Читать книгу Social Work; Essays on the Meeting Ground of Doctor and Social Worker - Richard C. Cabot - Страница 9

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As far back as 1895 the reforms introduced by Calmette and Grancher in the field of tuberculosis had begun to modify and improve the treatment given in our dispensaries, not only to tuberculosis but to all other diseases. Especially it had favored the growth of home visiting, at first for the specific ends for which it was designed by Calmette and Grancher, but later for the prosecution of various related purposes which the very process of visiting brought to light. Not only in tuberculosis, but in other diseases, it was soon found that a knowledge of home conditions and of the family was essential for the treatment of the single patient who chanced to appear at the dispensary.

It was my good fortune during the ten years preceding 1905 to work as a member of the board of directors of a private charitable society caring for children deserted by their parents, orphaned, cruelly treated; also for children whose parents found them unmanageable or for children who had special difficulties in getting on at school. The work of this society brought to me detailed knowledge of the life-histories of a good many children. I watched the careful studies made by the paid agents of the society into the character, disposition, antecedents, and record of the child, his physical condition, his inheritance, his school standing. I noticed during these years how the agents of this society, to whom the child was first brought by its parents or by others interested in it, utilized to the full the knowledge and resources of others outside its own field; how, for example, they enlisted the full coöperation of the child's school-teacher, secured facts and advice from the teacher, and agreed with her upon a plan of action to be carried out both by her and by the home visitor in concert. Moreover, I saw how physicians were consulted about the child, and how their advice and expert skill contributed something quite different from that obtained from the teacher or that gained by the home visitor herself. The priest or clergyman connected with the family was also asked for aid, and sometimes could give very great help, differing essentially in kind from that given by the teacher or by the doctor. If there were problems involving poverty on the part of the parents, other societies concerning themselves particularly with the problems of financial relief were asked to aid, in order that indirectly the help given to the parents might make itself felt in the better condition of the child. Sometimes free legal advice was obtained from the legal aid society formed for the purpose of giving such advice to those who were unable to pay for it.

As I watched the application of this method over a period of a good many years and in the case of a great many children, I saw a good many failures in addition to some most encouraging successes. But what most of all impressed itself upon me was the method, the focussing of effort on the part of many experts upon the needs of a single child, the coöperation of many whose gifts and talents varied as widely as their interests, to the end that a single unfortunate child might receive benefit far beyond what the resources of any single individual, no matter how well intentioned, could secure.

I have said that the doctor was a member of the group whose efforts were focussed upon the needs of a single child, but he was never a very closely connected member of this group. A few charitably inclined physicians, personal friends of those directing the charities, were called upon again and again to help out in individual cases by examining a child, by giving advice over the telephone or otherwise. Through the free hospitals and dispensaries help was also obtained for the physical needs of persons who had come to the notice of the different charitable associations by reason of economic need or other misfortune. But the medical charities, the hospitals, dispensaries, convalescent homes, and the benevolence of individual physicians were not well connected with the group of charitable associations which I have been referring to above.

At this period, in 1893 and 1894, I had been working for some years as a dispensary physician, concerning myself chiefly with perfecting the methods of diagnosis in a dispensary, so that the patient could obtain there a diagnosis as correct and scientifically founded as he could obtain from a private physician. But in the course of these efforts for a complete and exact diagnosis which should do justice to the actual needs of the patient, I found myself blocked. I needed information about the patient which I could not secure from him as I saw him in the dispensary—information about his home, about his lodgings, his work, his family, his worries, his nutrition. I had no time—no dispensary physician had time—for searching out this information through visiting the patient's home. Yet there was no one else to do it. My diagnoses, therefore, remained slipshod and superficial—unsatisfactory in many cases. Both in these cases and in the others where no diagnosis was possible from the physical examination alone, I found myself constantly baffled and discouraged when it came to treatment. Treatment in more than half of the cases that I studied during these years of dispensary work involved an understanding of the patient's economic situation and economic means, but still more of his mentality, his character, his previous mental and industrial history, all that had brought him to his present condition, in which sickness, fear, worry, and poverty were found inextricably mingled. Much of the treatment which I prescribed was obviously out of the patient's reach. I would tell a man that he needed a vacation, or a woman that she should send her children to the country, but it was quite obvious, if I stopped to reflect a moment, that they could not possibly carry out my prescription, yet no other filled the need. To give medicine was often as irrational as it would be to give medicine to a tired horse dragging uphill a weight too great for him. What was needed was to unload the wagon or rest the horse; or, in human terms, to contrive methods for helping the individual to bear his own burdens in case they could not be lightened. Detailed individual study of the person, his history, circumstances, and character were frequently essential if one was to cure him of a headache, a stomach-ache, a back-ache, a cough, or any other apparently trivial ailment.

Facing my own failures day after day, seeing my diagnoses useless, not worth the time that I had spent in making them because I could not get the necessary treatment carried out, my work came to seem almost intolerable. I could not any longer face the patients when I had so little to give them. I felt like an impostor.

Then I saw that the need was for a home visitor or a social worker to complete my diagnosis through more careful study of the patient's malady and economic situation, to carry out my treatment through organizing the resources of the community, the charity of the benevolent, the forces of different agencies which I had previously seen working so harmoniously together outside the hospital. Thus I established in 1905 a full-time, paid social worker at the Massachusetts General Hospital, to coöperate with me and the other physicians in the dispensary, first in deepening and broadening our comprehensions of the patients and so improving our diagnoses, and second in helping to meet their needs, economic, mental, or moral, either by her own efforts, or through calling to her aid the group of allies already organized in the city for the relief of the unfortunate wherever found. To bring the succor of these allies into the hospital and apply it to the needs of my patients as they were studied jointly by doctor and home visitor, was the hope of the new work which I established at that time.

In the thirteen years which have elapsed since this period, about two hundred other hospitals in the United States have started social work, some of them employing forty or fifty paid social workers for the needs of a single hospital. Unpaid volunteer work has always been associated with that of the paid workers in the better hospitals.

I should mention, in closing this chapter, three forms of medical-social work which had been undertaken previous to 1905, and which were more or less like the work which I have just described, though not identical with it:

(1) The after-care of the patients discharged as cured or convalescent from English hospitals for the insane (1880). The visitors employed in this work followed the patients in their homes and reported back to the institution which they had left. Their labors were directed chiefly to the prevention of relapses through the continuation in the home of the advice and régime advised by the hospital physician and previously carried out in the institution.

(2) The work of the Lady Almoners long existing in the English hospitals had begun about the time that I started medical-social-service work in America, to change its character so as to be more like the latter. Originally the purpose of the Lady Almoners was to investigate the finances of hospital patients in order to prevent the hospital from being imposed upon by persons who were able to pay something, but who represented themselves as destitute and therefore fit subjects for the aid of a charitable hospital. Gradually, however, the Lady Almoners had begun to be interested in the patients as well as in the hospital funds, and had begun to labor for the patients' benefit as well as for the hospital's. This brought them near to the idea of hospital social service as practised in this country since 1905.

(3) The visiting nurses or public health nurses, employed by a Board of Health or by private agencies for the care of contagious diseases in the home and also for the nursing of the sick poor whatever their malady, have found it more and more difficult in late years to confine their work wholly to physical aid. They have been forced to take account of the patients' economic, mental, and moral difficulties, to extend their work beyond the field of nursing proper, and thus to approach very closely to the field of the social worker. It is my own belief that the frontier separating visiting nurse and medical social worker should be rubbed out as rapidly as possible, until the two groups are fused into one. The visiting nurse must study the economic and mental sides of the patients' needs, and the social worker must learn something of medicine and nursing. Then the two groups will be fused into one, as indeed they are fast fusing at the present time.

SOCIAL WORK