Indian Journal of Health Social Work
MEDICAL SOCIAL WORK: AN IMPORTANT HOSPITAL FUNCTION
Senior Medical Social Service Officer, All India Institute of Medical Sciences, New Delhi
Correspondence: Mukesh Kumar , e-mail: firstname.lastname@example.org
The evolvement of scientific medicine, with specialties as a notable feature, has greatly enhanced the available knowledge and scientific and technical skills. As a result, the clinical treatment has not only become more efficient, but also complicated and costly affair. Extreme economic and social changes have had a firm impact on requirement, demand and one’s capability to pay for all the services modern medicine has to offer. The magnitude and seriousness of the problem of richness, from the social and economic viewpoints, have led to the realization that adjustments are necessary in the interest of all patients and such re-adjustments are beyond the power of the individual to achieve. Consequently, social philosophy has changed. Nowadays, the health of the people is viewed as public concern; sickness is not only a personal calamity; health care is an essential human right; and everyone shall enjoy equal opportunities for health care. Besides, emotional components of health and illness are also to be handled appropriately. Professional social workers are trained to manage psychosocial issues associated with ailments and health.
Keywords: Hospital, Social Work, Medical Social Work.
Webster dictionary views healthiness ‘being sound in body, mind or spirit, particularly absence from physical ailment or pain’. The Oxford English Dictionary defines health as the integrity of body or mind; that condition in which its functions are correctly and competently performed. Over the years, the concept of health has witnessed a shift from an individual concern to a world-wide social goal. The concept of health involves bio-medical, emotional, psychological, social, cultural, political and spiritual factors. The holistic concept is the conglomeration of all the above-mentioned factors. According to WHO (1948), health is a state of complete physical, mental and social well-being and not merely an absence of disease or infirmity.
Illness produces an unfavorable emotional environment. It makes a person weak, needy and dependent. Such a situation creates many reactions such as anger, anxiety, depression, dependency, guilt, denial, shock and rejection (Bawden, 1979). Therefore, it is necessary for healthcare personnel to understand these emotional reactions associated with illness. Apart from this, it is also essential to recognize the impact of social conditions on illness. In a study of 174 patients of multiple ailments, Robinson (1939) observed that without consideration of adverse emotional and social conditions, effective treatment cannot be implemented.
Wandell, Wajngot, Rane & Gafvels (2014) in the study on diabetic patients observed that the most identical issues were family problems (63%), work-related problems (59%), and emotional instability (52%). The level of anxiety and depression was higher in the PSP group than the NPSP group. Self-trust, minimization and social trust were lower while protest, isolation, fatalism and intrusion were higher in the PSP group. Kori et al (2014), in their study, described many psychosocial issues in mental illness like adjustment difficulties in the family, medico-legal problems, misunderstanding about the ailment, handling of unexpected behaviors, job related issues, disability related problems, social stigma, infringement of human rights of psychiatric patients, property issues related to psychiatric patients, poor medicine adherence, treating divorced psychiatric female patients, expressed emotions, weak social support, family disputes, domestic violence, financial barriers, sexual dysfunction, alcoholism, marital issues and so on.
According to Wiechman & Patterson (2004) burn patients come across social stressors such as family tensions, return to work, sexual malfunction, bodily appearance, and disturbances in daily life. Many people memorize the episode that caused difficulties. Patients may also undergo depression. It is found that gradually adjustment to burn injuries improves. Family and social support prevent the development of psychological distress.
Characteristics of individuals, educational background, vocation, financial status, housing, personal support system are the major area of psychosocial assessment of organ failure patients requiring solid organ transplantation (Dhooper, 1994). Page & Adler (2008) illustrated the following psychosocial needs of cancer patients:
• Knowledge of illness, therapeutic options, health, and services
• Assistance to cope with emotional reactions related to disease and treatment
• Assistance in handling illness
• Support in behavior modifications to minimize the effect of illness
• Physical and logistical resources
• Assistance in handling disturbances in work, school, and family life
• Financial resources
Hospital: Organized Healthcare Provider
Hospital first appeared before 1000 B.C (Joshi, 2000). In the middle ages, the hospital could function as almshouse for the poor or dwellings for pilgrims. At present, a hospital is health care facility that sometimes provides long term patient stays. W.H.O has defined the hospital as a unified part of the social and medical organization, aimed to offer all health care, both curative and preventive, to people and whose OPD services extend to the family and its home environment. It is also training institution for health workers and bio-social research center. Directory of Hospitals in India, 1988 defined hospital as an institution that is functioning for the medical surgical and/or obstetrical care of admitted patients and recognized as a hospital by the appropriate authority. According to Chandra (2007), the modern concept of the hospital envisages it, as one of the broad system of preventive and curative medicine and as an institution dedicated not only to inpatient treatment, but also to ambulatory and domiciliary use.
From above definitions, it can be said that the hospital is an organization and an institution which renders health services to people via complex and specialized scientific equipments and a team of trained manpower. They co-ordinate with each other for the purpose of restoring and maintaining good health of the people who go there to seek relief from the pain, suffering and disease. Therefore, the hospital is a specific body and all activities of the hospital revolve around the patient care. The doctor keeps the core position and other facilities and trained manpower are provided to support him/her in discharging the duties efficiently.As an organization, hospital mobilizes the skills and endeavors of multiple groups of medical, para-medical and non-medical staff to render highly personalized services to patients.
Significance of Social Work in Hospital Settings
The presence of social worker in the hospital is important in the interest of patient, doctor and community.
The patient visits the hospital to seek clarification of his medical problem and advice about the treatment. The doctor applies the knowledge and skill to diagnose the illness and suggest the required therapeutic modality. The scientific methods of medicine soon establish anemia, diabetes, heart disease, peptic ulcer or possibly a functional disorder. When the diagnosis is known, the doctor promptly looks for implementing the treatment plan which will assure the best possible result for the patient. In the meantime, the patient who came seeking relief from pain, or because of undue fatigue or of failing capacities, has endured several clinical examinations, investigations, and procedures that he often does not understand or finds sometimes unpleasant and threatening. In the process of medical assessment, he may have experienced much of the complexity of the modern hospital. He goes from one place to other with the mysterious slips of reference. He learns many things that were not expected when he came. Recommendations are made beyond his ability to carry out. He is asked to return for review, to admit for operation, to live with a permanent handicap, or to accept the idea of chronic disease and adjust to it. The patient may build anxieties, fears and confusion (McMahon, 1958). It is also essential to learn that the patient understands the illness and medical treatment prescribed by the physician. The anxieties, fears, tensions, misunderstandings and areas of misinterpretations are required to be discovered and sorted to ensure effective participation of the patient in the process of treatment.
Bartlett (1961) has rightly said that body illness is a reality problem with a large social and emotional component which is not merely the result of illness but needs treatment throughout the illness. Illness generates emotional stress in the patient and other significant ones. More severely, it brings isolation, helplessness, discomfort, dependency, uncertainty and fear for the sick person. She further emphasized that social and emotional stressors shall not be regarded as results only; rather, these are primarily the components of illness throughout its course of treatment. To help individuals cope with these stresses, one requires skills other than those of the medical profession. There has been a gradual realization that consideration of the patient as a person in the complex environment and as an organism subjected to many stresses and strains, calls for the collaborative team work of the persons of multiple disciplines. Social workers as a group were recognized as one of the professionals who have a definite role to play.
Strain and Grossman (1975) have identified eight types of stress which occurs as a result of illness:
1. The basic threat to self-esteem and sense of intactness. 2. Worry of strangers. 3. Fear of separation. 4. Distress of loss of love and sanction.
5. Anxiety regarding the loss of control of developmentally achieved functions. 6 Worry of loss or of damage to body parts. 7. Guilt and fear of retaliation and 8. Fear of pain. Fudemberg et al (2016) in their study found that emotional despair, cost of office visits, treatments and medicines, absence of health insurance, transportation, poor medical compliance, disturbances in daily activities, keeping follow-up and language were the psycho-social barriers in the treatment of Glaucoma patients in an adult ophthalmic setting.
Healthcare facilities in the country have evolved tremendously in the last few decades. The advancement in the field of medical technology has made it possible to cure the diseases that were once considered incurable. However, the cost of their treatment is so high that their affordability continues to remain out of reach for most Indians. From drugs, to surgeries, to other medical procedures, nothing costs less than a few lakh rupees. Social workers, being experts in making socio-economic assessment and mobilizing resources available within and outside the client systems can be very handy in this situation.
Nowadays, secondary or tertiary public hospitals in metropolitan cities are overcrowded. The enormous and unplanned hike of Indian cities has contributed in the urbanization of rural poverty resulting in expansion of slums and marginal people starved of health and other fundamental services (Bajpai, 2014). Data reveals that only at AIIMS New Delhi, a total number of 38, 14,726 patients arrived in casualty and O.P.Ds (Annual Report, 2018-19, AIIMS New Delhi). Shortage of urban health infrastructure, overloaded hospitals, absence of outreach, and functional referral system, standards, and norms for urban health care delivery system, social exclusion, lack of access to modern health care and purchasing power are some of the issues that have been recognized as difficulties to urban healthcare in the country (John, Chander & Devadasan, 2008). These factors are further worsened by inadequate functioning of sub-centers, primary health centers, and community health centers and forcing rural populations to greatly depend on hospitals in the big cities and towns for their curative needs thereby stretching the infrastructure at these hospitals.
A certain degree of self-fulfillment in the practice of medicine passed away with the disappearance of the family doctor. Its place has been taken by scientific achievements, through striving for greater exactness and technical perfection. This requires the application of wider knowledge and impersonal and objective thinking which leaves practically no room for personal human interaction. Though scientific knowledge and technological advancement have resulted in precision of patient care, there has been an erosion of the doctor patient relationship and care has become more fragmented. Anand (2019) highlighted this in the following words “Till a few decades ago, medicine was one of the most sought-after vocations, and doctors were highly respected members of Indian society. A family doctor’s advice was sought not only during illness but also on issues unrelated to health. Within one generation, the status of doctors in our society has been eroded to an abysmal low. Surprisingly, this has happened during a period that is marked by tremendous advances in the capability of modern medicine to treat disease”. This fragmented approach of care cannot accelerate the process of helping sick individuals to reach an optimal level of health, as it fails to deal with the social component of illness. The undesirable but also unavoidable increases in the clinic case-load of the individual physician in the hospital and the unavoidable decrease in the frequency with which the physician is able to maintain a close personal relation with patients have contributed to the progress of this specialized social service activity in hospital settings.
The merged or affiliated institutions with a major university teaching hospital is becoming common place, and is seen as offering many advantages to the patients, physicians and other health care professionals in joining educational, research, as well as capital equipment resources (Sheps,1973). The academic health center under the aegis of the university has profound influence on the operational services of its teaching hospitals. They also have been the beneficiaries of a great deal of medical research and education monies. Although the academic medical center’s major concentration is on quality of care, this concentration is largely biomedical. Factors such as access, effectiveness, economy and equity of services arise more out of social and community pressure to examine them, than as fundamentals to the delivery of medical services. Individuals suffering from the newly recognized social ailments of substance abuse, child, wife and parent abuse enter the academic medical center’s emergency rooms but in the context of the physical disorder. Although such problems are a major public concern, they are not within the purview of the biologically trained physician. The causes relevant to the before and after situations is not usually addressed. Although medicine has accepted the responsibility for the care of patients suffering from such problems, it has not been educated to deal with the complex social problems of today. These social problems call for knowledge from the range of social and behavioral sciences, and for treatments and programs with both a psychosocial and medical emphasis as mutually inseparable in the care of these sufferers. Hospitals often receive specialized and vulnerable group patients like children, women, older persons, physically disabled, mentally ill, victims of domestic violence, rape victims, homeless, unknown, illiterate, poor etc. These patients need necessary support so that they are kept safe in hospital surroundings and discharged to appropriate places. Social work is a value based profession committed to help the needy and serve the poorest of the poor. Hence, social work intervention is desirable in such cases.
Wong et al (2001) mentioned that frequent social issues that doctors would refer to hospital social service dept. included child abuse, thrashed spouse, rape, intended self-harm and older patients with discharge difficulties. Social work’s systems orientation and grounding in counseling methods and crisis intervention, the social worker is best suited to render services of this type.
Health and social justice is an important area of social work practice. Social justice perceives that everybody deserves equal rights and chances including the right to good health. Yet today, there are disparities in health that are preventable, needless and unfair. These disparities are the outcome of policies and practices that create a disproportionate allocation of money, power and resources among communities based on race, class, gender, place and other factors. To ensure that everyone has the chance to achieve their highest level of health, we must address the social determinants of health and equity. Everyone, irrespective of his/her status in the society, has fundamental human rights like liberty, safety, privacy, an optimum standard of living, health care, and education. Social workers acknowledge the global inter-relations of oppression and have knowledge about theories of justice and tactics to promote human and civil rights. Social work includes the application of social justice in organizations, institutions, and society to make sure that these basic human rights are distributed equally and without any bias. Social workers know the forms and ways of oppression and discrimination; advocate for human rights and social and economic justice; and indulge in practices that raise social and economic justice.
Advanced practitioners in clinical social work realize the possible challenging impact of economic, social, and cultural factors in the lives of patients and their systems. They also know the stigma and shame attached with disorders, diagnoses, and help-seeking behaviors across varying populations. They also appreciate methods for promoting human rights and social and economic justice in local and global contexts. Clinical social workers use knowledge of the impact of oppression, differentiation, and historical trauma on client and client systems to guide treatment planning and intervention; and support at multiple levels for mental health parity and depletion of health inequalities for diverse population (Educational Policy and Accreditation Standards (EPAS) 2008, Council for Social Work Education). There are many occasions to incorporate the wider knowledge of health disparities in the evaluation and documentation which a trained social worker can aptly do. For instance, a medical social worker may be asked to see a patient and their family requiring financial help for travel expenses as they live in a regional area which is a long distance from the hospital. This would be taken as a routine referral by most hospital social workers. The fact that this patient and the family have experienced financial problem as a consequence of uneven access to suitable health care for rural and regional communities is the wider social issue that has and will continue to influence on the patient’s ability to obtain desired treatment (Alston, 2007).
Requesting for financial support may also affect their self-esteem and sense of control over their own lives. The referral for financial assistance is both an individual problem to be acted upon and also an indicator of a wider health disparity. If the patient and the family were from a lower socio-economic background or if they were an Indigenous family, more factors of the complex social environment would be identified in practice. In extending the way the presenting problem is viewed to include health inequalities and systemic inequities, Giles (2009) recommends that social workers develop a ‘health equality imagination’ and that such an ‘imagination’ is needed to promote excellent practice in health care. Pockett & Beddoe (2015) believe that social work actions need to be expansive beyond the individual presenting problem and include the interpretation of ‘presenting problems’ as social circumstances requiring exploration via research and policy formulation, advocacy and social policy development. In other words, if social workers were receiving multiple requests for such financial help, it may induce them to take up research, conceptualizing the problem beyond the practical need of financial help. Discussion with other colleagues in the multidisciplinary team would include health disparity and inequity in addition to the provision of short-term financial assistance and the ‘presenting problem’ defined by the hospital referral.
Health and illness have biological, psychological and social components. Hospitals have the responsibility to provide holistic healthcare for which they utilize the services of different professionals to offer the best services to the patients. Trained social workers are important hospital functionaries who deal with the social, economic and psychological aspects of health and illness. They assist patients and their families to understand the medical problem and its remedy; alleviate the anxiety, stress, fear and confusions; and mobilize resources for the poor indigent patients, particularly the vulnerable sections of society in need of care and protection. Their theoretical imbibing in ‘systems theory’, ‘bio-psycho-social’ and ‘person-in-environment perspective’ enables them to visualize the patient in his/her totality and provide help on non-clinical issues of illness and disease.
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Conflict of interest: None
Role of funding source: None