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The social worker in the treatment team : an examiniation of representative cases in the Vancouver General… Le Huquet (Bowkett), Mary Frew 1951

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7 THE SOCIAL WORKER IN THE TREATMENT TEAM An examination of representative cases i n the Vancouver General Hospital Out Patient Department.  Thesis submitted in partial fulfilment of the requirements for the Degree of Master of Social Work i n the School of Social Work.  .1951.  University of British Columbia.  ABSTRAGT  The social worker i n the treatment team i s a phrase that i s heard often today*  In this age of scientific specialization, no one person can possibly  u t i l i z e a l l the available-knowledge required for health and welfare. Medicine, like a l l the other applied sciences, has developed so rapidly that theories change from day to day.  Through a l l this exciting and revolutionary change, the person  who i s sick i s often forgotten.  The patient i s often referred to as a peptic ulcer  or a tumour. At this present stage, there has been a rather interesting development. Medical scientists have suddenly realized that there i s a definite relation between the mind and the body i n sickness.  There i s , therefore, a need for a specialist  who has s k i l l s i n the treatment of social and emotional problems.  It i s i n this  area that the social worker lends her s k i l l s to the treatment team. Treatment no longer i s complete with r e l i e f from pain and the physical discomfort; i t must also be a r e l i e f from fear of financial insecurity, environmental problems, personality maladjustments and emotional frustration. This study i s an attempt to show where the social worker can be of value in the medical setting.  Social work i n the Vancouver General Hospital i s s t i l l  infantile i n i t s development and i t i s hoped this study w i l l be of some help i n defining the function of the social worker. The lack of r e a l casework services made the selection of cases very d i f f i c u l t .  The cases used were, for the most part,  done by students. The ten cases which were used were considered good examples of social work i n the hospital setting.  DEDICATION  This thesis i s dedicated to .Miss Eleanor Bradley, casework supervisor in the Social Service Department of the Vancouver General Hospital. The inspiration and encouragement she gave i s gratefully appreciated. I wish to express my gratitude also to Dr. Leonard C. Marsh for his assistance i n c r i t i c i z i n g and evaluating the research material.  (Miss) Mary Frew Bowkett  INDEX Page • 1  Chapter I  MEDICAL SOCIAL WORK. Medical Social Work before the 20th Century Influence of the Mayo Clinic Effect of the Child Guidance Clinic Medical Social Work i n Vancouver General Hospital  Chapter II  THE SOCIAL WORKER AND THE DOCTOR . Social Factors i n Illness Method of Referral Cases showing the Worker's Help i n Planning Discharge Cases showing the Worker'.s Help with Psychiatric Problems Cases showing the Worker's Help in Relieving Environmental Problems Proceeding Physical Care Summary  11  Chapter III  THE SOCIAL WORKER AND THE COMMUNITY. Group.Discussions . Inter Agency Conferences Inter Agency Methods of Referral Other Community Contacts Cases showing Referral for Financial Assistance or Outside Professional Contact Cases showing Inter Agency Co-operation Summary  31  Chapter IV  THE SOCIAL WORKER AND THE ADMINISTRATION . 47 Ways of Helping the Administration. Cases showing the Worker's Assistance i n the Discharge Plans Cases showing the Social Worker «.s Assistance i n Planning for Chronic Pre-Psychotic Patientsn Cases showing the Social Worker's Assistance i n Planning for Chronic Clinic Cases Summary  Chapter V  CONCLUSIONS AND RECOMMENDATIONS Recommendations  60  CHAPTER I MEDICAL SOCIAL TORK  1. The primary function of a hospibal i s the care of the patients.  The  manner of their organization and the efforts of a l l their administrative, professional and service personnel are directed toward the provision of medical care to combat i l l n e s s . of the hospital revolve.  The patient i s the focal point about which a l l activities (1).  Medicine today i s an exceedingly complicated and costly service.  Billions  of dollars are spent each year i n public health and medical care. The^rapid growth of governmental medical services has brought about a need for accurate thinking in the basic elements of complete medical care programs and standards of adequate quality of care. Hospitals no longer provide custodial care for the sick; instead they are medical centers for the whole community; providing a constellation of highly specialized and scientific f a c i l i t i e s for a l l people. The modern practice of medicine i s characterized by the exercise of teamwork, the doctor assumes the role of the leader and the other professional personnel associate with him.  The medical social worker contributes to this teamwork process  by the practice of social casework. Complete medical care cannot be effective i f the patient does not have the desire or-the a b i l i t y to carry out the medical recommendations. The social worker's contribution l i e s i n the understanding of the social and emotional factors which are preventing the'effective use of medical services•  Environmental problems, economic deprivation or medical misunderstanding  may be contributing toward the patients' illness or the duration of a d i s a b i l i t y . Knowledge of emotional behaviour i n illness, the understanding of medical science and practice, the acceptance of the patient as a whole organism and the knowledge of community resources are a l l basic to the role of the medical social worker i n the treatment team. (1)  Commission on Hospital Care, Hospital Care i n the United States. The Commonwealth Fund, New York, 1947, p. 66.  The professional social worker i n the hospital team has been a development of the late 19th and early 20th centuries.  Medical  social work before this  time was an unorganized lay service; stemming from the philosophy of responsibili t y toward one's fellow man*  The tremendous advances i n medical knowledge made a  division of tasks necessary for complete medical care.  This increasing specializ-  ation; the realization that illness was both emotional and organic was an influence in necessitating the need for a specialist i n dealing with the social and personality problems i n illness. MEDICAL SOCIAL WORK BEFORE THE 20th CENTURY Medical social work had i t s beginnings in the rise of the Christian Churches. The philosophy of the churches was based upon the obligation and responsibility of people to their fellow men.  An example of this philosophy was evident i n the  17th century in the work of St. Vincent de Paul.  This famous man i s considered to  be one of the fathers of present day social work. St. Vincent de Paul was responsible for organizing a group of nurses within the church for the purpose of visiting the sick*  This service may be presumed as a primitive beginning for both medical social  work or public health nursing. By the late 18th century, lady almoners had become a common part of the English hospital organization.  The almoners sought to comfort the patients in the  hospitals by caring in informal ways for their economic problems. The inception of lady almoners into hospitals was primarily for the purpose of establishing e l i g i b i l i t y for free medical care.  Hospital administrators of that time found the  e l i g i b i l i t y studies were tedious and time consuming; the need for personnel for this type of work therefore introduced the lady almoner to the hospital staff. Lady almoners attained a more responsible position i n hospitals i n 1690 through the influence of Charles S. Loch who was then Secretary of the London Charity  3«  Organization Society, With this new position of influence, the lady aim assigned the responsibility of bringing the resources of the community to the patients in need i n the hospitals.  This stage of development was an important  precursor of modern professional social work. There was also a form of social work developing i n the hospitals for the insane i n England,  This was an entirely voluntary organization known as the Society  for After Care of Poor Persons Discharged Recovered from Insane Asylums, Their services were concerned with the placement of patients either i n foster homes or convalescent institutions or guiding the adjustment of patients back into the community. The development of the nursing profession has had an important influence upon origination of medical social work. The primary function of the nurse i s of course the rendering of medical care. However, nurses have also given help to patients with their social and emotional problems.  The nurse has played a significant  part i n the unorganized services to patients by being constantly at the bedside during periods of pain and anxiety or visiting the home while the patient was becoming rehabilitated. The training of medical students has also been an instrumental in the formation of the profession of medical social work. The f i r s t example of instruction in medical social work for student doctors was instituted by the Medical School of Johns Hopkins University i n Baltimore, Maryland.  Dr. Charles P, Emerson, the  Director of the hospital included training not only in the classroom, but i n f i e l d work experience as well.  The students worked through the Charity Organization  Society of Baltimore. Each students was assigned a certain number of families and they were charged to "learn the intimate relationship between the i l l s of the physical body and the home environment. (2). !,;(2) Stroup, H.H., "Social Work; An Introduction to the Field". American Book Co&, New York, 19A8. u v  4. From these early unorganized services, the modern profession of medical social work has evolved*  The work of these early pioneers and the increasing  awareness of hospital personnel of the social and emotional needs of the patient have been responsible for the introduction of social workers into the hospital* Today, medical social workers provide four main types of servicesj (1) direct service to patients through casework, (2) indirect service to patients through administration, supervision and consultation, (3) community organization through the organization and co-ordination of resources within communities and (4) teaching.  Social workers provide these services in six general areas, (1) municipal,  provincial and dominion public health programs, (2) public and private hospitals, (3) professional schools, (4) public and private c l i n i c s , (5) municipal, provincial and dominion voluntary health agencies and (6) public and private welfare programs.(3) INFLUENCE OF THE MAYO CLINIC The division of tasks was begun by Dr. W.W. Mayo, Sr., and his two sons, William and Charles, when they graduated from medical school i n 1890*  They each  specialized to some extent, the father i n obstetrics and gynecology, Dr. William Mayo in abdominal surgery and Dr. Charles Mayo in eye surgery.  They consulted on  different cases and decided in conference on a plan of treatment for their patients. It was from this beginning that the c l i n i c idea evolved. Dr. Mayo, Sr., always held as a motto, "No man i s big enough to be independent of others"• (4)  It was this motto that influenced the beginning of the Mayo Clinic.  In the embryonic stage, the c l i n i c was involved essentially in surgery.  These con-  sultations took place i n the back room of a home belonging to Mrs. Carpenter, one of Dr. Mayo Sr.'s patients.  Dr. Mayo would advertise a certain operation and a l l  (3) "A Statement of Standards to be met by Social Service Departments i n Hospitals and Clinics", American Association of Medical Social Work, June 1949. (4) Helen Clapesattle, "The Doctors Mayo", University of Minnesota Press, Minneapolis, 1941* P» 534.  5.  who were interested were invited to attend to discuss and c r i t i c i z e . The c l i n i c became established i n the middle 1 8 9 Q ' s when St.Mary's Hospital i n Rochester was built and staffed by the Sisters of St. Francis. The Mayo doctors were invited to become the attending physicians because of the interest and help they had given during the formation of the hospital. added to the staff after this time.  Other partners were  With each new member, more f a c i l i t i e s were  added and greater-knowledge was accumulated. The reorganization and building of the Mayo Clinic was begun i n 1 9 1 4 * "It emerged as a distinct institution, a complete c l i n i c , including laboratories, housed under one roof". ( 5 ) Miss Clapsattlej author of the book, "The Doctors Mayo", suggests; that teamwork among doctors i s the most practical achievement i n modern medicine.  The  Mayo Brothers have been called the fathers of the teamwork process although Dr. William Mayo, J r . said i f they were, they did not know i t . . He has been quoted as saying, "We merely tried to solve the problems of their overwhelming practice in the way that seemed at the moment most likely to improve their surgery." (6) The Mayos, at a l l times, brought i n surgeons who would enhance the standards of the c l i n i c .  They were never-threatened by-the fear of having their glory dimmed.  They were interested in a l l phases of research and made special provision to participate i n lectures and clinics i n a l l other parts of the continent and Europe. The Mayo Brothers actually managed  to retain, i n co-operative form, the individ-  ualism Dr. William Mayo, Jr., said could no longer exist i n medicine. In actuality, the clinic did not remain a partnership but became a voluntary association that was both a group partnership and a corporation. A l l the members were on a fixed salary including the Mayo Brothers. (5) (6)  The organization was not  Helen. ,Clapesat t i e , "The Doctors Mayog University of Minnesota Press, Minneapolis, 1 9 4 1 * p. 5 3 4 * Helen GLapesattle, "The Doctors Mayo".University of Minnesota Press, Minneapolis, 1 9 4 1 , p. 5 3 4 .  •6. essentially a department store type of c l i n i c where there were separate sections for different needs*  "Its sections were not independent units> clustered in one  building for convenience; they were integral parts of a working whole".  (7)*  There was an insistence on the personal responsibility of the clinician to the patient. A patient entering the Mayo Clinic with a complaint would be-examined by two diagnosticians separately.  The diagnosticians would consult to determine the  most suitable specialist for the patient.  The patient would receive an explanation  of the tentative diagnosis and be prepared for transfer. The diagnosticians i n consultation with the specialist would make a plan for treatment for the patient. The physicians and patients i n this way were assured of exact diagnosis and confidence in treatment. "With growth a measure of specialization developed among the men.....the Mayo brothers• kept them working i n teams none the less, instead of splitting off each into a l i t t l e pigeonhole of his own - and wisely, because a team can undertake problems of greater magnitude than any one individual alone would have either the time or the technical knowledge to tackle".  (8)  In a l l cases, the doctors at Mayo*s treat the patients as an individual and not as a research subject. the patient himself.  The case i s studied and consulted upon solely to help  Dr. William Mayo, Jr. expressed this feeling when he said,  "Group medicine i s not a financial arrangement, except for minor details, but a scientific co-operation for the welfare of the sick", ( 9 ) . things are v i t a l l y important for the teamwork process.  Dr. Mayo said that;three  F i r s t l y , there must be an  (7) Helen Clapesattle, "The Doctors Mayo". University of Minnesota Press, Minneapolis, 1941,  p.  580.  (8)  Helen Clapesattle, "The Boctors Mayo". University of Minnesota Press, Minneapolis, 1941, P» 619.  (9)  Helen Clapesattle, "The Doctors Mayo". University of Minnesota Press, Minneapolis, 1941, p. 706. .  7. active ideal of service instead of personal profit.  Secondly, a sincere concern  for the care of the individual patient; Thirdly, an unselfish interest i n the progress of every other member of the professional group. With these ideals, the Mayo Clinic laid the foundation-for the momentous advance of medical teamwork i n the 20th century.  Many other professions have  been added to the original organization including medical social work. The medical social worker has been an active part of the treatment teamat MayoGlinic for approximately fifteen years.  Many important research-studies have developed since  1945 i n psychosomatic medicine i n the Clinic i n which the social-worker has played a major role.  Today at the Mayo Clinic a patient can receive the most complete  care known to medical science. EFFECT OF THE CHILD GUIDANCE CLINIC The Child Guidance Clinics, because of their research and their effective use of the team, have had a most speetular influence on the teamwork process. They were perhaps the f i r s t to recognize the value of the many professions, such as the psychologist, the social worker, the group worker, the doctor, and the psychiatrist. They recognized that every profession has an individual viewpoint i n diagnosis and treatment.  This was the result of the great variety i n background  of professional education.  They realized the value of the many opinions i n being  able to uncover diverse problems i n individual children.  They decided that for  complete professional service many points of view were necessary and. they utilized the s k i l l s of these professional people to the utmost. method of staff conferences for free discussion.  Accordingly > they used the  Each person contributed to the  maximum of his professional knowledge to produce with the greatest certainty the picturesof the l i v i n g child.  Together these members would construct to the best  of their a b i l i t i e s a tentative method of meeting needs.  8. The strength of the c l i n i c "lies in the fact that i t brings to the problem a breadth of view possible only from the interplay of diversity trained minds and i n providing natural liasons between the several professional groups which must be enlisted i n any effective attack upon children's problems". (10). MEDICAL SOCIAL WORK IN VANCOUVER GENERAL HOSPITAL The social service department of the Vancouver General Hospital grew out of the services of the Women's Auxiliary. Many of the functions of this original group are retained by the social service department today.  It was around 1913 that  the Women's Auxiliary found that the services they were providing were too great for their voluntary organization.  They, therefore, hired a f u l l time person to  provide their social work services to the hospital. This social worker who was untrained began to increase the services of the Women's Auxiliary u n t i l the work could not be handled by one person alone. The Women's Auxiliary could not encumber i t s e l f financially with the hiring of more social workers. The Vancouver General Hospital, therefore, took over the social work service and made i t a department within the hospital. By 1926 the social service department was firmly established. small, however, and was staffed by untrained personnel.  It was very  The service given by the  department was mainly environmental. The main objective was, however, to keep the patients' welfare in mind. A l l the services though, maintained the distinct flavour of the Women's Auxiliary which was, of course philanthropic. In 1940 there was an attempt to clarify the function of the social service staff.  The department was s t i l l influenced by the traditional ties of the Women's  Auxiliary and the untrained personnel. clerking function.  The workers were performing a routine  There was no recognition of the s k i l l s of a medical social worker,  (10) The Staff of the Institute for Juvenile Research, "Child Guidance Procedures. Methods and Techniques Employed by the Institute for Juvenile Research". D. Appleton Century Co., Inc., New York, 1937, p. 335.  9. The services were concerned with the environmental problems f o r the non-pay patients. These problems consisted generally of needs f o r appliances, f i n a n c i a l assistance and nursing home care. This constant pressure of routine prevented any v a l i d interpretation to other hospital personnel. In 1948 an important development took place within the department. The Health Centre for Children was opened with a trained social worker on i t s s t a f f under the supervision of the case-work supervisor. •. This* was the- f i r s t " t i n e • * •• •• department had opened with the recognition of the need f o r social work t o integrate the s o c i a l with the medical structure f o r treatment. There are at the present time thirteen s o c i a l workers i n the department. The Director of the department, the casework supervisor and the worker i n the Maternity C l i n i c have nursing degrees. There are three workers with certificates: i n social work.' Five workers have B.S.W. degrees and two have M.S.W. degrees. The aim of the department at present i s that no new workers w i l l be hired unless they have the M.S.W. degree. This, of course, should have a dramatic influence i n the growth of the department. The department has,been prevented from growing normally because of three main reasons. Firstly> the department was held by the t i e s of t r a d i t i o n set down by the Women's Auxiliary.  Secondly, the time consuming routine work has limited  the opportunities f o r good interpretation. Thirdly, "the presence of untrained personnel did not permit good casework services and created misunderstanding of the actual function of medical s o c i a l workers". ( U ) In 1951 a work * survey was done and presented t o the administration. This survey pointed out the ways t i n which the workers were*prevented from performing as medical s o c i a l workers because ^*f»the- time consuming c l e r i c a l work which they (11) C o l l i e r , E.G., "The Social Service Department of the Vancouver GENeral . Hospital". 1950 M.S.W.. U .B.C. p. 26. """"""  10. had to do. It was recommended that more c l e r i c a l staff be hired i n order to release workers for casework.  If these recommendations are carried out, i t i s  expected that the department w i l l be able to f u l l f i l the four Standard services recommended by the American Association of Medical SOcial Workers.  CHAPTER II THE SOCIAL WORKER AND THE DOCTOR.  •11. The organic approach iii medicine s t i l l retains a strong effect on the practice of medicine. This system i s one i n which there i s insistence on a "solid pathological foundation for medical understanding . (12). H  The psychoso-  matic approach, however, i s not a new discipline; i t has only been case aside because of the medical discoveries i n bacteriology,-pathology, biochemistry and biophysics.  "Actually medical literature dropped the word 'man* and began to speak  of the human organism which was being studied so precisely, and which could be manipulated so mechanically".  (13).  The term "psychosomatic" infers that every disease has i n i t s cause both psychological and physical factors which influence the course of the illness. English and Weiss i n their book, "Psychosomatic Medicine'?, make four classifications of psychosomatic problems. (14).  Group one includes the functional problems with  no definite bodily disease to account for the illness.  Group two includes those  diseases which are partly dependent on emotional factors.  Group three includes  those diseases wholly within the realm of physical disease which have to do with the vegetative nervous system. Group four includes those diseases which have a relationship between psychological disturbances and structural alteration. Not a l l doctors accept the psychosomatic approach to illness.  This approach  depends on the physician's sensitivity to and understanding of the patient-as well as his knowledge of tissue pathology. He* must know about the emotional factors i n illness and human motivation. ation.  This approach i s d i f f i c u l t i n this era of specializ-  The social worker who has received adequate training in the understanding  of human behaviour as i t i s related to illness, frequently can f i l l the gap which (12) English & Weiss. "Psychosomatic Medicine? W.B. Saunders Co., Philadelphia, London, 1943, p. 74. (13) Margolis, H.M., "The.Psychosomatic Approach to Medical Diagnosis and Treatment". Journal of Social Case Work, December 1946, p. 291. (14) English & Weiss, "Psychosomatic Medicine".W.B. Saunders Co., Philadelphia, London, 1943, p. 25.  12. may exist between the needs of the patient and the service which the physician i s prepared to give. Today, a complete diagnosis of a patient must be threefold; that i s , the patient must be viewed-as a biological, psychological and social entity.  The  general practitioner i n the small town many years ago, could himself make this complete diagnosis.  Since the era of the "Family Doctor" has vanished and has  been replaced by the "Specialist", there is evidence that a complete diagnosis can best be achieved by the hospital team. (15).  The medical soeial w o r k e r l i k e  other members of this team has a specific function to perform*  the  From her contact  with the patient and his family during this period of stress, she i s able to objectively discern those psychological and environmental factors which may influencing his i l l n e s s .  be  From her numerous contacts, not only with the patient,  but other members of the hospital staff, she can formulate an impression of the patient as a total social being.  In this way, the medical social worker can  f a c i l i t a t e the physician's desire to make a more complete diagnosis. It i s no longer important to know only the name of the disease that the patient has.  It i s , oh the other hand, v i t a l l y important to know how, and even  more particularly why, a patient became i l l * s k i l l to get this information*  It i s the social worker who has the  She has been trained to evaluate the significant  and causitive social factors i n i l l n e s s .  The social worker's knowledge of the way  personality, economic factors and environment affect a patient and the doctor's knowledge of physical conditions give an accurate basis for diagnosis and treatment of the patient's medical-social problems. The value of a social worker's contribution to the treatment i n the psychosomatic approach depends on the very fact that she has been trained in a different field. (15). The term, "Family Doctor" was. used through the late 19th and early 20th centuries to denote the family friend, counsellor, guardian and teacher.  13. SOCIAL FACTORS IN ILLNESS Illness i s said to be the major cause of a dependency in people.  There  are many major social problems i n our society which are at the root of illness i n many instances.  Such things as poverty, malnutrition and poor housing spread  infection and lessen people's resistance to disease.  Illness is also common in  people who are humiliated, depressed and despairing with the threat of low incomes and social assistance. The person who i s sick usually has a group of symptoms both physical and emotional.  It i s , therefore, important to know what kind of a person i s suffering,  what was happening to him when he became i l l , how he i s reacting to his illness, what has been the pattern of his whole l i f e situation and f i n a l l y , what i s most important, what does illness mean to the individual. The social worker is trained to understand and evaluate these social factors and their Influence on people.  She receives this information through her case work  s k i l l s i n interviewing. The social history which she prepares for the doctor is valuable for estimating the personality and the a b i l i t y of the person to accept treatment and the reaction pattern of-the person i n l i f e . a therapeutic purpose.  The history also serves  Through discussing his problems with the social worker, the  persoh feels relieved from his anxieties and feels as though someone i s interested in him as an individual.  Finally, the history i s indispensable i n making a diagnosis  and planning treatment. METHOD OF REFERRAL In the Vancouver General Hospital, a referral to a social worker i s supposed to come directly from the doctor.  Since the patient comes to the doctor because he  has physical discomfort, the doctor, therefore, is the person responsible for his care.  If the doctor recognizes that there are some personal or environmental d i f f -  iculties which may be responsible for the illness or i s interfering with his recovery,  then a referral to the Social Service Department i s made. The referral slip i s put on the patient's chart stating the reason for the referral and the physical diagnosis.  The social worker on the ward receives the  referral s l i p and interviews the patient. In this f i r s t interview, the worker attempts to make a social diagnosis.  She then contacts the doctor and together they  plan the method of treatment. • Up to the present time, this method of treatment has not been i n practice in the Out Patient Department.  Two of the four workers i n the Out Patient Depart-  ment have*been performing i n a c l e r i c a l capacity.  That i s , the morning hours are  taken up i n establishing e l i g i b i l i t y for service i n Out Patient Department, the afternoons spent i n procuring appliances for the patients. The referrals that have been given to the two ward workers i n the past have been concerned mainly with the placement i n nursing homes, procuring appliances and referring to the City Social Service Department for financial assistance. From this picturej i t can be seen that the social worker has not been functioning according to the standards set down by the American Association of Medical Social Workers. According to these Standards, the function of medical social workers should be i n five general areas.  F i r s t l y , the social worker should practice  social casework. Secondly, the social worker should participate i n program planning and policy formulation within the medical institution.  Thirdly, the social worker  should participate i n the development of social and health programs i n the community. Fourthly, the social worker should participate i n the educational program for professional personnel.  Fifthly, the social worker should participate i n social  research. Social casework i n the past has only been made available to patients i n Out Patient Department or staff patients. This may be due to the fact that no particular effort has been made to indicate to the doctors that casework treatment can be a  15. very worthwhile part of medical treatment.  The time consuming clerical jobs of  the social workers i n Out Patient Department have prevented them from doing good casework.  The cases used for this study have, therefore, been limited.  The cases  that have been chosen were those which showed referrals according to the Standards of the American Association of Medical Social Workers and have been carried out oh the most part by students. CASES SHOWING THE WORKER'S HELP IN PLANNING DISCHARGE Mr. M was a 48 year old labourer with a physical diagnosis of rheumatoid arthritis.  He was referred by the doctor for help i n discharge planning because  Mr. M did not have any money and this was making him feel anxious. spend 900 days i n hospital over a period of four years.  The patient had  His handicap had progressed  from a mild pain i n his ankles to confinement i n a wheel chair where he was considered to be absolutely helpless. During the f i r s t interview with the patient, the worker found that he had suffered a series of emotional frustrations and economic deprivations which correlated with his admission into hospital. Each admission found the patient's condition considerably weakened. The worker and doctor i n conference decided to make a concrete plan of treatment for the patient. The worker gave case work help to the patient and his family.  In this way, she was able to lessen the frustrations and build up the  strength of the family and the patient. She acted as a liaison between the physiotherapist, occupational therapist, the City Social Service Department and the doctor.  In this way, the patient f e l t that people were really interested in his  welfare and he responded to the help. In time Mr. M was able to buy a small store and sold the products made by himself and other handicapped patients. His handicap was lessened considerably although he never completely regained his former physical strength because the  16.  damage of four years had changed his bodily structure. He lived i n a small dwelling unit in the back of his store and the housekeeping duties were performed by the patient's mother. Through the case worker's recognition of the social factors i n illness and what illness meant to the patient, she was able to give a real service to the patient, the doctor, the patient's family and the community i n helping to restore the patient to independence and comfortable mental and physical health. Mr. P was a sixty-four year old single labourer from out of town. He had been referred from an out of town doctor to Out Patient Department, because he could not find any organic reasons for his complaints.  He was given a physical examinat-  ion i n Out Patient Department; and they>-in turn, could find no organic reason for his pains.  The doctor referred the patient to the social worker to see i f any  social problems could be responsible for his illness. The social worker interviewed the patient. She found that he was exceedingly depressed.  He wept constantly during the interviews and seemed to be suff-  ering from terrible pain.  Mr. P had been unemployed for two years and his resources  were nearing depletion. His pains had begun when he was dismissed from employment. He had been employed i n heavy construction work a l l his l i f e and he could not accept the fact that he was no longer an asset to an employer.  Illness to Mr. P was,  therefore, a socially acceptable mode of escape from an intolerable situation.  His  only wish was to be admitted to hospital so that he could die. This information was given to the doctor who did nothing constructive from there.  The patient came i n to Out Patient Department a month later and another  doctor saw him.  He was interested by the social information and contacted the  worker. Mr. P i n the meantime had developed a physical diagnosis of muscular atrophy and diabetes melletus.  He was then admitted to hospital.  The doctor and the worker held a conference concerning the patient.  The  17.  doctor f e l t that the prognosis for the patient was not favourable. He had not responded to treatment and was not interested i n co-operating with the doctor. The doctor asked the worker to find out what was troubling Mr. P i n order that he would respond to treatment. The worker saw Mr. P over a period of one and one half months. The patient's main concern was that he had-nothing to l i v e for. The worker gave Mr, P considerable warmth and sympathy. She contacted the Social Welfare Branch i n his area to help him financially.  Mr. P washable to express his anxieties; gradually he began to  feel secure and responded to treatment.  Mr.- P was fearful that his niece, with  whom he had been l i v i n g , would not be able to care for him. the niece and helped her to understand the illness.  The worker interviewed  The worker referred the niece  for financial help and also secured the assistance of a public health nurse in the area to talk to the niece regarding the diabetic diet.  Mr. P began to feel more  and more secure and his response to treatment was rapid.  The prognosis changed from  exceedingly grave to exceedingly favourable. The worker and the doctor talked with him about his limitations and his capacities.  He accepted these well and made concrete plans for a small truck garden  on his farm.  He said i t was always something he wanted to do; he was f i n a l l y dis-  charged after one and one half months of treatment. If the f i r s t doctor in this case had been able to follow up the social diagnosis, the patient might have been spared his illnesses.  Fortunately, the  second doctor recognized what the social worker could do in this case and included her i n treatment two days after the patient was admitted.  As soon as the frustrat-  ions were removed, the patient responded and was discharged much earlier than had been expected. The social worker played a definite part i n treatment i n this case.  Her  knowledge of community resources and her diagnostic s k i l l s prevented the man from  18. developing a chronic illness.  The doctor i n his turn was able to give a more  effective physical treatment to the patient as his anxieties were lessened. Mr. K was a 23 year old unemployed man.  He had never been: employed for  longer than a month because he was deaf and dumb and was therefore dependent upon his family for financial support.  He had been hospitalized for a period of eight  days because of a nasal obstruction.  The doctor referred the patient because he  f e l t this minor operation would restore the patient's hearing to some degree and he would therefore need some help in rehabilitation.  The doctor felt that the patient  had considerable intelligence and the worker could help through her knowledge of community resources. The social worker i n interviewing the patient and h i 3 family found that there was considerable enmity between the patient and his father.  This had been  brought about because the patient resented his dependent position and the father had done nothing to help him regain his hearing. The worker was able to enlist the help of a speech therapist and a school teacher for the patient.  While he was receiving this education, financial support  was given to him so that he could be independent of his family.  The worker also  helped the family to recognize and accept the patient's needs to emancipate and be independent from the family. The patient learned to read and speak well enough to take permanent employment and was no longer frustrated because of his feelings of dependence and i n adequacy. The social worker was able to help the doctor because of her s k i l l in diagnosing the environmental situation and her knowledge of community resources. She acted as a liaison between the speech therapist, the school teacher and the doctor i n helping them to understand the patient's personality and what his handicap meant to him.  19. Miss L was a seventeen year old g i r l from out of town with a diagnosis of hysterical paralysis. The doctor made a referral to the social worker because he wanted casework treatment for the patient and foster home placement or discharge. The cause of the paralysis stemmed from the patient's father's desire to send her to a Pentecostal Bible School which the patient did not l i k e .  She could  not defy her father verbally, and as a result, she developed a complete paralysis. The doctor knew about this conflict, but he recognized that he lacked the s k i l l to deal with the problem and asked that the social worker give the treatment. The social worker and doctor met i n a conference every two weeks and planned their treatment with the patient, so that they could give the patient the security of a united front. The worker acted as a liaison between the doctor, physiotherapist, occupational therapist and the nurses.  She helped these members i n the team to  understand the patient, and in this way each person knew the patient and what their role in treatment was to be.  The patient received considerable security i n this  and responded to treatment through resolving her conflict.  In a period of seven  months, the patient understood her conflict and changed her pattern of behaviour. The social worker found the foster home for the patient and prepared the foster parents for the transfer. The social worker saw the patient constantly and i t was with her that the patient developed the strongest relationship. The-worker acted as the hub i n the wheel of treatment for this patient. The doctor recognized her s k i l l i n dealing with this problem which was essentially an emotional one. CASES SHOWING THE WORKER'S HELP WITH PSYCHIATRIC PROBLEMS Mr. T was a thirty-eight year old unemployed labourer with a diagnosis of inadequate psychopath. He had been known to the psychiatric ward at Vancouver General Hospital five years previously under a different name. He had been admitted  20.  for shock treatment at that time. He was referred by the Family Welfare Bureau because he requested psychiatric help.  He was given an appointment with a psychiatrist and the doctor  asked the worker to prepare a social history. In interviewing the patient, the worker was able to find that the patient had had a grossly inadequate environmental background. The patient had no inner strength to change his pattern nor could he establish a relationship long enough to benefit from case work help. When the patient was seen by the psychiatrist, he wished to sign a voluntary committal for Essondale,  The doctor and the worker in conference, decided that the  patient's personality was so badly damaged that he would not receive any benefits from his committal. and the committal was  They recognized too the patient's right to self  determination  signed.  The patient returned from Essondale two weeks later and said that he had received no help.  The doctor and the worker decided at this time that no psychiatric  help could be given to the patient at this time.  They f e l t , therefore, that the  worker would be the person to give the patient enough support through a warm relationship to release his anxieties at the moment and help him to secure employment. The worker was able to help the patient to carry out this plan.  Mr. T's  personality would have been threatened in a long term casework relationship. His anxieties at that time were relieved enough for him to take employment. The worker realized that when the frustrations became too much for Mr. T, he would again seek some support. In this case, the worker's social history was instrumental i n helping the psychiatrist to make a diagnosis.  The psychiatrist recognized the worker's a b i l i t y  to help the patient and requested her social s k i l l s in this area. Miss M was a thirty-six year old unemployed stenographer. physical problem but was requesting psychiatric help.  She had no  The doctor referred the  21.  patient to the social worker for a social history.  In the process of securing  this,the social worker f e l t that the patient would not benefit from psychiatric treatment. Miss M and her mother lived' together and Miss Mwas extremely dependent upon the mother. She did not agree with the mother's wishes but she was so depentent that she could not emancipate herself.  She was unable to retain employment for  any length of time because she could not make decisions or take any responsibility without the mother. The psychiatrist and the social worker decided i n conference that psychiatric help would be of no benefit.  They decided that the social worker could give the  patient help i n her area of conflict by giving her a warm relationship.  It was-felt  that this relationship would give the patient enough support to emancipate herself from her mother and also give her a feeling of strength i n her capabilities. The worker developed a strong relationship with the patient over a period of time.  The worker helped her to emancipate enough to take employment. The  worker worked closely with the employing agency so that the patient would have an opportunity to take very gradual responsibility.  In this way, the patient was able  to f e e l secure and an asset to the community. The strength she gained i n her area of employment had considerable effect on her emancipation from her mother. The period of treatment continued for approximately seven months. At the end of this time, the patient l e f t her mother and was successful in procuring employment i n another c i t y .  The patient gained so much strength i n herself that she  was f i n a l l y able to get married. In this case, the psychiatrist was able to see, through the social diagnosis made by the social worker, that psychiatric treatment was not what the patient needed. He was able to understand the abilities of the social worker to deal with an environmental problem and give supportive treatment.  The patient's real problem  22. lay i n her earliest development. If the: psychiatrist had offered help in that area, the patient would have become so threatened that a psychosis might have been the result.  The psychiatrist and the social worker realized this problem. They were  able to recognize, therefore, the patient would receive enough strength to meet her l i f e problems without too much discomfort and frustration. CASES SHOWING THE WORKER'S HELP IN RELIEVING ENVIRONMENTAL PROBLEMS PROCEEDING PHYSICAL CARE Mrs. F was a sixty-one year old widow employed as a domestic.  Her physical  diagnosis was a single glaucoma. She had been attending Out Patient Department for a period of 5 years with a series of physical problems.  She was a person who had  a need to be extremely independent and she could not accept her physical diagnosis. She was exceedingly hostile i n the clinic and caused a great disturbance on her visits.  The doctor referred her to the social worker because he was desirous that  the worker help her accept her limitations so that she would become less troublesome to herself and the c l i n i c . Mrs. F had been independent a l l her early l i f e . and was exposed to a great deal of economic instability.  She married i n later l i f e In spite of her deprivat-  ions, she was happy with her husband. Mr. F died i n 1944 and i t was then that the patient began to develop her illnesses. did not want to get well.  She did not respond to treatment because she  She had an outward need to be independent and illness  was a socially acceptable form of satisfying her inner needs to be dependent. The worker received this foregoing information while i n the f i r s t interviews with the patient. In conference, the worker and the doctor decided that not a great deal could be done to actually help this patient i n accepting her illness.  They  decided, therefore, that the worker should establish a warm relationship with the patient and to help her release the-hostility she f e l t toward the c l i n i c ;  They also  planned to help Mrs. F retain her need for independence but perhaps join i n the entertainment at Canadian National Institute for the Blind. They felt that this  23. might help her to accept" her illness to some degree and also give her a pleasant social release with her limiting handicap. The social worker served as a source for the patient's h o s t i l i t y for many weeks. As the patient f e l t acceptance and reassurance f1*001 the worker during the periods of hostility, her behaviour changed. She no longer Had a need to be hostile in the c l i n i c and she therefore accepted treatment.  She was able to retain her  independence because the worker secured assistance for her through the City Social Service Department u n t i l she f e l t well enough to take employment. Finally, the patient joined into some of the entertainment at the Canadian National Institute for the Blind. The worker, through her s k i l l i n diagnosis, was able to show the doctor how the patient became i l l , what illness meant to her and the kind of personality she had.  The worker helped the doctor again i n her recognition that the patient could  never really accept her illness and i t s reasons. l i v e more comfortably with her limitations.  They could only hope to help her  The worker's knowledge of community  resources was of considerable-benefit i n this case. If the doctor had not realized that the worker could be of some help, the patient would very probably have l e f t the c l i n i c .  That i s , her hostility over her  own inadequacies may have forced her to refuse the service.  I f that had been the  case, the patient may have done some permanent damage to her sight and to her personality. Mrs. S was a thirty-two year old housewife with two children.  Her husband  was a labourer. She had a physical diagnosis of myasthenia gravis, Reynauds Disease, migraine and anxiety state. The psychiatrist made a referral to a social worker because he realized i t would only be a matter of about a year before the patient would feel the limitations of the myasthena gravis.  He wanted the worker to secure homemaker service for  24. the patient while she was i n hospital i n order to reduce her anxiety state.  Lateri  when the patient was: discharged, he wished the worker to help Mrs. S accept her illness and help her to make permanent plans for the family. The worker, i n conference with the doctor, decided that they would carry this problem together.  The worker was to prepare the home for the homemaker and  relieve Mrs. S's anxieties i n that area.* The-doctor i n the meantime continued to see the patient i n the hospital and treated her on a more intensive level. The patient's anxieties diminished considerably when she attained a feeling of security with the doctor and social worker  working together to help her.  The patient was discharged a month later.  Her anxieties around the environ-  mental level were diminished and she experienced no feelings of fear or frustration in returning home. The patient continued to see the doctor i n Out Patient Department once- i n every six weeks. The worker on the other hand saw the patient every week. The psychiatrist lessened his v i s i t s with the patient because he f e l t his services would not longer be of any value. developmental history.  Mrs. S's- illness had originated very early i n her  She was now the victim of an incurable disease because her  body had become sensitized to this constant frustration. The psychiatrist realized that he could d o nothing to help the patient. Her greatest need at this point was help i n accepting her illness and in planning for her family for her eventual invalidism and their acceptance of that. The patient had experienced many emotional trauma i n her lifetime. Her mother had suffered through a mental disorder and eventually became an alcoholic. She later committed suicide (by hanging), and for this, the patient f e l t responsible. The patient then married Mr. S who was exceedingly dependent. He had a desire to be independent and went into business for himself. As a result, the family suffered through economic instability. not offer his wife any support.  The husband's personality was so weak that he could Their marital relationship was exceedingly strained  25. because both were dependent people. The children were also affected through this disharmony and were-developing physical complaints. The worker recognized that Mrs. S had the greater strength in this relationship.  She was, therefore, able to give enough support and counselling to Mrs. S  to understand the strains and help her to modify them. This supporting relationship helped to stabilize the family economically and emotionally.  Mr. S was able  to continue his business without undue hardship which increased his feelings of independence. The children, were i n turn, relieved from the emotional strain and the physical complaints were lessened.  Finally, Mrs. S was released from these  environmental pressures and was able to accept her.illness and plan concretely for her family. This case clearly illustrates the role of the medical social worker i n treatment. As the patient's anxieties were relieved in the hospital setting by the psychiatrist and the social worker, the patient was able to be discharged. The doctor realized that the main source of frustration was i n the social area. It was there that the social worker was able to bring her s k i l l s into treatment.  This  team process, therefore, enabled the patient to accept her illness and prevented the family from physical, emotional and economic deprivation. Mrs. G was a forty-eight year old housewife with seven children with ages ranging from four to twenty years. complaints.  Her physical diagnosis was gynecological^'  ,  The doctor referred the patient because she was so upset i n her environ-  mental problems that she could not accept treatment.  The'doctor recognized that  the environmental situation needed the s k i l l s of a social worker. He prepared the patient for her interviews by explaining that u n t i l her social problems were -relieved, he could not beneficially give her physical treatment. Through the process of interviewing the worker found that the main source of frustration i n the family was a thirteen year old spastic child.  This child  26. had been severely rejected by a l l the family.  The father, who was an inadequate  psychopath accused the mother of being responsible for the defective c h i l d . The father completely dominated Mrs. G and she, therefore, had so many mixed feelings that illness seemed like the only escape for her. The worker and the doctor, i n conferencej decided that the personalities of Mr. and Mrs. G could not be changed. The best plan, therefore> would be to remove one of the sources of frustration, namely, the spastic child.  The doctor  realized that the social worker knew the community resources and had special s k i l l s in dealing with this environmental problem. The social worker continued to see Mr.. & Mrs. G and helped them to accept the removal of the child to a mental institution for children. Psychological and physical examinations were given to the child and her mental status warranted the move. This l i t t l e spastic child would definitely benefit from the Institution emotionally because of her severe disturbance i n that area. were able to talk about this with the worker.  The mother and father  The patient received considerable  benefit because she released her guilt and anxious feelings about the child. The social worker knew that the mother did not have the inner strength to understand her own feelings about the c h i l d .  It was f e l t , therefore, by the doctor and the  worker that with the removal of the child, the main source of f r i c t i o n in the family relationships would be eliminated. Mrs. G was f i n a l l y able to accept treatment for her own illness when the child was removed. Her frustrations and anxieties around the child had been decreased and she was willing to focus on and receive benefit from treatment. In this case, i f the doctor had not recognized that Mrs. G had been upset, a l l attempts to treat her would have failed. in time and i n terms of the patient's health. her refusal to come back.  The result would have been very costly Such a delay*might have resulted i n  The patient's husband's personality and her own physical  57. weakness may have promoted a severe-illness either mentally or physically, The doctor's recognition of the environmental problem, therefore, resulted i n reducing the family strains, enabled successful treatment of a minor illness and, f i n a l l y , gave the thirteen year old spastic g i r l an opportunity to grow i n comfortable and accepting surroundings. Mr.- C was a sixty-four year old married farmer.  He had a physical diagnosis  of muscular dystrophy and idiopathic epilepsy. Mrs. C, the patient's wife was exceedingly handicapped i n that she was completely paralyzed on the whole left side of her body. Mr. C was referred to the social worker for placement. He was; a problem for the doctor because he could not accept his condition as chronic and would not accept the doctor's plan of treatment. , The plan was to put Mr. C i n a nursing home run by the City Social Service Department which i s on hospital grounds. The doctor f e l t that then the dystrophy would be controlled and some attempt could also be made through over-feeding to give Mr. C greater strength. Mr. C was exceedingly hostile to the worker i n the f i r s t interviews.. Mr. C had always been proud of his independence and because of his strong inner needs to be dependent, he f e l t that i f he got into hospital he would never come out again. The worker was able to help Mr. C understand his chronic condition and the benefits he would receive from hospitalization.  Mr.. C decided that he would see  a private doctor once more before he consented, just to see i f the opinions regarding his diagnosis were the same. The doctor and the social worker agreed to this because they understood Mr. C's personality and his right to self determination. Mr. C came back later and decided to accept the f i r s t plan of treatment. In this case, the social worker through her s k i l l i n diagnosis, understood the patient's personality and respected his right to decide for himself. She was able to help the doctor understand this also and he did not become impatient. The  28. The doctor could see that the patient had a need to satisfy himself i n a l l other directions before committing himself t o a plan other people had made f o r him SUMMARY  Since the unwell person usually presents symptoms indicative of emotional as well as physical disturbance, i t i s important to have some awareness of the kind of person who i s presenting the symptoms. The pattern of his whole l i f e situation, significant incidents which occured prior to the onset of his i l l n e s s , h i s reaction to his i l l n e s s and f i n a l l y the meaning which i l l n e s s has for him, are the integral part of his i l l n e s s . The s o c i a l worker, because of her casework s k i l l s i n interviewing, i s able to obtain this information. The gathering of t h i s information i s not an end i n i t s e l f but rather a means to an end.  The social worker i s equipped  to understand and evaluate social factors and t h e i r influence upon people; prepares a history which enables the physician to come to some conclusions regarding the patient's personality and his a b i l i t y to accept and respond to treatment. Miss De La Fontaine i n her a r t i c l e of "Psychosomatic Medicine and Case Work", has an interesting comment as t o how the two disciplines of medical s o c i a l work and the doctor can function. (16). She suggests that i t i s the s o c i a l worker who treats the " i l l n e s s " and the doctor who treats the "disease". by defining the two areas.  She c l a r i f i e s t h i s statement  "Illness i s a deviation from health or from that state i n  which a l l natural functions and a c t i v i t i e s are performed freely, e f f i c i e n t l y , without pain or discomfort.  Illness Is a state i n which the process of l i v i n g produces  symptoms that prevent some of the natural a c t i v i t i e s of the body from being performed freely and e f f i c i e n t l y . " In her second d e f i n i t i o n , she states that, "Disease may be defined i n a restricted sense, as an abnormal state of the body resulting from the harmful effects (16) De La Fontaine, Miss "Some Implications of Psychosomatic Medicine for Case Work", Journal of Social Case Work, June 1946, p. 128.  29. of processes, inpirous substances, or accidents. Disease i s recognized by objective examination either as a structural change or as an abnormal condition revealed by chemical, physical or biological methods; as such, i t i s called organic disease". Miss De La Fontaine goes on to aay, "These definitions are not meant to differentiate between different degrees of involvement of mind, body and environment, but rather they are attempts to clarify the area appropriate to the layman and physician; that i s , illness to the patient, social worker and doctor and the area appropriate to the physician only (that i s , disease)." Patients develop illness and diseases as a response to the stresses and strains of external and internal stimuli.  It i s not known why certain people have  organic vulnerability i n one area and not i n another.  People react differently,  even though they may have the same organic defect. Medical doctors have begun to realize that certain somatic functions are correlated closely with certain emotional conflicts.  The main area of conflict seems to be i n the consideration of which  comes f i r s t , the emotional disturbance or the organic d i f f i c u l t y .  There are some  diseases, however, i n which there i s some vague knowledge as to which comesfirst. It can be seen, therefore, that i t is v i t a l l y important to know the patient as a whole person i n treatment.  It must be known why the person chose this part-  icular organic disturbance to express his discomfort and trouble. The history must also contain the environmental factors which may show the constitutional predisposition to the organic defect. This social information, accompanied by the doctor's physical information, should give an accurate basis for treatment. The psychosomatic of Medicine",  approach to illness i s as old as Hippocrates, the "F ther a  The tremendous advances i n medical science have reached such proport-  ions that i t i s now impossible for one person to know the whole f i e l d .  The emphasis,  therefore, has been placed i n specialization i n small areas of the body. process, the patient as a whole living person has been l o s t .  In the  Medical doctors are  30. now aware that man does not function i n small sections; his body and mind are so closely interrelated that they cannot be separated.  It i s i n this area, therefore,  that the medical social worker becomes an indispensable part of the treatment team. It is the social worker who can assist in pointing out the interrelationship of the patient's family and environmental constellations. It i s with her knowledge and s k i l l , therefore, that she brings to the doctor the patient as a living man, a human being with individual worth and not an organ by i t s e l f .  CHAPTER III THE SOCIAL WORKER AND THE COMMUNITY  31. In a medical s e t t i n g , the s o c i a l worker has a d i f f e r e n t r o l e to play from workers who  are i n family or children's agencies.  The patient comes t o the  c l i n i c or hospital because he has physical discomforts. patient therefore, i s to seek r e l i e f from his pain.  The objective of the  The doctor, i f he  recognizes  the psychic problems around the disease, w i l l refer the patient to the s o c i a l worker. The s o c i a l worker's status therefore, i s very much d i f f e r e n t from the s i t u a t i o n i n other s o c i a l agencies where a c l i e n t seeks d i r e c t help with a s o c i a l or emotional problem from the s o c i a l worker.  The medical worker on the other hand has only her  s o c i a l s k i l l s i n diagnosis and treatment to the patient.  There are no resources  such as f i n a n c i a l assistance, foster homes or homemaker services within the s e t t i n g . The worker i n the medical s e t t i n g , therefore, has to have a great knowledge of the resources i n the community so that she can co-ordinate care of the patient.  them s k i l f u l l y i n the t o t a l  The s o c i a l workers i n the medical s e t t i n g are too apt to f e e l  that when the patient i s r e l i e v e d of t h i s i l l n e s s , he has been treated.  According  to the National Council on R e h a b i l i t a t i o n , "Rehabilitation i s the r e s t o r a t i o n of the handicapped to the f u l l e s t physical, mental, s o c i a l , vocational and economic usefulness of which they are capable". (17). Mr. K. Hamilton i n h i 3 a r t i c l e , "A Sound R e h a b i l i t a t i o n Program", says that, "Rehabilitation i s c r e a t i v e .  It aims to define, develop and u t i l i z e the  assets of the i n d i v i d u a l and h i s community. capacity, independence and personal  Its purpose i s t o restore  s a t i s f a c t i o n " . (18).  competitive  In order to carry out a  program of r e h a b i l i t a t i o n there must be a u t i l i z a t i o n of a l l e x i s t i n g community resources, an i n t e l l i g e n t r e a l i z a t i o n of those that are l a c k i n g , and f i n a l l y , some s o c i a l action to overcome the lacks i n the community. It i s therefore a r e s p o n s i b i l i t y of the professional s o c i a l worker to be (17) "National Council on R e h a b i l i t a t i o n " . August  1943.  (18) Hamilton, K., "A Sound Rehabilitation Programme", proceedings, Canadian Conference on S o c i a l Work, 1950, p. 130.  32. well informed regarding the available resources. The social worker with her knowledge of social diagnosis and her s k i l l s in social treatment i s i n an ideal position for integrating, u t i l i z i n g and promoting community services.  The social worker can  f u l f i l l this responsibility i n many ways. Firstly, she must have an extensive knowledge of illness and i t s social implications.  Secondly, she must be aware of  people s attitudes toward illness and the social implications involved for them 1  individually.  Thirdly, she must be aware of the meaning and experiences of patients  as individuals and as members of family groups toward i l l n e s s .  Fourthly, she must  share this knowledge with the members of the hospital team and other agency personnel. Fifthly, she should promote group conferences with patients and with their families and friends.  Sixthly, she should be a representative i n the planning and initiating  of group resources both curative and preventive. Seventhly, she should reach out and present her knowledge to appropriate citizens and volunteer groups i n the community. GROUP DISCUSSIONS The use of group discussions i n Vancouver General Hospital i s exceedingly limited.  The discussions are usually confined to two people i n various combinations,  for example, the doctor and the social worker, the doctor and the nurse, the social worker and the occupational therapist. are never group decisions.  The decisions regarding treatment therefore,  It has not been general practice for a l l the various  people helping the patient to s i t down at one set time to confer. However, a new system was set up i n the Neurology Clinic in the Out Patient Department f o r epileptic patients, employing the group discussion method exclusively. The group consists of a psychiatrist, a neurologist, an occupational therapist and a social worker. Other professional persons serve i n a consulting capacity when the need arises.  These other persons may be a neuro surgeon, an employment counsellor  of Y.M.C.A, representative. This group was formed because there had been no real treatment for the epileptic or his family. The disease i t s e l f bears a social stigma  33. and i t has always been shrouded in mystery.  The group f e l t that these people could  become independent and useful citizens i f they were to receive help i n the physical, mental, social and vocational area. The c l i n i c at the present time i s for young adults and i t i s organized under the Neurology Clinic,  This c l i n i c i s held once every week. The social worker  receives a referral on each patient automatically from the attending doctor. used for her social s k i l l s and for her knowledge of resources.  She i s  The worker interviews  each patient and formulates a social diagnosis from the social history.  The worker  also tries to contact and interview the patients' parents. At the end of the week the members of the group have a conference concerning a l l the patients interviewed by the social worker.  The social worker presents to  the group the social and emotional diagnosis of the patient and his family. The other group members present the diagnosis of their contact with the patient and then together the group w i l l assess the patient. At the present time only those patients who w i l l benefit from the group help i n a very short period of time are chosen. The object of the c l i n i c i s not medication alone but the treatment of medical, social, emotional and vocational problems. One evening every week i s set aside for a group discussion with the parents, relatives and friends of the epileptic.  These meetings are useful in three main  ways. Firstly,they are arranged so that the parents may have an understanding of the illness i t s e l f and i t s emotional and social implications for the patient and his family.  Secondly, i t i s an opportunity for the professional group to understand  the problems and the conflicts of the parents.  Thirdly, i t i s a form of therapy  for the parents i n that they realize other parents are having similar problems. The clinic at present i s s t i l l i n i t s infancy and no report was available at the time of this study.  The group intends to expand i t s services to a l l categories  of people,not just those i n the Out Patient Department. Their intention i s to  34. include the middle income groups, particularly those who are eligible for the Out Patient Department and yet cannot afford specialised care.  The group also  plans a definite program of social information through addresses to lay groups and pamphlet and newspaper publicity. The epileptic c l i n i c i s an interesting development at Vancouver General Hospital.  The group realized an immediate need for a person with a knowledge  community resources.  of  The social worker was considered to be the logical person for  this work; she was hired therefore, to function in that capacity. It was later shown that the social worker was also of definite help in the treatment process because of her knowledge of the social and emotional factors i n illness.  It i s  interesting i n this instance that the other professional people i n the group should f i r s t see the worker as a resource person.  The worker made use of this opportunity  and served i n that capacity until she had the opportunity to use her other s k i l l s . If the epileptic c l i n i c i s to be used as a measuring stick for the understanding of social work by other professions, the workers must have a more than average knowledge of the community resources.  If the worker i s accepted by the group for this  s k i l l and i c able to proceed i n this capacity with competence, she may then be able to initiate the use of her other s k i l l s . INTER AGENCY CONFERENCES The professional contacts between agencies are a great area of weakness in Vancouver General Hospital. referrals are poor.  There i s l i t t l e actual sharing of cases, and the  The department considers that the best referrals are received  from the City Social Service Department where there i s recognition that casework is a function of the department.  The other agencies do not seem to understand the  function of the medical social worker. This situation i s the result of poor social work in the hospital i n the past; a lack of recognition on the part of social workers both i n and out of the hospital regarding the actual function of the medical social worker.  25. The medical social worker should have contacts with a l l agencies because not a l l patient problems are essentially medical.  If the social worker were to  receive a child with asthma as a referral from the doctor, withthe problem stemming essentially from a parental marital conflict, the worker would make a referral to another agency. This case may be handled by the family agency helping the mother and father, and the medical social worker helping the child.  The same principle  of the social worker and doctor helping the patient applies to inter agency cooperation.  The patient has a right to feel the security of a l l professional people  working with unity and co-operation for his benefit. If the patient were to feel discrepancy and disharmony, he would immediately feel guilty or insecure and no one agency would be able to give him complete help. The medical social service department i s completely dependent on other agency help for problems other than medical.  It i s therefore extremely important  that there should be co-operation and understanding of roles within the various agencies.  The situation as i t i s at present could be rectified through inter agency  conferences and v i s i t s , and by reports and discussions. Good services to patients can only be given when the community relationships are strong and well co-ordinated. INTER AGENCY METHODS OF REFERRAL The most common referrals from the Vancouver General Hospital social service Department are for financial assistance and for nursing home care to the City Social Service Department. The percentage of referrals to other agencies i s much smaller than those sent to the City Social Service Department. There i s a much smaller percentage of referrals to the social service department i n the hospital than there is from the hospitals out to the agencies.  Nearly a l l of the referrals are from  the City Social Service Department. The reason for this is that the workers i n the City Social Service Department do not have time for casework services and they depend on the medical workers to provide this service for the patients which they refer.  36.  Since this study was started there has been an increase in the referrals from other agencies, especially the Family Welfare Bureau. There are perhaps three main ways of making good referrals. an agency has a client  Firstly, i f  whose problem seems to be i n the area of physical illness,  there should be a referral to the medical social worker. The agency worker, the doctor and the medical worker should s i t down in conference and decide who would be the person best suited to serve the client's needs.  Secondly, i f the medical worker  has a patient whose problem seems to be a family one, the worker would refer the case to the family agency. The medical worker would arrange to have a conference with the doctor i f necessary, the appropriate agency worker and herself.  Again,  this method of group conference is the answer for the client receiving the best kind of service for his problem. Thirdly, the medical worker and an agency worker may share a family problem. A fictitious case was suggested previously regarding the asthmatic child and the parents with a marital problem.  This sharing of work  requires a high degree of co-operation and teamwork. The clinent is' the f i r s t one to feel conflicting ideas among those who try to serve him.  It i s , therefore, a  responsibility to the profession and the standards of agencies to co-ordinate the services so that there i s neither overlapping nor gaps i n the services to clients.  OTHER COMMUNITY CONTACTS The group discussions i n the epileptic c l i n i c and the inter agency contacts are the main sources of community activity conducted by the workers in the social service department.  The workers in the hospital have made only very meagre contacts  with the community i n the past.  Now that there i s some definite idea as to the real  function of the worker i n the hospital, more community activities and understanding can be expected. Within the hospital i t s e l f , there i s some inter departmental contact. Director of the social service department and the case work supervisor do give  The  37. some lectures on the function of medical social work to groups such as student nurses, student dieticians and student administrators.  Lectures are also given  to the volunteers who assist in the C^t Patient Department c l i n i c s .  These volunteers  are from the Women's Auxiliary; they assist by giving soup to patients during the morning, providing a transportation service for non-ambulatory patients coming to clinic and serving as part-time stenographers.  The lectures given to these groups  of people have been very inadequate because they are too brief.  It would be more  beneficial i f they were carried out over a period of months instead of days.  The  reason for this brevity l i e s generally with the lack of understanding of the role of the medical social worker by the social workers themselves and of course by the rest of the hospital staff.  The lectures are concerned for the most part with  routine matters as to how the social workers function in securing glasses, appliances and nursing home care for patients.  If the workers are going to integrate the  services within the community, they must f i r s t begin in the institution where there are 1200 employees. The workers could gain recognition within the walls of the institution by giving lectures to various groups, being represented on committees, giving written interpretations through reports and employees' bulletins and f i n a l l y by showing good casework practice to employees in the day-to-day contacts.  As yet, the workers  have not been asked to discuss their role to the doctors in such things as ward rounds and symposiums.  It is to be hoped that the workers w i l l make an attempt to  do this i n the near future. The workers could gain some recognition in the community outside the institution by various means. Firstly, by inter agency discussions and v i s i t s . Secondly by discussion groups with families and friends of people suffering from illnesses like arthritis, cancer, glaucoma and many others.  Thirdly, by being  represented not only in professional organizations but groups like Church Young  38.  People's Groups, Canadian Clubs, Rotary and many others.  Fourthly, by writing  articles for magazines, newspapers, bulletins and reports. Fifthly, and f i n a l l y , by practising good casework, because i t i s patients who w i l l carry the results of good treatmentinto the community. CASES SHOWING REFERRALS FOR FINANCIAL ASSISTANCE OR OUTSIDE PROFESSIONAL CONTACT Mr. P was a sixty-four year old single labourer with a diagnosis of diabetes melitis and muscular atrophy.  Mr. P's illness was an escape for him from  the frustrations of financial deprivation. Mr. P was most anxious to be admitted to hospital.  He had been an independent labourer and now he was too old to be an  asset to the labour market. He had been unemployed for a period of two years and his savings were depleting rapidly. The worker recognized that M r . P's financial frustration was aggravating his physical condition. Mr. P was eligible for Provincial social assistance and theworker notified the appropriate agency.  The worker discovered that Mr. P's  niece with whom he lived was also without funds.  She was also eligible for  assistance and the worker made the appropriate referral.  Mr. P experiences consider-  able relief from frustration on receiving financial assistance. He was assured of security for l i f e . assistance.  His niece could not stay with him because she too would receive  Mr. P began to discuss plans for discharge.  He wanted to get well and  his response to treatment was amazing. The doctors f e l t he would be i n hospital for many months but he recovered so rapidly that he l e f t in less than two months after admission. The worker contacted Mr. P's niece to make plans for discharge.  The worker  discovered that she was very apprehensive about the discharge because she did not understand the illness or i t s implications. The worker was able to help the niece through her interpretations.  The worker secured the assistance of the public  health nurse in the area and the niece felt more secure in having M r . P discharged.  39. The public health nurse was going to c a l l twice weekly for a time in order to help the niece understand the illness and the nursing problem involved. Later, when the niece f e l t more secure, the v i s i t s would be on a weekly basis. In this case there would have been very l i t t l e response to treatment i f the worker had not recognized Mr. P's main source of anxiety.  Her knowledge of  resources in the community helped Mr. P to recover very rapidly and prevented a chronic illness.  In understanding the family problems related to illness, the  worker prevented Mr. P's niece from undue frustration and anxiety.  The preparation  of the home for the patient's discharge assured Mr. P a comfortable and relaxed home atmosphere which came through the niece's understanding of the illness and i t s implications. The worker's knowledge and use of the community resources in this case prevented a chronic invalidism and certainly made rehabilitation a reality for Mr. P and his niece. Mr. M was a forty-three year old labourer with rheumatoid a r t h r i t i s . had been incapacitated for a period of four years.  He  He would spend a period each  year in hospitals or the city nursing home. As soon as he f e l t better he would be discharged and given social assistance. Mr. M was referred to the worker by the doctor for a social history.  The worker was able to help Mr M receive release from  the tensions and frustrations he was feeling regarding his problems. were reduced, Mr. M was able to relax and use his r i g i d limbs.  As the tensions  He was eventually  able to work and with the worker's help face the future r e a l i s t i c a l l y . He was able to own a store which retailed the products made by handicapped veterans.  In t h i 3 way he became a productive and independent citizen, no longer  dependent on the public for support.  Mr. M was able to give to the community  instead of being supported by i t . The worker in this case enlisted the support of the City Social Service Department. They worked closely i n trying to understand why Mr. M became i l l .  40. The medical worker showed the agency that Mr M had so many frustrations and tensions in his history that he became increasingly r i g i d .  When his tensions  were reduced and he was given some direction, he wanted to become self-supporting. The City Social Service Department was able to understand this and co-operated with the medical worker in giving financial assistance u n t i l Mr. M could become independent. Mr. K was a twenty-three year old unemployed deaf and dumb patient.  He  was referred for discharge plansbut was eventually helped to emancipate himself from his parents on whom he depended,by learning to speak and write. The worker received the co-operation of the City Social Service Department for financial help. She showed the patient's need to be independent and the agency co-operated by giving the patient financial assistance while he was taking lessons from the speech and language therapists. The speech therapist who i s employed by the Health Centre for Children, co-operated with the worker in helping Mr. K.  He was actually not eligible for the  therapists assistance, but the worker's presentation of Mr. K's case made the therapist f e e l that the extra work with Mr. K would be beneficial to him. The worker went to the Normal School to obtain a language therapist for Mr. K.  The principal of the Normal School became interested i n Mr. K's case and  offered the services of one of his students. The worker co-ordinated a l l these community services for Mr. K's total rehabilitation.  The worker realized that Mr. K's problem was not essentially a  medical one and her knowledge of the community resources helped Mr. K to become independent.  The worker acted as the hubin the machine of rehabilitation.  It was  the worker who interviewed Mr. K and diagnosed his social needs. Through her s k i l l in diagnosis and her knowledge of resources, she made these f a c i l i t i e s available to Mr. K.  She prepared the patient for the new people in the rehabilitat-  ion team and also prepared the team members for Mr. K.  The worker initiated the  u. new resources as the patient needed them. She gave Mr. K continual support by seeing him every week and encouraging him.  She helped Mr. K's family to under-  stand the treatment and why i t was being given. Thus the worker was able to use the community resources to their greatest extent to help this patient gain complete independence. Miss M was a thirty-six year old unemployed stenographer.  She requested  psychiatric help but the psychiatrist and social worker f e l t that here the worker would be the best person to help Miss M with her environmental and employment problems. The patient was overly dependent on her mother. She resented her dependency but was not strong enough to emancipate herself. The worker contacted the employment bureau of a company where Miss M finally sought employment.  The worker was able to enlist the support of the woman  in charge of the bureau through her explanation of Miss M's case.  Together they  were able to help Miss M adjust to the employment situation and receive satisfaction from small successes.  With this adjustment and the worker's continued support  in the environmental area, Miss M was able to emancipate herself from her mother and obtained satisfaction and security from employment. The worker was able to recognize and u t i l i z e the community resource in the person of a personnel officer in a large company. The patient's rehabilitation lay in the employment area and the environmental area.  Rehabilitation i n both of these problems was necessary  before she could receive the help she requested. CASES SHOWING INTER AGENCY CO-OPERATION Mr. C was a sixty-four year old married farmer with a diagnosis of epilepsy and muscular dystrophy.  The referral was made to the worker for planning nursing  home care for the patient. The patient was exceedingly hostile about plans for entering a nursing home. He had always been very independent and he resented giving way to dependency  ,42. and would not accept his illness.  Eventually the worker was able to help him  accept and plan for nursing home care. A referral was made to the City Social Service Department through whom applications must be sent for nursing homes. The worker in the City Social Service Department did not realize Mr. C's need to be considered independent and her method of approach when f i l l i n g out the application made Mr. C exceedingly hostile.  As a  result of this interview, Mr. C refused to enter a nursing home. The medical worker recognized this problem and talked with the City Social Service Department worker concerning i t .  The medical worker again helped Mr. C  accept the plan for admission and again called in the worker from the City Soeial Service Department. This time the relationship was good and Mr. C accepted the application form. Both the worker from the City Social Service Department and Mr. C had been prepared by the medical worker for this interview. Mr. C had been helped to understand why certain questions were put on the application forms particularly concerning financial e l i g i b i l i t y . This case points out the benefits from close co-operation between financial and case work agencies.  If the medical worker had not recognized Mr. C's need to  be considered independent, he might never have been able to accept the nursing home plan.  The worker from the City Social Service Department was also helped  through her understanding of this need.  She may have felt that Mr. C really did  not wish care and thus would have dismissed his application. Mr. C's rights to self determination were respected in this case. He resented feeling dependent and through recognition of this he was able to plan for himself which would probably make him more responsive to treatment and be a retention of his personal pride and self respect. The worker's knowledge of the community resources and the ways of using them helped Mr. C accept a plan which was not essentially his but that of the  43. doctor's.  The worker was able to carry out his plan by using the resource as  though i t was Mr. C's plan and his decision. Thus she protected Mr. C from dependency and also carried through with the doctor's orders. Mrs. F was a sixty-one year old widow whose occupation had been char woman. She had a diagnosis of glaucoma which she could not accept and i t made her exceedingly troublesome in the c l i n i c .  The referral was made for the worker to  help Mrs. F accept her illness and thus become less troublesome. Through case work help, the worker l e t Mrs. F use her as a sounding board on which she could give vent to her hostility about her illness.  This relation-  ship with the worker helped Mrs. F to adjust herself to the c l i n i c routine and receive some benefit from the medical treatment. As Mrs. F began to feel better physically, she became more accepting of her disease.  The worker was able to suggest the Canadian National Institute for  the Blind recreation clubs to Mrs. F which she previously would have refused.  The  worker contacted the Canadian National Institute for the Blind to t e l l them about Mrs. F and which clubs she would be most likely to enjoy.  Mrs. F f i n a l l y joined  one of the clubs and seemed to feel satisfied with the a c t i v i t i e s .  Mrs. F now had  something to live for, she could enjoy recreation even though her capacity was limited by partial blindness.  She felt comfortable with other people whose illnesses  were similar and she was no longer hostile and unhappy. This case shows that the doctor andthe worker did a great deal to help Mrs. F accept her illness and the treatment but Mrs. F needed something more. worker recognized this need for recreation and used the conmunity resource best suited for Mrs. F's rehabilitation. Mrs. S was a thirty-two year old married woman with a diagnosis of myasthenia gravis,,Reyauds Disease and an anxiety state. The referral was for  The  44.  the worker to assist the psychiatrist i n helping the patient understand her illness and for homemaker service. The worker through her knowledge of community resources sought the assistance of the Family Welfare Bureau. She explained Mrs. S's problem to this agency and they decided through the conference method that the Family Welfare Bureau would provide the homemaker but the medical worker would supervise the home because the problem was essentially a medical one. Through the services of the homemaker, the patient was able to relax and rest enough to accept the treatment of the psychiatrist.  As she received strength  in treatment she could accept her illness and plan for the future.. Thus this community resource made possible a complete treatment plan by the worker and the psychiatrist. Miss L is a seventeen year old single clerk with a diagnosis of hysterical paralysis.  The doctor referred this g i r l to the social service department because  he wanted some help i n treatment and also because he wanted the worker to find a foster home. The worker worker closely with the homefinder at Children's Aid Society.  She explained the case to the homefinder and what she would expect the  foster parents to be l i k e .  From this description, the homefinder found what she  felt was a suitable home. It was decided i n conference with the Children's Aid Society that the medical worker should select and supervise the foster home because the problem was a medical one.  The worker investigated and chose the home and continued to  see Miss L when she f i n a l l y was moved there.  This case of inter agency co-operation  saved this patient from the trauma of a change i n agencies and workers.  It shows  that i n certain instances the client's welfare stands above the agencies' policies. It i s only through professional co-operation therefore, that this kind of plan can be handled efficiently for the patient's complete rehabilitation.  45. Mr. T was a thirty-eight year old unemployed single man with a diagnosis of inadequate psychopath.  This case i s an example of an excellent referral from  another agency. The patient went to the Family Welfare Bureau seeking psychiatric help.  The worker i n this agency recognized Mr. T's need for a proper diagnosis  both psychiatric and medical.  She explained the services of the Family Welfare  Bureau and,why she was making a referral to the Vancouver General Hospital social service department. She explained the function of the medical service department and how they would help him.  She f i n a l l y phoned the department for Mr. T and made  an appointment. Thus, when Mr. T arrived for his appointment he understood the services of the department and the role of the worker. This process saved a great deal of time for the medical worker.  She was able to work into the social history data  for the psychiatrist immediately.  The client too received the service he was seek-  ing with the greatest possible speed. Mrs. G was a forty-eight year old married lady with seven children. Her diagnosis was psychogenic gynecological complaints.  The referral was made because  the doctor f e l t there were personal problems which were preventing Mrs. G from accepting treatment.  The worker found that the home situation was very poor and  that the main source of frustration was the presence of a thirteen year old spastic daughter. The worker f e l t that the daughter was neglected and the mother f e l t exceedingly guilty about this.  The worker felt that nothing could be done to help the  g i r l i n the home. She therefore discussed the possibility of placement of this child i n a school for mentally disturbed children.  Mrs. G seemed to feel consider-  ably relieved with this suggestion because i t reduced her feelings of guilt. The worker contacted the school and preparations were made for the child's admission.  Mrs. G was helped to feel as though she was doing the right thing for  46. the child.  The child i n turn was prepared and the move to the school was made.  The worker's knowledge of this community resource and how i t was used helped to restore the G family to unity and gave Mrs. G an opportunity to accept medical treatment for herself.  The worker realized that the school would help  the severely disturbed child and i t would also help Mrs. G whose guilt feelings were partly responsible for her illness. SUMMARY  In this chapter i t can be seen how v i t a l l y important i t is for the medical social worker to have an extensive knowledge of community resources.  Rehabilitat-  ion is not just the restoration of physical strength but instead the restoration of a l l the areas which make up daily living.  A person cannot be a healthy and  wholesome individual unless he can function physically, mentally, socially and vocationally to his own and society's satisfaction. The worker i n the medical setting has only the f a c i l i t i e s for helping a person regarding the problems i n the area of illness.  She therefore has to depend  on the resources i n the community for giving the patients a professional standard of casework help. The medical worker more than any other type of social worker i s dependent on the community for assistance. It i s therefore a responsibility of the worker not only to know the existing resources but to be instrumental i n developing new ones. The medical worker too has a responsibility for social action i n the community not only for the promotion of new resources but for the prevention of illness.  This should be carried out through lectures to patients, families and  friends, to community groups and through written publicity.  The worker i s  interested i n the prevention of sickness and in the social maladjustments which result from such sicknesses: she i s in a position to know the causes and the results from these sicknesses and i t i s therefore her responsibility to speak with authority i n the community.  CHAPTER IV THE SOCIAL WORKER AND THE ADMINISTRATION  47. The Vancouver General Hospital i s a public institution or functions under the authority of the British Columbia Hospital Act; and under this assumes responsibility for any person who requires medical attention. employees, both professional and non-professional, service every day i n the year.  Staffed by 1200  i t gives a 24 hour per day  The American Hospital Association which is recognized  as the authority for setting the standards for medical care, has given the Vancouver General Hospital a grade A standing.  One of the standards which i s emphasized by  the Association is a social service department which upholds the recommendations of the American Association of Medical Social Workers, The hospital i s controlled by a group of lay citizens known as the Board of Governors.  The membership to this Board i s open to any interested person requir-  ing only a $10.00 fee for an annual membership and a $100.00 fee for a l i f e membership.  The function of the Board i s similar to that of the stock holders in a  corporation.  The principle responsibility of the Board i s the election of seven  of the members of the corporate body to the Board of Directors. The Board of Directors is composed of seven members elected by the corporate body, three appointed by the province of British Columbia and three appointed by the municipality of Vancouver. The Medical Director and the lay Director of the hospital serve as advisors to this Board but they do not possess any voting power. The main function of this Board is the formulation of the over-all policy of the hospital, the provision of personnel and f a c i l i t i e s for the care of patients and the selection of the medical staff. The Medical Board is made up of a l l the chiefs of the different medical services.  The chief i s the oldest senior doctor under sixty years of age in a  particular service. administration.  This Board does not have any direct authority on the hospital  They serve in an advisory capacity in the formulation of policy,  in relieving medical staff problems and i n suggestions for new kinds of treatment  48. service for patients. There are three lay assistant directors under the supervision of the lay Director.  They are responsible for the supervision, planning and organizing of  the f i f t y various departments.  These assistant directors have a great deal of  power in that they can usually finalize matters of policy and finance within the various departments.  An appeal can be made to the Director but his decision is  usually i n accord with that of the assistant directors. It can be seen therefore that the line of authority in the Vancouver General Hospital is very clear and concise. of the smallest of the f i f t y departments.  The Social Service Department i s one This department is not represented on  the Board of Management which consists of a l l the Directors of the important departments which are concerned with treatment.  This is because the value of the  department has not yet been recognized within the administration.  It i s f e l t that  with advertisement to the administration i n the form of good casework practice and good reports, a real acceptance and recognition would be the result. WAYS OF HELPING THE ADMINISTRATION In an institution where there are 1200 employees and 50 various medical departments there i s an excellent opportunity for the patient to become lost i n the sea of specializations.  The patient may see many different kinds of special-  ists with no one person taking the time or the interest to make the patient feel that he is a person.  The social worker has the training and s k i l l to f u l f i l this  function i f she i s given the time and the opportunity to assist. If a patient were to be allowed to receive treatment from various departments with no one person to help him understand the treatment, he could very likely become a chronic clinic case.  For example, a man with feelings of tension brought  about by a marital problem may demonstrate symptoms of a r t h r i t i s . become so great that his limbs become rigid and sore.  His anxieties  If he were referred to such  49. clinics as physiotherapy, X-ray therapy, physical medicine, general medicine, internal medicine and many others with l i t t l e r e l i e f from his real problem, his physical condition would probably become increasingly rigid and immovable.  The  treatment would not help the patient because the source of tension i s i n the marital problem. As the physical condition becomes worse the marital problem too is aggravated. This might be through loss of earning power or through the physical deformity that usually accompanies the disease. This circle of v i s i t s to clinics with no benefit from treatment i s exceedingly costly to the administration.  If, however, there had been a social worker  there to help when i t was found the patient was not responding to treatment, this situation would have been different.  The worker with her s k i l l s in interviewing  would have noticed that the patient was suffering from tensions in the environmental situation.  The worker would have allowed the patient to discuss his problem  which would in turn have released the tensions.  In this case the worker might  have referred the case to the Family Welfare Bureau where the patient could receive the best sort of help for his problem. The illness i t s e l f could probably have been treated in shorter time, thus reducing the cost to the administration, and prehaps preventing the development of a chronic condition. Another problem of considerable importance with which the administration must deal are those patients who either have not paid the B.C. Hospital Insurance Service premiums and are thus made staff patients or those who are in hospital over 30 days and are not acute cases.  The B.C. Hospital Insurance Service scheme does  not cover patients who are not i n the category of acute care after 30 days. These patients too become staff patients i f they are s t i l l confined after 30 days.  In  the 1950 annual report of the Vancouver General Hospital, i t stated that Yl% of the work done in the hospital was free work for staff patients. (19). (19)"Annual Report of the Vancouver General Hospital .' 1950. 1  This was  •50.  illustrated as a very serious problem and because of i t the hospital was  having  a difficult time avoiding a deficit in the budget. This year a ninety-day experiment was tried in the Semi-Private  Pavilion  to try to remove some of these "long-stay" patients. A social worker was used in the experiment because of her knowledge of the community resources for such things as nursing homes and financial assistance.  The department f e l t that this would be  an excellent opportunity to show the administration the value of medical social workers• The doctors would refer their "long-stay" patients to the social worker and then she would make an i n i t i a l interview.  In other cases, the administration  knew those persons who were "long-stay" and the worker would interview them, then consult with the doctor.  No report was available at the time of this study but i t  is known that a great deal of successful work was done through the s k i l l of the social worker.  The experiment i s now to be considered a permanent part of the  hospital treatment and may be extended to other wards in the hospital. The team used in this removal process included as well as the social worker, the head nurse on the ward, the assistant director in charge of the ward and the doctor of each patient involved.  The worker through referral either by the doctor  or the administration would interview the patient for a social diagnosis.  The  social diagnosis would be presented in conference to the other team members. Each team member would present his opinion and together a decision would be reached regarding the patient. This process has been found very useful to the administration.  Many "long-  stay" patients have been discharged thus reducing the costs for the administration and i n turn making more bedsavailable for acute patients. benefits from this experiment.  The patients have received  Through the casework help given by social workers  they have either been able to make concrete plans for discharge or they have been  51. helped to reach the point where they wish to get well and leave hospital. The administration has been helped to realize that the "long-stay" patients cling to the hospital for security.  They realize that i f these patients  were discharged without the help of a social worker they would probably develop another illness in order to remain i n the hospital. in having the social worker help the patients.  They can now see the value  The worker uses her techniques to  understand the patient and his problems. Her s k i l l s enable her to decide whether the patient's problem i s i n the environmental, economic or personality areas. When she has decided upon the area of conflict she brings i t before the team members. It may be that with a short casework contact with the worker the patient w i l l be ready for discharge.  In other cases the casework treatment may take longer; the  social worker therefore must convince the administration that the patient should remain in hospital until casework treatment can be given.  The members of success-  f u l discharges and the social worker's a b i l i t i e s i n discussing human motivations and the functions of social workers to the team members has convinced the administration that the social worker can be of inestimable value to the hospital. The social worker could also help the administration i f they were to be represented on the Board of Managers. The worker's understanding of the patient and his problems would help in the co-ordination and promotion of treatment services and administrative policies within the hospital.  The worker sees the patient as  a whole person, not as an organic part i n a broken machine.  She knows and under-  stands his needs and would be helpful in presenting them to the administration. The professional worker has been trained to understand the role of other professional people i n the hospital and of the administrative practices.  As she  sees the patient as a whole person, so does she see the hospital as a whole unit. Her s k i l l in understanding the institution, the people served and the professional persons who serve, should be helpful to the administration where they do not  52. actually have contact with the people they serve nor are they represented on the treatment team. The administration should make referrals to the social service department in cases involving "long-stay" patients or chronic hospital cases i f the doctors do not refer them. The workers i n receiving these referrals would expect to work with the administrator involved as she would with the doctor or outside agency. The patient must feel secure through the unity of policy and ideas by a l l professional employees in the hospital, CASES SHOWING THE SOCIAL WORKER'S ASSISTANCE IN THE DISCHARGE PLANS Mr. M had rheumatoid arthritis and had received over 900 days of care in the hospital over a period of 4 years. Every time he was admitted, he became a staff patient.  The worker, through casework help i n the treatment tem was able  to help this man to restore his independence and his physical health so that he no longer required hospital care. If this man had been referred to the social worker at an earlier point in treatment, i t would have saved the administration a great deal of money and time.  What i s even more important of course, i t would have prevented Mr. M from  becoming damaged physically. If Mr. M had been referred to the department when he f i r s t entered the clinic at which time he suffered with only vague pains i n his ankle, i t would have saved a tremendous amount of time and money. At the present time, the administration feels i t costs |13.00 per day to treat a patient i n hospital.  Mr. M's treat-  ment for 900 days i n hospital has therefore cost $11,700.00 at present day rates. If this patient had been seen as a whole person with environmental problems, he never would have been admitted to hospital because his frustrations around the environmental situation would have been relieved immediately through the social worker's s k i l l i n social diagnosing and treatment.  As i t was, the patient was  53. saved f r o m c h r o n i c i n v a l i d i s m and l i f e t i m e c a r e b y t h e a d m i n i s t r a t i o n o f  either  t h e h o s p i t a l o r some n u r s i n g h o m e .  M i s s L was t h e s e v e n t e e n y e a r o l d p a t i e n t w i t h h y s t e r i c a l p a r a l y s i s . was a n i n t e r e s t i n g e x a m p l e o f t h e t y p e o f p a t i e n t who c h a n g e d f r o m a n a c u t e chronic case. of  a staff  patient  after  M i s s L had a s e r i o u s and  only s o c i a l l y acceptable making i t  In order to relationship. she f e e l s  from the B . C . H o s p i t a l Insurance  t h i s p e r i o d a n d was c l a s s e d  neurosis,  r e l i g i o n c o u l d not be expressed  paralysis,  the c o n f l i c t s the f e l t  way s h e c o u l d d e f y h e r f a t h e r ' s  impossible f o r her t o  c a r r y out h i s  help t h i s type of patient,  i n the w o r k e r she w i l l  a defence  against  her c o n f l i c t s .  a long period of t i m e . more d e f e n c e s .  If it  regarding her  is  ready to  t h e w o r k e r must d e v e l o p a  The a d m i n i s t r a t i o n was and why t h e p a t i e n t n e e d e d t o remained a s t a f f  helped to  trusting  conflicts. illness  can be g i v e n o n l y o v e r f e e l g u i l t y and  develop  a n d when t o  will  stop.  r e a l i z e what the p l a n o f treatment  remain i n h o s p i t a l f o r a long period of t i m e .  patient  a  t h e s t o r y o f h e r l i f e a n d when  the p a t i e n t w i l l  treatment  The  demands.  This type of treatment  accept  father  w i s h e s was t o d e v e l o p  t a l k about h e r f e a r s and her  hurried,  period  a chronic case.  The w o r k e r t h r o u g h h e r s k i l l s i n u n d e r s t a n d i n g t h e p a t i e n t ,  know when t h e p a t i e n t  patient  is  a  Service.  i n words b e c a u s e she f e a r e d p u n i s h m e n t .  The p a t i e n t m u s t b e h e l p e d t o t e l l  trust  as  The w o r k e r m u s t t h e n h e l p t h e p a t i e n t u n d e r s t a n d w h y s h e d e v e l o p e d t h i s as  to  H e r c o n d i t i o n was c o n s i d e r e d a c u t e b y t h e a d m i n i s t r a t i o n f o r a  s i x months and she r e c e i v e d b e n e f i t s  She b e c a m e  She  f o r one a n d o n e - h a l f m o n t h s a n d t h e n was  was The  dis-  charged. If  t h e d o c t o r had not r e a l i z e d t h a t  t h e p a t i e n t had an e m o t i o n a l  illbess,  t h e p a t i e n t would p r o b a b l y have remained i n h o s p i t a l o v e r a p e r i o d o f y e a r s . patient  recovered  the area o f  This  very r a p i d l y b e c a u s e t h e d o c t o r a n d t h e w o r k e r r e c o g n i z e d w h e r e  c o n f l i c t l a y and t o g e t h e r  t h e y planned the method of t r e a t m e n t .  A l l  54.  the people on the team of treatment understood the patient because the social worker had discussed the patient with them. The administration understood the patient's illness and i n this way everyone knew the goal of treatment and they a l l worked toward i t . rapid.  The patient f e l t secure and her response was exceedingly  The worker therefore helped to prevent the administration from years of  free work for this patient. Mrs. S was the thirty-tvro year old married lady with the physical diagnosis of Reynaud's Disease, myasthenia gravis and anxiety state.  The worker's help in  securing home maker service for the patient's family and her casework treatment in the environmental level was of tremendous benefit to the administration. Mrs. S was i n hospital at the time of referral.  Her discharge was hastened  by the relief of having a homemaker in the home. The anxiety she f e l t regarding her home situation was aggravating her physical condition.  When Mrs. S realized  that her home was operating efficiently, she was able to accept and benefit from treatment. When Mrs. S was discharged, the casework treatment she received from the worker helped to relieve the problems Mrs. S was having with her children, relieved a rather precarious marital situation and finally helped to stabilize the economic situation. Through this help the patient was able to accept her illness and plan concretely for her eventual chronic condition. If this patient had not had the social work treatment with the environmental problem, the anxiety state which was aggravating her condition would probably have advanced the time of her chronic condition. As i t was, she was relieved of the anxiety state and discharged.  Her environmental  problems were dimished, her physical condition was not aggravated and she would probably be able to enjoy two to three years of normal healthy living i n her home. The financial state of Mrs. S and her family would force her to become a  55.  staff patient. Thus, i f she had not received social work help, the administration would have been responsible for the case of Mrs. S for possibly fifteen years. With the aid of the social worker, however, the time of hospitalization was  reduced  and through relieving the marital situation the economic status of the family increased. Mr. P was the sixty-four year old single labourer with a diagnosis of diabetes meletus and muscular atrophy.  Through casework help the patient was  relieved of the financial burden which was aggravating his condition and the fear of no longer having his niece to care for him. As the problems were brought out by the patient and relieved, he no longer wished to remain in hospital.  The doctors were prepared for the fact that Mr. P  was a chronic case and after several months in hospital would need nursing home care.  However, after casework help over a period of one and one-half months, the  patient recovered his physical strength very rapidly and was discharged to his home. This case i s a startling example of the value of the social worker to the administration.  In terms of money, thousands of dollars were saved by the admin-  istration i n this case. CASES SHOWING THE SOCIAL WORKER'S ASSISTANCE IN PLANNING FOR CHRONIC PRE-PSYCHOTIC PATIENTS Mr. T was diagnosed as an inadequate psychopath who was requesting psychiatric help.  The personality of the patient was so damaged that he could not have  benefited from psychiatric help.  The doctor recognized through the social worker's  social history that some help could be given to the patient i n the area of social support.  He therefore made the referral to the worker for her skills in this  supportive treatment. The worker did help the patient to secure employment and relieved the mental frustration he was experiencing at that time.  This treatment by the worker  56. prevented Mr. T from becoming a chronic mental patient. The social worker recognized that Mr. T w i l l always need support when his frustrations become too much for him.  His personality was so damaged i n his early years that no real  treatment can be given now.  He can manage adequately i f he i s given help when  l i f e becomes too much for him at certain times. This type of help can be given over a period of about two months i n clinic interviews.  If he was not able to see a social worker at these times, Mr. T would  probably develop a psychosis which would then confine him to an institution for a long period of time. This case illustrates how the worker can save the administration from the cost of chronic care.  This type of patient needs supportive treatment probably once  every two or three years for a period of two months. If he did not receive this help, however, his mental health would become seriously impaired and lead to an eventual confinement.  Thus, with social work help the patient remains an independ-  ent productive citizen and the hospital i s prevented from the cost of long term care. Miss M was a thirty-six year old stenographer who was requesting psychiatric help.  Her conflicts lay i n the areas of her environmental and employment  situations.  The worker gave the patient the treatment she needed and helped her  to emancipate herself from her mother and receive satisfaction from employment. The interviews were held in the Out Patient Department clinic over a period of seven months. If this patient had not received the help of a social worker she probably would have developed a severe neurosis. to deal with reality alone.  She did not have the strength  The psychiatrist did not have the time nor the s k i l l  to deal with this problem. The patient could only be helped around her reality problems. If an attempt had been made to help the patient on a psychiatric level she would probably have developed a severe neurosis.  The worker had the s k i l l to  diagnosis where the area of treatment would be most beneficial to the patient.  57. The treatment the patient needed was given by the social worker and prevented tremendous costs to the administration.  If this help had not been  available, the patient would have been a chronic mental case through either not receiving any help from the Out Patient Department or through incorrect treatment by the psychiatrist because of his lack of time and s k i l l in social treatment. CASES SHOWING THE SOCIAL WORKER'S ASSISTANCE IN PLANNING FOR CHRONIC CLINIC PATIENTS Mrs. F was the sixty-one year old widow with a diagnosis of glaucoma. The worker helped Mrs. F to become less troublesome in c l i n i c , helped her to accept her illness and f i n a l l y through this, to enjoy some recreation.  Mrs. F could not  accept her physical diagnosis and made many unnecessary v i s i t s to the Out Patient Department with many types of physical complaints. This was of course exceedingly costly in both time and money for the c l i n i c .  Through casework help the patient  was able to accept her illness and take pleasure in outside a c t i v i t i e s .  In this  way she no longer needed to have vague physical complaints and the c l i n i c v i s i t s were reduced.  Thus, the administration was saved from the costs of needless v i s i t s  which might have resulted in a chronic hospital case. Mrs. G was the forty-eight year old woman with seven children who had a diagnosis of psychological gynecological complaints. The doctor realized that environmental problems were preventing Mrs. G from accepting treatment.  The worker  was able to diagnose the problem and succeeded in removing the source of the frustration which was the presence in the home of a thirteen year old spastic c h i l d . When this removal took place, Mrs. G was extremely relieved and ready to accept treatment for her physical complaints. If this patient had continued to receive physical treatment with no exploration into the source of the anxiety, i t would have been a costly experience for the administration.  The patient might have  received years of c l i n i c treatment from the Out Patient Department without feeling  58. any relief from her anxiety.  The anxiety would have aggravated her physical  condition u n t i l permanent physical damage might have been the result.  As i t was,  the source of the frustration was removed in a period of one month. Her illness stemmed from the guilt she f e l t in rejecting her spastic child.  The r e l i e f from  this frustration would probably result in the patient's physical complaints being almost nebulous, for she would no longer have any need to be  ill.  SUMMARY The social worker can help the administration in the hospital, not only by saving cost and time in the Out Patient Department and on the ward but in other ways such as representation on the Board of Managers and assisting the co-ordination of treatment services. The administration of a large institution such as the Vancouver General Hospital has a tremendous responsibility i n the maintaining of adequate f a c i l i t i e s and in spending public money. These administrative problems are often so timeconsuming that the administrator i s completely removed from the people he i s serving.  It is the social workere therefore, who can help the administrator in  understanding the patient and his needs and the administrator who makes the satisfaction of these needs available. This service by the worker could be available to the administrator through reports and conferences.  It would be a saving both  in time and money and what i s more important, assure patients of adequate treatment. The worker can also be of help to the administration in her s k i l l in handling of staff relationships.  When many services are available i n treatment,  there i s usually a division between departments.  The worker could be of great  assistance i n helping to co-ordinate the services and in defining the roles.  The  medical worker has been trained to use many resources in the rehabilitation of the patient and this experience would help in her assisting i n bringing the resources together and in inter-departmental understanding.  59.  Finally, the worker can help the administration i n resolving one of the largest problems of any general hospital, the removal of the chronic patient.  "long-stay"  The "ninety-day" experiment described i n this chapter pointed out how  the worker has had a great number of successes because i t i s now to be considered a permanent function of the social service department. The social service department i s growing rapidly and i s becoming more and more an integral part of the administration.  In the future i t can be expected  that the service to the administration w i l l be as much a function of the department as i t i s to the doctors.  The hospital i s growing so rapidly and there i s such a  tremendous influx of new treatment service that the administrators are even more removed from the people they serve.  It i s to be expected therefore that the social  worker's work w i l l be increasingly in the area of bringing the patient as a social personality to the administration i n the co-ordinating of treatment services for his benefit.  CHAPTER V CONCLUSIONS AND  RECOMMENDATIONS•  60. From various angles this study has illustrated the role which the social worker can play i n the treatment team i n the medical setting. accepted in some areas, but not as yet in others.  Team work i s  The tremendous advances in  medical science in the late 19th and early 20th centuries brought about an era of intense specialization.  There was a great amount to be learned about each small  area of the living body and i t was found impossible for one man to know i t a l l . The doctors, therefore, became specialists in sections of the human organism. Later, i t was found that in this increasing need to specialize, the patient as an integrated social and emotional being, was l o s t .  It was then, therefore, that  medical social work became a valuable asset in the treatment team with the doctor, the community and the administration. Of course the social worker in the hospital works under the leadership of the physician.  The patient comes to the hospital because he i s seeking r e l i e f  from physical pain.  The doctor decides in which way the social worker can help  him and he w i l l refer the patient to the social worker, stating the problem on the referral s l i p .  Workers in the past have received referrals for routine environmental  problems for the most part, with l i t t l e recognition of the potentialities in the medical social worker. This lack of recognition has been particularly noticeable in the doctors who serve in general medicine. the neurologists and psychiatrists.  The best referrals seem to come from  This situation is obvious because the emotional  factors i n neurological and psychological illnesses are much more easily seen than they are in the field of general medicine. In the Vancouver General Hospital Out Patient Department the doctors do not receive any monetary reward for their services. These doctors serve in the clinic for a three month period and i n a consulting capacity for the remainder of the nine months in the calendar year.  These staff doctors, as they are called, are appointed  by the Medical Board; they are a l l specialists and i t i s considered an honour to  61. become a staff doctor.  Their duties consist of serving in the Out Patient  Department, consulting for staff patients on the ward, and teaching and supervising of internes.  In return for this service, each doctor has a certain number of  beds assigned to him for the patients in his private practice. From this outline, i t can be seen that service in the Out Patient Department is considered an arduous, non-profit duty by 3ome doctors. to the c l i n i c although appointments begin at nine A.M. and often inefficient.  They arrive late  Their services are rushed  Patients have to wait for hours for appointments and in  many cases receive only five to ten minutes of attention. The patient, therefore, is often hostile about waiting and, feeling physical discomfort, he does not give a true picture of himself.  This disgraceful handling of patients i s not true in  a l l cases but i t does happen often enough to include i t in this study.  There are,  on the other hand, many doctors who give a great deal of time and interest to these non-pay patients.  These doctors are usually the ones who give excellent referrals  to the social service department and some worth while treatment has been the result. The value of the social worker in medical treatment is that the patient's physical recovery is usually dependent on his emotional and social state of health. The worker, through her s k i l l s in social diagnosis and treatment, can be of tremendous service to the doctor.  It is an accepted fact that the doctor is more competent  in the area of physical treatment.  Physical and social treatment cannot be  separated  like the "mind" and the "body". The worker and the doctor, must, therefore, work closely together i f there i s going to be a successful rehabilitation of the patient. In the proceeding chapters, there was a l s o an attempt to point out that the workers in the medical setting had a greater need for community resources than any other type of social agency. It was pointed out that the inter-agency referrals were not good at the present time. This present situation is not the fault of the medical social workers alone but of the other agencies as well.  There seems to be  62. a general lack of understanding of the functions of the separate agencies.  This  i s the result of poor administrative policies within the agencies and a lack of skilled personnel.  The increase of trained personnel should change this situation  to some degree. The workers in the hospital are totally dependent on outside resources for the rehabilitation of the patient.  It seems that the worker in the hospital i s  being accepted by her knowledge of community resources. important that the inter-agency functions improve.  It i s , therefore, v i t a l l y  The workers in the hospital are  responsible for the integration and promotion of community resources.  If they are  to receive recognition, they must accept their position as resource persons and perform successfully in this role.  When they achieve success, i t will be much  easier to present their potentialities i n treatment s k i l l s . It has been pointed out that the Vancouver General Hospital is expanding rapidly.  New buildings are being constructed and new buildings are being added.  This tremendous increase in specialties has of course increased the financial budget.  The administrators are more than ever occupied with administrative duties  and are becoming more and more removed from the people they serve.  The social  worker can be of inestimable service in bringing the patient as a person to the administrators.  It is she who knows the patient and his needs and i t i s she  who  can present them to the administrator who makes the fulfillment of these needs possible. The main source of frustration to the administrators at the present time i s the chronic non-pay patient.  The ninety-day experiment described previously,  pointed out the usefullness of the worker in helping to remove these patients. The worker had an opportunity to work directly with the administrator and i t has helped tremendously in showing the real function of the social worker i n the medical setting. It was so successful that this work with the administration w i l l  63. be a permanent function of the social work department. The experiment was started in the Semi Private Pavilion which does not include patients from the Out Patient Department.  This has, therefore, increased the status of the social worker.  Their  service i s not available for indigent patients alone but for a l l patients, RECOMMENDATIONS  The f i r s t recommendation of this study has already been carried out. It was that a job analysis be done so that the routine c l e r i c a l functions of the workers be eliminated.  It is f e l t that well trained and supervised volunteers or a well  selected clerical staff would do this work successfully. The supervision of this staff could be conducted by the Social Service Department.  The e l i g i b i l i t y , routine  application forms which must be f i l l e d out are exceedingly time consuming for the workers.  If this intake job was taken over by c l e r i c a l staff, i t would release the  workers for good casework. The second recommendation would be that the Women's Auxiliary put the fund they have available for appliances in a central place.  As i t i s , when a patient i s  in need of an appliance, the workers must c a l l the Women's Auxiliary for approval, phone the supply depot for the cost of the appliance and again phone the Women's Auxiliary for the approval of cost before the requisition can be put through.  This  type of work is time consuming also and prevents the workers from doing casework. It i s therefore, recommended that the Women's Auxiliary permit the workers to make requisitions up to the cost of #50,00.  Anything above that amount should, of course,  have the approval of the Women's Auxiliary. A third recommendation would be that workers should be able to order taxis for their own patients without f i r s t having the approval of the Director.  This  again i s time consuming and pointless. The workers in the medical setting actually have a great deal of personal responsibility.  They receive their cases directly  64. from the doctor, the casework supervisor acts only as a consultant.  It is f e l t ,  therefore, that with this tremendous responsibility toward the patients, the workers could also take responsibility for ordering taxis. The fourth recommendation is that with the release of the workers from e l i g i b i l i t y studies and routine functions, there would be enough workers released for clinic duties.  It is recommended that there be one worker in each clinic to  handle those cases exclusively. The worker should s i t in the clinic with the doctor and discuss each case for i t s possibilities. problems could be detected immediately.  In this way, patients with social  Their social problems could be dealt with  so that they could benefit from physical treatment and therefore reduce the cost to the administration. Some clinics may need more than one worker.  It is recommended that there  should be a study done in each c l i n i c to try to detect the percentage of the cases that could benefit from casework treatment.  The problems of the patients in the  Out Patient Department are greater because of the financial problems and the infrequent personal contacts with the doctors.  If the worker can present an adequate  history and an adequate plan for follow-up, the doctor w i l l be able to handle more patients with less time and with more efficiency. The f i f t h recommendation is that there should be a worker for every one hundred staff beds. These staff patients, like the patients in the Out Patient Department, have greater social problems i n financial stress and brief contacts with doctors.  The workers, therefore, have a greater pressure in preparing histories and  in making discharge plans. The sixth and f i n a l recommendation is that there be a greater effort on the part of the Department to define i t s function and the role of the individual workers. There should be an attempt to present the function of the workers through interdepartmental discussions and lectures and through the employees bulletin. 1  There  65. should be a vigorous attempt to co-ordinate and integrate the resources of the community.  It i s recommended that there be more inter-agency contacts through  reports, v i s i t s and conferences so as to eliminate this present lethargy and jealousy between agencies. If these recommendations were put in practice, i t would be expected that there would be a change in attitude toward the social service department.  The  workers would have time for good casework service and through this practice t h e change would become evident. The younger doctors who are coming into the hospitals at the present time have been taught how to use the social service department.  If  the workers are to participate i n the treatment process, they must be released from routine c l e r i c a l work. There have been great changes in the department this last year.  More and  better referrals have been coming from the doctors, the agencies and the administration. The workers cannot do both casework and c l e r i c a l duties e f f i c i e n t l y . If they are to be truly professional, they must be strong enough to release themselves from the routine and practice what i s truly social work. The medical worker is responsible f i r s t l y , to the people he serves. If the worker i s fully convinced that i t is her responsibility to help people to develop and use their capacities to deal adequately with their social environment, then they w i l l take the necessary steps to secure the highest in professional service.  66. BOOKS and REPORTS 1.  Alexander, F. & French, T.  "Studies in Psychosomatic Medicine", Donald Press Co., New York, 1948.  2.  Bartlett, Harriett M.,  "Some Aspects of Social Casework i n a Medical Setting". The Committee on Functions, American Association of Medical Social Workers, Chicago, I l l i n o i s , 1942.  3.  Binger, Carl,  "The Doctor's Job", Norton, New York, 1945.  4.  Cabot, Richard,  "Social Service and the Art of Healing", Dodd, Mead, New York, 1928.  5.  Cannon, Ida M.,  "Social Work in Hospitals", Russel Sage Foundation, New York,  6.  Clapesattle, Helen,  "The Doctors Mayo", University of Minnesota Press, Minneapolis, 1941*  7.  Commission on Hospital Care,  "Hospital Care in the United States", The Commonwealth Fund, New York, 1947.  8.  de Schweinitz, Karl,  "England's Road to Social Security", From the Statutes of Labourers i n 349 to the Neveridge Report of 1942, University of Pennsylvania Press, Philadelphia, 1943.  9.  Elledge, Caroline H.,  "The Rehabilitation of the Patient", J.B. Lippincott Co., Philadelphia, London, Montreal, 1948.  10.  English & Weiss,  "Psychosomatic Medicine", W.B. Saunders Co., Philadelphia, London, 1943.  11.  Lowrey, Lawson, G.,  "Psychiatry for Social Workers", Columbia University Press, New York,  12.  Richardson, Henry B.,  "Patients have Families", Commonwealth Fund, New York,  13.  Robinson, George C ,  "The Patient as a Person", A study of the Social Aspects of Illness, Commonwealth Fund, New York, 1939.  1923.  1946.  1945.  67. 14.  The Staff of the Institute for Juvenile Research,  "Child Guidance Procedures, Methods, and Techniques Employed at the Institute for Juvenile Research", D. Appleton Century Co., Inc., New York, 1937.  15.  Stroup, Herbert H.,  "Social Work an Introduction to the Field", American Book Co., Mew York, 1948.  16.  White, William A.  "The Meaning of Disease", The Williams & Wilkins Co., Baltimore, 1926.  ARTICLES, etc. 1.  Alexander, F.,  2.  American Association of Medical Social Workers Education Committee,  "The Social Worker's need for Medical and Health Information", January 1941-  American Association of Medical Social Work,  "A Statement of Standards to be met by Social Service Departments in Hospitals and Clinics", June 1949.  "Psychological Aspects of Medicine", Journal of Psychosomatic Medicine, January 1939. 1  3.  "Annual Report of Vancouver General Hospital".  4.  1950.  5.  Burns, Margaret M.,  "Multi-Disciplined Effort in Treatment Services", Proceedings Canadian Conference on Social Work, 1950.  6.  Canadian Association of Social Workers,  "Introducing the Medical and Psychiatric Social Worker", Ottawa, Canada.  7.  Cockerill, E.,  "New Emphasis on an Old Concept of Medicine", Journal of Social Casework, January 1949.  8.  De La Fontaine, Elise,  "Some Implications of Psychosomatic Medicine for Casework", Journal of Social Casework, June 1946.  68.  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