases, ind i c a t e d the lack of information regard-i n g v o c a t i o n a l t r a i n i n g , and i n c e r t a i n instances, r e t r a i n i n g f o r s p e c i a l jobs. I t may well be, that i n both the areas suggested here, there i s a necessity f o r a c t i o n on the part of medical s o c i a l services i n regard to the development of adequate f a c i l i t i e s i n the f i e l d of r e h a b i l i t a t i o n . This, of course, would mean co-operation with the physician and other h o s p i t a l personnel. I t could happen that the lack of a v a i l a b l e information i n r e l a t i o n to c e r t a i n areas of r e h a b i l i t a t i o n i s r e l a t e d to the lack of adequate f a c i l i t i e s i n the community. Since i t was stated above that the least-mentioned item by doctors was the patient's r e a c t i o n to h i s i l l n e s s , the f a c t should be further c l a r i -f i e d . Some expressed the f a c t that they d i d not see t h i s as an area of s o c i a l information, but was p r i m a r i l y the doctor's r e s p o n s i b i l i t y to obtain 49 such information from the patient. On the other hand, part of a l l social work orientation i s to see the patient as a person, and to help him express his personal feelings i n regard to a particular situation i n which he finds himself. Again, a patient's reaction to his il l n e s s i s related to the way i n which the family views his i l l n e s s . It does not seem possible that an assess-ment of a patient's reaction to his present d i f f i c u l t i e s could be given a r e a l i s t i c perspective i n isolation from these considerations. In reviewing the responses given by the doctors i n regard to the most useful kinds of information, i t appears there i s a wide variation i n what they expect from social workers. Some would confine the wanted information from medical social service, to a small area, assuming responsibility for the remainder, themselves. A large majority of the doctors, however, realizing the value of pertinent information i n relation to the social component of il l n e s s would desire a closer working relationship where a more complete under-standing of most useful information could be achieved. From the interest and concern shown by the doctors i n this project, i t would appear this area i s one i n which further research would be profitable. While i t i s important to know the kinds of social information which are most useful to the doctors, i t i s also important to know how they would prefer to obtain this information. This i s the substance of the third question. The responses given by a l l the doctors i n this instance show the majority are i n favour of not one, but a combination method of obtaining information from the medical social services. Nine of the doctors preferred to have the social information placed on the medical chart, while another two would sooner have i t given verbally. Those who indicated preference for a combination method believed the social information should be written on the 50 chart, and supplemented by a discussion with the worker. There were a number of comments i n t h i s regard, and they are, i n the main, as follows: (a) Basic f a c t s on the chart, with impressions given v e r b a l l y . (b) Information given v e r b a l l y , but a l s o placed on the chart, as a permanent record f o r the doctors. (c) Information should be w r i t t e n on the chart, and occasionally given v e r b a l l y i n urgent s i t u a t i o n s . (d) Information should be written on the chart, and i f something i s omitted (on the chart) i t could be given v e r b a l l y . (e) The most suitable method of obtaining information depends on the problem. ( f ) I t was also suggested the report to be written on the medical chart should not be verbose, but b r i e f and concise pertinent s o c i a l information based on the p a r t i c u l a r area of i n q u i r y i n r e l a t i o n to a s p e c i f i c case. The responses given by the doctors, indicated above, suggests t h e i r preference f o r a combination method of obtaining s o c i a l information i n most instances, sometimes depending on the nature of the problem. Some of the suggestions i n regard to the method would appear to indicate that doctors do not always receive the information they d e s i r e , and c e r t a i n l y , t h i s i s a f a c t , but may, i n some instances, be r e l a t e d to the nature of the method used i n requesting s o c i a l s e r v i c e s , and c l a r i t y here may undoubtedly f a c i l i t a t e the kind of information to be given. The r e f e r r a l s to the s o c i a l service u n i t examined e a r l i e r i n t h i s p roject appear to indicate there are instances when the service requested was not i n any way too c l e a r , because of the f a i l u r e to state s p e c i f i c a l l y the nature of the request. At a l l events, f u r t h e r examination of the t o t a l s i t u a -t i o n would be necessary to continue the d i s c u s s i o n and i t seems the crux of the matter has been mentioned a number of times by the doctors i n suggesting c l o s e r l i a i s o n between the medical personnel and the s o c i a l services s t a f f 51 of the out-patient department. Reasons f o r R e f e r r a l Doctors r e f e r patients to medical s o c i a l services f o r a number of d i f f e r e n t reasons. To a s c e r t a i n the most frequent reasons, categories were developed i n a c a r e f u l l y considered l i s t , where the doctor was given the choice of checking the items he repeatedly used i n r e f e r r i n g patients to the s o c i a l service u n i t , and/or adding others which were not on the l i s t . Included on the l i s t were seven types of services u s u a l l y performed by s o c i a l service personnel i n a medical s e t t i n g : (a) Obtaining a s o c i a l h i s t o r y e i t h e r general or s p e c i a l . (b) Assistance i n planning convalescent care. (c) Helping r e l a t i v e s towards a better understanding of the patient's i l l n e s s and h i s needs. (d) Helping ameliorate patient's anxieties and f e a r s . (e) Helping patient toward r e h a b i l i t a t i o n planning. ( f ) Helping patient with f i n a n c i a l d i f f i c u l t i e s . (g) Helping patient modify unfavourable a t t i t u d e s . Table 3 S o c i a l Information Considered MostJJserul (Analysis of 24 questionnaires, A p r i l .1961..). Number of Number of Information Requested (Frequency) To t a l items items Doctors . - requested. checked a b c d e f £ h A l l 8 8 8 8 8 8 8 1 49 One 4 - - 1 - - 3 - 4 Two 3 1 1 - 2 •1 1 - 6 Three 4 3 1 3 2 3 - 12 Pour. . A A 2 . 3 • .3 4 1 17 Five 1 1 1 1 1 - - - 5 Total 24 17 13 16 16 10 19 1 1 93 52 In Table 3> the items l i s t e d from the questionnaire were as follows: (a) patient's family and s o c i a l r e l a t i o n s h i p s , (b) employment h i s t o r y , (c) economic status, (d) patient's plans on discharge, (e) h i s r e a c t i o n to hi s i l l n e s s , ( f ) home and community resources f o r h i s use. The a d d i t i o n a l items l i s t e d by the doctors were: (g) vocat i o n a l t r a i n i n g , and r e t r a i n i n g f o r s p e c i a l jobs f o r the handicapped, and (h) more information from medical s o c i a l services i n regard to home and community resources, f o r use of the pat i e n t . There was a wide v a r i a t i o n i n the responses given, both i n the number of items checked by doctors, as w e l l as i n the p a r t i c u l a r items checked. This seems to in d i c a t e the use, by the doctors, of the s o c i a l service u n i t i n the out-patient department f o r a v a r i e t y of se r v i c e s . I ndividual doctors make r e f e r r a l s f o r d i f f e r e n t reasons, which may w e l l be r e l a t e d to the p a r t i c u l a r d i f f i c u l t y f o r which the patient i s being treated. The doctors, as i n former questions, were s e l e c t i v e . In i n d i c a t i n g t h e i r reasons f o r r e f e r r a l from the items on the l i s t , a group of the doctors numbered t h e i r choices on a basis of the frequency i n which they were used. Nine doctors answered the question i n t h i s way: one doctor d i d not check any items on the l i s t , but gave h i s own reason f o r making r e f e r r a l s , none i n the group checked a l l seven items l i s t e d i n the section. The other twenty-three doctors checked the f o l l o w i n g number of items; two doctors checked one item, f i v e checked two, seven checked three, three checked four, three checked f i v e , and three checked s i x items. In ad d i t i o n to t h i s , three doctors o f f e r e d other reasons f o r r e f e r r a l . The reason f o r r e f e r r a l chosen repeatedly by the doctors, was that of h elping the patient with f i n a n c i a l d i f f i c u l t i e s . This was followed c l o s e l y 55 by the item i n regard to helping the patient towards rehabilitation planning. It i s important to connect this with the fact that financial requests, includ-ing appliances, dentures and glasses, made up 78/o of the referrals to medical social services. (Chapter 2 ) . At the bottom of the l i s t , preferences indicated by the doctors were items; (c) economic status, (d) patient's plans on discharge, and (g) vocational training, and retraining for special jobs for the handicapped, which might be considered as direct treatment services. These items were mentioned six, ten, and four times i n order of preference. Again, i n making a comparison with the requests for services i n Chapter 2 , i t i s significant that these services comprised only about 5*5 per-cent of the requests to the medical social service unit during November, i 9 6 0 . What might be called the middle group i n this section are items; (a) obtaining a social history, which was mentioned eleven times by the doctors, i n checking their preferences, and (b) assistance i n planning con-valescent care, mentioned thirteen times. It i s not surprising item (g) vocational training, and retraining for special jobs for the handicapped would be important, because, i n an out-patient department, patients are often referred from the wards, when they are discharged from the hospital. These requests are made for assistance i n f a c i l i t a t i n g the use of community resources on their behalf. Item (a), the obtaining of social histories, received more promin-ence in this section, than i t did in the examination of referrals. Again, there is no special reason why any particular section of the questionnaire should agree with the indications i n Chapter 2 , since they would not neces-sa r i l y be the same. 54 Looking at this section of the questionnaire from the standpoint of the overall responses given, the indications point to the doctors' evi-dent awareness of the contribution the social service unit can make towards the rehabilitation of patients, particularly through practical services such as financial assistance, accomodation, assistance i n finding employment, vocational training, and, to a lesser extent, because of the greater need for brief services, social histories as an aid i n diagnosis. It appears the doctors feel there i s l i t t l e need for assistance from medical social services i n helping to interpret illness either to the patient or his relatives. What may be involved here was expressed by several of the doctors, that there i s no substitute for the doctor-patient relationship. Because of this, the whole area requires further exploration before the situation can be amplified. (See Figure 2, page 55.) Other Social Information Required. The questionnaire at this point asks for suggestions from the doctors for kinds of social information which might be helpful, yet were not included in question No. 2. Of the twenty-four doctors i n the group who answered the questionnaire, twelve did not answer this question. Another four doctors stated that either they were satisfied with the information they were receiv-ing, or they used the word "None", i n relation to other information that could be helpful to them. Eight doctors, however, or a third of the group, did give excellent suggestions regarding information they needed, but found great d i f f i c u l t y in obtaining. Because of the varied nature of the kinds of information and their value to the social service unit i n the out-patient department, they w i l l not be grouped together, but stated individually as they were suggested. The 55 Figure 2. Social Services Requested by Doctors. Frequency of reasons for which referrals made to  Social Services Department: 24 doctors. 10 - J L 15 i 2 0 25 J L 30 Financial assistance. 1 Rehabilitation planning. Planning for convalescent care. Diagnostic aid. Direct treatment services. Helping relatives of the patients. = 1 Helping patient's attitudes. 56 following are the suggestions* (a) Social service follow-up. (b) Types of available accomodation for cardiac patients. (c) Social histories of a number of patients often indicate that because of family background, they have a poor attitude to health and work. Information i s important i n this area for some c l i n i c s . (d (d) Most d i f f i c u l t problem: finding employment for the physically disabled. (e) Better liaison between medical social service, and other agencies in the community. (f) Specialized service for the specialty c l i n i c s . (g) Closer liaison between doctors and social workers, such as a social worker being attached to a particular c l i n i c for a stated period of time. (h) Since social service personnel cannot v i s i t the home, the information given i s second hand. These suggestions need amplifying, so that they may be more clearly understood. In two instances, (a) and (b) the suggestions of community follow-up are quite important, since the information of the home situation i s equally important i n both diagnosis and treatment. It i s not possible to grasp what actually takes place i n regard to the interaction that takes place i n the home, or the patient's habits of l i v i n g , unless i t can be observed f i r s t hand. Again, i t i s hard to plan a successful rehabilitation program without being able to assess the needs and progress i n relation to the patient's home situa-tion. Also, i t seems important for the doctor to have different types of accomodation suitable for cardiac patients available for his use. Having this information, he can refer a patient for a certain type of accomodation and know his patient i s not climbing three flights of stairs when this i s 57 detrimental to h i s health. Suggestions (c) might have "been discussed with (a) and (g) because pertinent information required i n regard to s o c i a l h i s t o r i e s of some patients i n regard to family background can only be grasped i n the home situation.fronr family, r e l a t i v e s , and f r i e n d s . This i s only possible when the worker can v i s i t the home s i t u a t i o n and make an "On the spot" assessment. Another doctor mentioned the d i f f i c u l t problem of the s o c i a l service u n i t i n f i n d i n g s u i t a b l e employment f o r disabled patients. Not only informa-t i o n i s l a c k i n g here, but so are the work opportunities, and i t may w e l l be, that only as the community i s helped to a r e a l awareness and concern f o r i t s r e s p o n s i b i l i t y i n providing employment f o r the disabled person, that better r e s u l t s may be achieved i n t h i s important area of r e h a b i l i t a t i o n . The kind of information requested from the s o c i a l u n i t by a doctor, i s c l o s e l y r e l a t e d to an atmosphere of understanding f a c i l i t a t e d through a close working relationship} the f u r t h e r need f o r which being indicated by two doctors, one i n regard to the c l i n i c s i t u a t i o n , and the other to the community. Undoubtedly, i t i s not only advisable, but extremely important, and since both the doctors and the s o c i a l s e r v i c e workers are aware of the increased need f o r a c l o s e r working r e l a t i o n s h i p , procedures w i l l be sought to enhance the present s i t u a t i o n . F i n a l l y , one doctor stressed the need f o r s p e c i a l i z e d services f o r the s p e c i a l t y c l i n i c s . In t h i s respect he was not alone, as a number of others implied the same, i n a discussion of the questionnaire. The a c t u a l i n d i c a t i o n here, was that a s o c i a l worker, supplying s o c i a l information i n regard to any of the s p e c i a l t y c l i n i c s , needs an o r i e n t a t i o n i n the c l i n i c s i t u a t i o n , so 58 that, through a better understanding of the way i n which the p a r t i c u l a r i l l -ness a f f e c t s the patient, he w i l l have a better idea of the information most valuable to the doctor. I t was suggested by several doctors from d i f f e r e n t c l i n i c s that a medical s o c i a l worker might spend at l e a s t a year working with a p a r t i c u l a r s p e c i a l t y c l i n i c to gain the o r i e n t a t i o n needed. While t h i s suggestion may appear to be i d e a l i s t i c , i t i s c e r t a i n l y not, from the stand-point of g i v i n g the optimum treatment i n the r e h a b i l i t a t i o n of p a t i e n t s , which must be the goal of any h o s p i t a l program i n i t s desire to f u l f i l i t s community o b l i g a t i o n . Improvement This section of the questionnaire i s c l o s e l y r e l a t e d to the l a s t s e ction asking f o r suggestions of kinds of information not mentioned i n sec-t i o n two, but deals i n a general way with the improvement of s o c i a l services i n the out-patient department. F i v e p o s s i b i l i t i e s f o r changes i n the u n i t operation were l i s t e d as considerations towards making the work more e f f e c t i v e from the point of view of the medical s t a f f . These suggestions are r e a l i s t i c , and a l l l i e within the realm of p o s s i b i l i t i e s f o r future changes within the s o c i a l service u n i t of the out-patient department. They are as followss-1. Is there a need f o r more a v a i l a b l e information regarding the services of Medical S o c i a l Service among the medical s t a f f ? 2. Do the doctors see a need f o r c l o s e r co-operation between the s o c i a l s e r v i c e s t a f f and themselves? 3. Would a s o c i a l worker a l l o c a t e d to each c l i n i c be more h e l p f u l to the medical s t a f f ? 4. Should, there be more s o c i a l workers a v a i l a b l e i n the out-patient department? 5. Should s o c i a l workers p a r t i c i p a t e i n d a i l y c l i n i c rounds? 59 These were the suggestions, leaving room f o r other suggestions of the doctors. The t o t a l group* of twenty-four doctors answered t h i s question, but f i v e d i d not check any of the items, but gave t h e i r own suggestion instead. These suggestions w i l l be discussed l a t e r i n t h i s section. Just over h a l f the doctors i n d i c a t e d that the a v a i l a b i l i t y of a worker i n each c l i n i c would, from t h e i r standpoint, be a r e a l help. I t was a l s o noted, since there are at l e a s t twenty-three c l i n i c s i n the out-patient department, i t would be an i m p o s s i b i l i t y to have a worker attached to each c l i n i c ; s t i l l , at l e a s t ten of the c l i n i c s are small, i n terms of numbers of new patients being admitted each month, and, i n a d d i t i o n , a number of c l i n i c s are held at d i f f e r e n t times, and on d i f f e r e n t days. In any event, the sugges-t i o n i n terms of a worker attached to each c l i n i c was i n r e l a t i o n to the l a r g e r c l i n i c s . In t h i s respect, i t i s s i g n i f i c a n t that, i n most instances, i t was the doctors from the l a r g e r c l i n i c s who indicated t h e i r approval of t h i s suggestion. Second i n importance to the medical s t a f f , was the need f o r more a v a i l a b l e information i n regard to the services offered by the s o c i a l service u n i t i n the department. I t would appear that i t i s sometimes too easy to assume medical personnel are aware of the services o f f e r e d by the s o c i a l service department, when often t h i s might not be the s i t u a t i o n . The f a c t of t h i s need being expressed by the medical s t a f f i s important, i n that the s i t u a t i o n can be r e c t i f i e d accordingly. S l i g h t l y less than h a l f of the group mentioned the need f o r closer co-operation between medical and s o c i a l service personnel. I t i s s i g n i f i c a n t 6.0 that the doctors, as a group, made reference to t h i s same area i n question No. 1, on methods of r e f e r r a l , where the need f o r a discussion with the worker was mentioned as desireable i n r e f e r r i n g a patient to medical s o c i a l s e r v i c e . The two other suggestions l i s t e d i n t h i s part of the questionnaire received l e s s a t t e n t i o n . Only four of the medical personnel drew a t t e n t i o n to the possible need f o r more medical s o c i a l s ervice personnel i n the out-patient department; yet, i f workers were to be attached to the larger c l i n i c s , as suggested, f o r a possible type of interneship, then t h i s change would be con-sequent upon the necessity of increasing the present s t a f f , even i f one worker was serving several c l i n i c s . Again, at an e a r l i e r point i n the questionnaire, follow-up procedure and home v i s i t i n g were stressed as important. Both of these suggestions are a l s o dependent upon enough s t a f f to carry out the program. Several of the doctors were i n favour of having workers take part i n c l i n i c interviews, as a portion of an o r i e n t a t i o n process to become more f a m i l i a r with the p a r t i c u l a r needs of the patient as the doctor sees them. Perhaps t h i s procedure could be c a r r i e d out on an experimental basis, to evaluate i t s importance i n r e l a t i o n to improved s e r v i c e s . There were some suggestions given by the doctors, and which were not included on the l i s t , which should be mentioned. Two of the medical s t a f f suggested p e r i o d i c conferences, both at the c l i n i c l e v e l , and at the group l e v e l . This seems to be a worthwhile procedure i n helping to achieve closer co-operation between the two groups, and at the same time would provide an opportunity f o r the sharing of information and ideas. One other suggestion was given i n regard to the improvement of the present r e q u i s i t i o n f o r medical s o c i a l s e r v i c e s , form M. 234* I t i s suggested 61 that i t would be helpful to the doctors i f the social service department was able to develop a routine, simplified, assessment form, as i t i s thought the present form may be too broad and vague. What could be of much more value, i s a form stating the particular areas used for social assessment, as they could be checked, with a few remarks, i f necessary, and returned to the doctor as a help to him i n gaining a total picture of the patient's d i f f i -culties . While i t appears there i s a real need for a type of form such as has been mentioned, the matter would have to be explored i n detail before being possible to determine whether such a form could be devised, and at the same time, used universally i n the social service department. The next section of the questionnaire asks a question which i s closely related to the reason for making referrals to medical social service, or, i n fact, the function of a social service department. The question asks, "What do you regard as the chief, or most important functions of social service i n out-patient department cl i n i c s ? " Out of the group of twenty-four doctors, two did not attempt an answer to this question. Several others referred to the answers given i n question four. Most of the answers given by the doctors varied considerably, from viewing the function of medical social services within narrow limits, to a broad base. Because of this fact, i t i s d i f f i c u l t to combine the answers given, and they w i l l be numbered "below. Pour of the doctors mentioned assistance to patients with finan-c i a l problems as the main function of medical social services i n the out-patient department. It would seem that while this i s an important function, i t i s only one of a number. Here are the remainder of the answers given:-62 1. Furnishing the medical staff with what i t cannot know, the patient's home background. (a) Emergency, as well as long-term help to patients with financial and family problems. 2. Follow-up advice to patients at home regarding co-operation i n treatment. 3. Patient rehabilitation — helping him by finding what type of work to which he i s suited, and directing him towards obtain-ing this work. 4* Assistance i n financial and convalescent problems. 5. (a) Agency for providing additional information about patients. (b) Relating patients to agencies and resources outside the hospital. 6. (a) To be of assistance res information and background, (b) Planning for overall management through knowing what services are available. 7. (a) To provide information on patient's social-economic situation. (b) To advise patient res various forms of social welfare services to which he may be entitled. 8. Diagnostic assistance, assistance i n planning convalescent care, desired treatment services, and f a c i l i t a t i n g services and practical help. 9. Better education of doctors res function of the social service worker, and the assistance he can give. 10. (a) To obtain the social history so i t can be applied to treat-ment, and (b) To help patients with employment and financial problems. 11. (a) The gathering of social histories, (b) Rehabilitation of patients. 12. Assistance i n the family setting, and acceptance of limitations imposed by the disease, and rehabilitation within the framework of the limitations. 13. Helping patient towards rehabilitation planning, and financial assistance. 14. Taking social histories and arranging rehabilitation planning. 15. (a) To supplement information given to doctors, by what happens outside the c l i n i c , i n order to arrive at accurate information, (b) Can he seen as an extension of the doctor i n giving support. 16. Restore confidence to patient, assistance i n clarifying economic d i f f i c u l t i e s , providing adequate housing accomodation, and a favourable environment socially and emotionally. 17. Convalescent care, financial assistance, rehabilitation planning, helping relations to a better understanding of patient's illness and needs. 18. To help i n untangling various home and economic problems. Prom the varied answers given, i t would appear the doctors view the main function of the medical social service unit from their particular c l i n i c perspective. It i s significant that a number of the doctors emphasize the home and family setting, and while this aspect has been commented upon before, this consistent approach seems to indicate that one of the important functions of a social service department is seriously hampered when a worker has to obtain his information second hand. Again, i n view of the fact sooial histories are mentioned a number of times, i t seems to be apparent this i s an important aid to medical diagnosis. The casework treatment aspect of medical social work has also been given attention. In general, i t appears the doctors have indicated their awareness of the important functions of social services i n the out-patient department. There are some instances where more information as to the ser-vices offered would be helpful. On the other hand, the social worker needs to be better informed i n regard to the particular needs of the various c l i n i c s . On this basis, i t would be possible for the social service unit to give more varied and improved services i n relation to the kinds of requests received. a The f i n a l section of the questionnaire queries as to whether enough patients are being referred to medical social services i n the out-patient department, and i f not, why not? From the group of twenty-four doctors answering the questionnaire, five did not answer this question, and four indicated they did not know. Five other doctors thought there were enough patients being referred to social services. A group of ten of the medical personnel indicated there were not enough patients being referred to social services, and gave their reasons. These were expressed i n the following way: a. Doctors are not aware of the services offered by Medical Social Services. b. Some doctors may not have had satisfactory experiences with medical social services i n the past. c. Sometimes doctors do not take time enough i n trying to under-stand the emotional aspects of patient's i l l n e s s . d. Often doctors are not aware of what services can be given, so they hesitate to refer patients. e. Patients are not desirous to be interviewed by medical social services. f. Referral of more patients could mean the necessary expansion of the social service department. The reasons given here, as to why more patients are not referred, show a considerable degree of self-analysis and thought. It has been again suggested that lack of information as to the services offered i s one reason, and oertainly this has been mentioned in many of the sections of the question-naire. Another factor to be given due consideration i s the unsatisfactory experience some doctors may have had i n referring patients to medical social service. 65 One cannot help hut suggest the need for social workers to subject themselves to the same self analysis, and through the same degree of enlighten-ment, come to grips with a consideration of the referral of patients. The question may be, are a l l the referrals from the doctors being given due con-sideration, and appropriate action? Is a suitable referral form being used which makes for c l a r i t y and appropriate action? Are we "hiding our light under a bushel" so that the help we can offer i s known only to ourselves? Such questions are a part of a necessary analysis for the f a c i l i -tation of adequate services to patients. Again, i t has been stated that some patients do not want to be interviewed by social services. Many reasons could be given for this, such as earlier experiences with other agencies, public opinion i n regard to the stereotype of welfare services. Inevitably, however, i n the search for answers to the question, i t i s necessary to inquire whether this attitude has been encouraged, or discouraged i n his previous experience with medical social service. Is the patient seen as a person or a case? Further examination of the situation would be necessary because of the implications involved before further discussion would be appropriate. To summarize the section, i t could be said that the reasons given as to why more patients are not referred to the medical social services depart-ment, are clear i n their implications i n regard to both doctors and social workers. The implications i n regard to expansion of social services i n the department, i s dependent upon further study as to the adequacy of present services and the actual need. In any event, the discussion of the doctor's responses to the questionnaire, i s not intended to be a comprehensive review of either their use of social services i n the department, or, indeed, what 66 the potentialities of the department might be, from the point of view of the medical staff. The twenty-four questionnaire reviewed here, are intended to produce enough of the doctors 1 experience and thinking to indi -cate their assessment of the referral system i n present use, and how improve-ments may be in i t i a t e d . Chapter IV Can Referrals Help Clin i c Service? It i s now possible to take up the most important task of the study. To what extent, and i n what ways can referrals aid c l i n i c service? The f i r s t step i s , perhaps, the method of referral, whether used by doctors or others i n requesting help from medical social service i n the out-patient department. A large majority of the doctors indicated their preference for the written requisition, with the opportunity to discuss the referral with a social worker. On the other hand, an examination of the referrals to the social service unit for the month of November, i960, appears to indicate a variation of methods. Methods of Referral When requests are made to the social service unit i n regard to discovering financial resources for the payment of dentures, glasses, and often appliances, i t i s done by means of a prescription from the doctor, and in some instances, such as for some appliance, accompanied by a written re-quisition. Requests to the social service unit for other services were also made, in a number of instances, by a written requisition, and sometimes, a discussion with the worker. There were, however, at least eleven instances where the patient was just sent to see a social worker. While i t i s under-stood that a variety of methods of referral may be required to suit p a r t i -cular c l i n i c situations, and, again, that requests are made to medical social service from hospital personnel other than the doctors, as well as the community, i t would seem there i s a real need for a l l requests to be made i n i t i a l l y on the form M.234. 68 The improvement of standards of medical care i s a continuing responsibility of a l l hospital personnel. Medical social services are a necessary part of an adequate hospital program, and the workers carry out many important functions, but the most important i s the practice of social casework. The effectiveness of "this service depends upon individualized study of the patient, so that his medical situation and i t s interrelationship 1 with his personal needs and problems may be understood." This involves co-operation with other professional disciplines, particularly medicine, and, as the doctor i s head of the treatment team, he has a responsibility, as part of study and treatment, to recognize the social and personal problems that may affect the patient's medical care, and to bring these to the atten-tion of the medical social worker. It can be done most effectively through the use of a written referral because of the following reasons. In the f i r s t place, medical social services, while a necessary part of the hospital program, are ancillary to that offered by the doctor, and should, i n fact, only be given with his consent. The Social Service Manual states, i n regard to casework services, "Referrals to Social Service are made primarily by c l i n i c doctors. Other personnel referring patients should 2 consult the doctor concerned and have his sanction for re f e r r a l . " Since the doctor i s the head of the c l i n i c team, i t follows that social services should only be given with his authorization. Because of this, fact, i f a request for service i s not indicated on the written requisition, 1.. The American Association of- Medical Social Workers, A Statement of. Standards to be Met by Social Service Departments i n Hospitals. Clinics . and Sanatoria. 1839 K s t . N.W., Washington 6,D.C. Third revision, 1949. 2. Policy Manual, Social Service Department, Vancouver General Hospital, August I960, p.12. 69 the medical social services have no authority to give any service. In the second place, the written requisition contains not only the doctor's signa-ture as authorization for service, but an indication of the service requested. Again, the tentative medical diagnosis i s also indicated, and i t w i l l be relative to the patient's illness that his needs can be assessed. It may, possibly, be said that a l l this information can be given when the doctor has the opportunity to discuss the patient with the social worker, which i s granted, for there i s no substitute for the advantages gained when the doctor and social worker are able to discuss the patient's needs. This procedure i s most important i n giving the quality of services desired. In actual practise, however, there are many occasions when i t i s not practical, from the standpoint of time, or a v a i l a b i l i t y , for either the doctor or social worker to meet for discussion. Thus i t i s imperative that a l l requests for medical social services be made i n i t i a l l y on the requisition form provided for this service; then i t may be supplemented by whatever pro-cedure may be desired by the referring party. Numerous other reasons could be given i n regard to the necessity for the written requisition, however, the writer does not wish to labour the point, but to stress i t . Some suggestions were given by several doctors regarding improve-ment of the re f e r r a l form, indicating there should be more questions asked of the doctor. These suggestions are appreciated and i t may well be the time when the present form ought to be revised. This, however, would require further examination which was not possible when this study was undertaken, but could be a point of further research. 70 Kinds of Information Most Useful to Clini c Doctors. The kinds of information most useful to the c l i n i c doctors i s another important aspect; here a large majority of the doctors stated that information on home and community resources and in regard to the patient's family and social relationships was most valuable. (Table 3). This emphasis upon the home as an important area of information has been stressed i n other sections of this questionnaire. Because of this particular stress upon the home and family relationships, i t becomes necessary to again ask the question. How i s medical social service to obtain such important information when, at present, i t i s not allowed to v i s i t outside the hospital area? This question i s clearly related to the standards of medical care which the hospital would seek to give the community i t serves. Medical social services, i n conjunction with other disciplines, has a responsibility for participation i n program planning and policy formation with the medical institution" to help improve the standard of medical care. The medical social worker,, when able to see the interaction between patient and family in the community setting, i s able to evaluate effectively such facts as the patient's personality assets and l i a b i l i t i e s , the st a b i l i t y of the family group, and their response to his i l l n e s s , and the importance of medical re-commendations. These are important considerations i n determining whether a patient can obtain an optimum of health and satisfaction i n the community. Again, the medical social worker, i n the persuance of these duties, gains a wealth of understanding and knowledge which can be helpful to hospital personnel i n the planning of policies and programs which w i l l improve medical care. A corollary of this statement i s that, in day-to-day relationship with 71 patients, they become consciously aware of d i f f i c u l t i e s which impede the improvement of medical care given to patients. This appears to be the point at which the medical personnel of the out-patient department could discuss this weakness in the treatment program with the hospital administration, in an effort to have the situation changed. In this relation, the onus i s on both c l i n i c doctors and social service personnel to prove the treatment value of such a step. Thus, i t might be possible to i n i t i a t e the change by a p i l o t project, where the situation could be evaluated from time to time and extended on a basis of i t s contri-bution to the high standard of treatment which the hospital would seek to give the community. Again, this i s not a new suggestion, but an extension of the hospital on the part of social services, which a number of hospitals i n the United States and Canada have found necessary to make, i n an effort to serve the community more adequately. One might question the f e a s i b i l i t y of the above suggestion by an examination of Figure 1, (Chapter three) which gives an indication, by percentages, of the services requested from medical social services i n the out-patient department, and indicating the requests were few i n number for information i n regard to home and family. Why the necessity of social workers v i s i t i n g the homes? This question could be answered i n several ways. Some doctors have indicated the information they are receiv-ing i s second-hand. Others have offered the suggestion that sometimes patients have not been referred because the doctors have not been satisfied with the services given. Part of the answer to this dissatisfaction may have resulted from the fact the information they were given by the medical social service was already known to them. Also, hospitals are desirous of 72 attaining the highest possible treatment standard within their a b i l i t y to create. This i s not only i n regard to assessment of the situation, but also in relation to follow-up of the treatment services given. One of the prime reasons for the establishment of medical social services i n the early part of the century was that the doctors saw the need, but did not have the time, to v i s i t the home situation, thus, the establish-ment of medical social services. It does not appear to the writer that any particular circumstances have developed which, in any r e a l i s t i c way, have changed the need for this important function. The responses given i n several sections of the questionnaire by various doctors, point to the lack of adequate information i n the areas of rehabilitation. This was particularly i n regard to the training or retrain-ing of the handicapped, and finding suitable employment for them within their limitations. Part of the problem could be related to the fact that the social workers are not well enough acquainted with the programs that are available i n regard to training and retraining for specific jobs. It seems desirable, i n this respect, that the social worker should have the opportunity to v i s i t , and develop a better liaison with the agencies giving these part i -cular services. In this way, they would be more familiar with the programs offered. On the other hand, there are very few opportunities i n the Greater Vancouver area for the employment of handicapped people. Therefore, i t would seem to be the responsibility of the community to provide such employ-ment f a c i l i t i e s . It i s true there are a few small industries i n the area who employ a majority of handicapped people, but these are small i n relation to the demand. Before very imich can be done to alleviate the situation, the community 73 needs to be better informed in regard to the actual need, and given an i n d i -cation of i t s responsibility to fellow citizens. The task of helping the community to become more knowledgeable res creating employment for the handi-capped seems to f a l l upon the shoulders of those who are working in the situation. Thus, doctors, social workers, and other rehabilitation agencies should co-operate together to inform, and to help the community carry out i t s responsibility i n this regard. To create suitable employment opportunities for the handicapped. This i s an area where medical social services have a responsibility with other hospital disciplines to participate in the develop-ment of social and health programs in the community. It does not seem possible that any hospital program of adequate rehabilitation can be developed without the consequent growth of community resources. Since medical social service personnel are i n constant contact with community agencies they have oppor-tunities to see the specific need for the development of new resources, i n trying to make suitable referrals for patients i n relation to their rehabili-tation needs. The whole area of rehabilitation requires further research, to determine what community resources are available, and how adequately they are presently being used. Any abrogation of our responsibility here, continues to place greater limitations upon the rehabilitation of the handicapped than i s either appropriate or necessary. Seasons for Making Referrals to Medical Social Services. this While i t i s important to/Study to know the kinds of information most useful to the medical personnel of the hospital, i t is equally important to know their reasons for making referrals to medical social services. Their responses to this particular section of the questionnaire were indicated i n Figure 2. It should be mentioned again, however, that f a c i l i t a t i n g services 74 and practical aid were the reasons most frequently suggested for referral to medical social services, while diagnostic aid and direct treatment services were not regarded as of the same importance. On the other hand, Figure 1, gives an indication of the frequency of services requested on the basis of new referrals to social services for the month of November I960. Upon examination, Figure 1, agrees f a i r l y closely with the frequency of reasons given for making referral by the doctors. In other words, i t appears that the referrals from the medical personnel, are, i n most instances, for environmental services — services external to the patient. For instance, only 5*1 per-cent of patients were referred for services i n relation to social information res diagnostic aid and treatment, or assistance with emotional problems. This indication of a desire for assistance from medical social service?for service i n the patient's environment,only becomes more clear when the doctors were asked to suggest the most important function of medical social service i n the out-patient department. The suggestions give very l i t t l e indication of the need for social services i n regard to helping patients with emotional d i f f i c u l t i e s . It seems to the writer that a subtle, but important, distinction has been made here, the external, as separate from the patient. It appears to stem from certain conceptions of the doctor-patient relationship, and i t would be foolish to underestimate the necessity and the therapeutic import-ance of such a relationship; but at the same time, i t should be pointed out that the medical social worker, i n fact a l l social workers, are professionally trained to use relationship as a technique i n assisting the individual to improve his social functioning. One could go even further,and say that relationship, used di f f e r e n t i a l l y , depending upon the circumstances, i s the 75 most important therapeutic function of casework practise. This function of casework, i n relation to the improvement of social functioning, has "been referred to i n (Chapter l ) , through a state-ment of Gordon Hamilton. Again, the team approach in c l i n i c a l treatment became a necessity as a result of specialization i n medicine, where, after a period of t r i a l and error, the concept of wholeness, or the treatment of the total individual was emphasized. Prom these considerations i t would follow that relationship with the patient i s shared between the various members of the treatment team. It may well be that a re-examination of the psychosomatic approach to ill n e s s may be necessary, both for medical and social service personnel. Such a re-examination could conceivably mean a considerable increasein requests to medical social service for diagnostic aid and help with emotional problems of patients. Prom the point of view of medical social service, i t would seem that this further opportunity would be welcomed to indicate the assistance that can be given, i n this way, to improve social functioning. Since the requests to medical social service, for services, are based upon an understanding of the functions of the department, here i s one way i n which referrals could be used more adequately to improve and extend c l i n i c treatment. There are other ways i n which referrals can help c l i n i c services. One of the functions of medical social service in any hospital setting, is to participate i n the educational program f o r professional personnel. This involves formal teaching of students i n conjunction with schools of social work, also work with students and practitioners of 76 related professions. This is one way i n which other hospital disciplines can become aware of the particular areas i n which medical social work can help to f a c i l i t a t e adequate rehabilitation of patients. There are also improved ways in which medical social workers have the opportunity to inter-pret their particular role to other personnel such as a discussion with the doctor regarding the patient, and c l i n i c a l conferences. Participation by a l l medical social service personnel i n an adequate educational program i n the institution can contribute to the improvement of medical care through a better informed use of referrals to the department. This i s very important since requests for services are made i n relation to the knowledge of the services offered. The study generally has revealed a lack of knowledge by medical personnel of the kinds of services which are available to patients. If more adequate information i s available, the medical social service unit should receive more requests for the services they are best qualified to give. The need for more co-operation has been expressed, and while this fact has pro-bably been noticed before, i t has not, presumably, been placed on record. Now that i t i s recognized, i t i s hoped suitable action w i l l achieve the working relationships necessary for improved functioning within the depart-ment. Referrals Can Help Clinic Services. A f i n a l , and big question, i s whether sufficient patients are being referred to medical social services? As was mentioned i n the previous chapter, a majority of the physicians answering the question did not f e e l that enough patients were being referred to medical social service. The main reasons 77 offered were; lack of knowledge of services offered, some unsatisfactory experiences, not following up the emotional aspects of a patient's i l l n e s s , and some patients not desirous of "being interviewed by medical social service. Before commenting further, upon these suggestions, i t would appear appropriate at this point to again draw attention to the fact that there were only 195 new patients referred to medical social services from a total of 600 new patients admitted to out-patient c l i n i c s for the month of November,1960. This figure, excludes Psychiatry, Gynaecology, and Obstetrics. While the implications of stat i s t i c s must be governed by due caution, i t i s quite evident the number of new patients referred to medical social services i s less than one third of the total for that month. While i t i s con-ceivable there were some of these patients who did not need the aid of social services, i t i s most l i k e l y a considerable increase of referrals to medical social services might have improved the medical treatment program for this group. In accordance with this trend of thought, i t is significant to specu-1 late as to why the World Health Organization i n "Technical Report" series No. 22, indicates that one medical social worker i s required per 2000 out-patients per annum in an out-patient department. During the year i960, the Vancouver General Hospital Out-patient Department had a total patient group of approximately 12,611. This would indicate the need for at least six professionally trained medical social workers. The staff complement indicated here, is i n considerable excess of the professional workers presently employed i n the unit; the- present staff-1. "Expert Committee on Professional and Technical Education of Medical and Auxiliary Personnel", World Health Organization Technical Report  Series. No. 22, Geneva, December 1950. 78 of the medical social service unit i n the Out-patient Department consists of one supervisor, two full-time professional workers, one case aide, and one driver clerk. While i t i s not the intention of this study to discuss the deploy-ment of staff, there i s sufficient indication given here that the number and qualifications of the staff are related to the number and kinds of requests made to the unit for services. Another way of indicating the implication here, i s that, on the basis of the World Health Organization standards, these referrals to social services f a l l far short of what might be expected, and that these requests do not make adequate use of the services offered by professional medical social workers. Therefore, more referrals to medical social service ought to be made by the doctors for particular services related to aid i n diagnosis, treatment planning, and emotional problems. Returning again to the discussion at the beginning of this section, as to some reasons why more patients were not referred to medical social services by c l i n i c doctors, there are several comments to be made. What has actually been indicated here by the doctors, i s that, through a more complete understanding of the services offered by medical social services, and better co-operation between the two disciplines, more referrals may be made to the social service unit. This would, again, have a bearing upon the improvement of c l i n i c services given to patients, since more patients would be receiving help i n accordance with their unmet needs. Therefore, medical social service would be giving services for which they have received special training. In such a manner, the quality and number of referrals would presumably reflect confidence i n the standard of services offered by the department to give 79 each patient the optimum opportunity for rehabilitation. It must be reiterated that an improved standard of care i n medical social service i s dependent upon implementation of recommendations such as are indicated i n this study. The present study has been one of exploration, i n which more questions have arisen than could be answered. It definitely points to some action which would be immediately demanded; i t leaves plenty of scope for the extension of c l i n i c a l services into wide areas of disease, disa b i l i t y , and social problems. These cannot be separated from other welfare services, and other community programs without loss or delay to the patients, and indeed, sometimes to the hospital. It i s the potential of the Out-patient Department, and the Social Service Department, to bridge the gap. 80 Appendix A THE UNIVERSITY OF BRITISH COLUMBIA School of Social Work USE OF SOCIAL WORK SERVICES; O.P.D. CLINICS, V.G.H. Many requests or referrals to the Social Service Department are made for help to 0. P.D. patients, but no assessment of this has been made for some time. I am now engaged in an exploratory survey of these referrals for a group of the O.P.D. Clinics. With Dr. Whitelaw's approval, i t is suggested that the views of the doctors most concerned (whether or not you make many Social Service referrals) should be sought. It would be greatly appreciated therefore i f you would take the time to answer the following questions. If you would like to supplement this with further comments, or ask me for further explanations, I should be glad to make an appointment at a- time suitable to you. Edwin Stilborn (Master of Social Work student, University of British Columbia). 1 . Do you find the writing of requisitions a convenient method of referral to Medical Social Service? Yes _ _ _ _ _ _ _ _ No As an alternative, do you prefer any of the following? Telephone conversation Discussion with social worker Sending patient to the Social Service office Other 2. What kinds of social information do you find most useful? patient's family and social relationships employment history economic status patient's plans on discharge his reaction to his illness _________ home and community resources for his use Other 3. Do you prefer to obtain social information verbally written on the chart some other method or combination ______ 4. Por what reasons do you most frequently make referrals to Medical Social Service? social history: general special assistance in planning convalescent care a helping relatives towards a better understanding of the patient's illness and his needs to help ameliorate patient's anxieties and fears helping patient towards rehabilitation planning for financial assistance _________ helping patient modify unfavourable attitudes towards the community on his return home Other (please give details) 5. What kind of aid or information do you think Social Service could offer which is not offered at present 6. What suggestions would you make to improve the work of the Social Service Department for O.P.D.? more information available about the services of MSS closer co-operation between IBS staff and doctors _________ a social worker allocated to each clinic more social workers available i n O.P.D. participation by social worker in daily clinic rounds Other 7. What do you regard as the chief or most important functions of Social Service in O.P.D. Clinics? 8. In your judgment, are enough patients finding their way to Social Service If not, why not? , Page 81, Appendix B FORM M-234 REV. 54 THE VANCOUVER GENERAL HOSPITAL NOTICE OF REFERRAL TO THE SOCIAL SERVICE DEPARTMENT Patient's Name Date Unit No. Nursing Unit Clinic Medical Diagnosis , REASON FOR REFERRAL: 1. Social History V 7. Discharge Plans 2 . Family Problem (a) Nursing Home Emotional Problem 3 . Affecting Illness (b) Boarding Home 4. Rehabilitation Plan (c) Institutional Care 5 . Appliance (d) Home 6. Financial Assistance 8. Other REMARKS: Doctor SOCIAL WORKER'S REPORT: S o c i a l Worker 82 Appendix C BIBLIOGRAPHY Books 1 . Alexander, Franz, M.D. Psychosomatic Medicine. W.V. Norton & Co. Inc. New York. 2 . Bartlett, Harriet M., Some Aspects of Social Casework in a Medical Setting. The Committee on Functions, American Association of Medical Workers, Chicago, I l l i n o i s , 1942. 3 . Cannon, Ida M., On the Social Frontier of Medicine. Harvard University Press, Cambridge, 1952. 4 . Cannon, Walter B.,The Wisdom of the Body. Norton, New York. 1952. 5 . Dunbar, Helen, Flanders, Mind and Body: Psychosomatic Medicine. Random House, New York, 1947* 6. Goldstine, Dora (ed.) Expanding Horizons i n Medical Social Work. University of Chicago Press, Chicago, I l l i n o i s , 1955« 7 . Goldstine, Dora, Readings in the Theory and Practice of Medical  Social Work. University of Chicago Press, 1954* 8 . Hamilton, Gordon, Helping People - The Growth of Expression. Social Casework, Columbia University Press, New York, 1952 . 9 . MacEachern, Malcolm, T., Hospital Organization and Management. Chicago, Physicians Record Co. 1947* 10 . McGibony, John R., Principles of Hospital Administration. G.P. Putnams, New York. 1 1 . Upham, Frances, A Dynamic Approach to Illness. Family Service Association of America. New York, 1953* (Second printing). Articles. Documents. Periodicals. 1 2 . Annual Report of the Vancouver General Hospital, 1916-1948 . 1 3 . Barsky, A.N. Casework i n a Veteran's Hospitals An Analytical Study of Referrals from Doctors, Shaughnessy Hospital, 1953-54*» unpublished Master of Social Work thesis, University of British Columbia, 1954* 1 4 . Chisholm, Brock, Organization for World Health, Mental Hygiene, July 1948 , Vol. 32 . pp. 3 6 4 - 3 7 1 . 83 1 5 . Collier,- Elizabeth, The Social Service Department of the Vancouver  General Hospital. 1 9 0 2 - 1 9 4 9 . 16. "Expert Committee on Professional and Technical Education of Medical and Auxiliary Personnel", World Health Organization Technical Report  Series. No. 2 2 , Geneva, December, 1 9 5 0 . 1 7 . Extract from Report on Mental Health Services. British Columbia, I960, pp 4 3 - 4 4 . 18. Hamilton, Gordon,"Helping People - the Growth of Expression." Journal of Social Service. Vol. 2 9 , October 1948. 1 9 . Fields,- Minna,- "Role of the Social Worker in a Modern Hospital", Social Casework. Vol. 3 4 , No. 9 , 1953* 20. Paton, John Robert Drury. )Medieai Social Service i n a -Veteran' s and Wiebe, John ) Hospital Out-patient's C l i n i c . University )of British Columbia, I 9 5 5 . 2 1 . Personnel Department and Function of the Social Service Department, Combined with Out-patient Department, Vancouver General Hospital. Mimeographed material, 1 9 3 0 . 2 2 . Policy Manual, Social Service Department, Vancouver General Hospital, August, i 9 6 0 . 2 3. Selye, Hans,- M.D.,"The Adaptation Syndrome in C l i n i c a l Medicine." The Practioner. January 1954* 2 4 . Towle,-Charlotte, Common Human Needs. National Association of Social  Workers. 95 Madison Ave., New York 1 6 , N.Y. 2 5 . The American Association of Medical Social. Workers, A Statement of  Standards to be met by Social Service Departments in Hospitals,  Clinics, and Sanatoria. 1839 K St. N. W. Washington 6 , D.C. Third revision, 1949* 2 6 . Weaver, Kenneth H..,. History and Organization of a Social Service Department, Canadian Welfare. Vol. 3 2 , 1 9 5 6 . Reprint from Canadian  Hospital. December 1 5 , 1 9 5 6 . 2 7 . White,- Grace,"Distinguishing Characteristics of- Medical Social Work," Readings in the Theory and Practise of Medical Social Work. 28. Woods, Walter S., Canada's Uebabilitation-Program, Department of Veteran's Affai r s . Treatment Service Bulletin. May 1 9 4 8 . 

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