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Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
Community Fieldwork Collaboration Between Medical and Social Work Students a
Neil Bracht MA, MPH, ACSW & Inge Anderson
b
a
Associate Professor and Assistant to the Dean for Health Affairs, School of Social Work, University of Washington, Seattle, WA 98105 b
Grad Student, School of Social Work, University of Washington Published online: 26 Oct 2008.
To cite this article: Neil Bracht MA, MPH, ACSW & Inge Anderson (1975) Community Fieldwork Collaboration Between Medical and Social Work Students, Social Work in Health Care, 1:1, 7-17, DOI: 10.1300/ J010v01n01_03 To link to this article: http://dx.doi.org/10.1300/J010v01n01_03
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
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COMMUNITY FIELDWORK COLLABORATION BETWEEN MEDICAL AND SOCIAL WORK STUDENTS Neil F. Bracht, MA, MPH, ACSW Inge Anderson, BA
ABSTRACT. This article describes an educational demonstration in interdisciplinary community field experiences between social work and medical students at the University o f Kentucky Medical Center at Lexington. The joint training effort involved collaboration between the medical school, the hospital social service department, the school o f social work, and community social and health agencies. The pilot program in which students from different professions lived for 6 weeks in outlying rural communities served by the medical center, provided an opportunity: (a) to study the feasibility o f combining a broad community health study experience with casework services in a hospital-based educational program and (b) to assess the benefits o f early interdisciplinary community and clinical work between future doctors and social workers. Students saw the advantages o f cooperatiue teamworlz in studying community problems, pnd were able to apply classroom theory about community organization to real community situations. The organizational structure and staff resources required to carry out such a demonstration are described, and the implications of the training project are discussed.
INTERDISCIPLINARY EDUCATION Modem health profession education has embraced the concept of the interdisciplinary health team as necessary t o the provision of high-quality comprehensive health care.' The number of professionals on today's health team has risen markedly in the past 2 decades, posing problems of communication, organizational efficiency, and role differentiation. While lip service has been given t o the imporMr. Bracht is Associate Professor and Assistant to the Dean for Health Affairs, School o f Social Work, University o f Washington, 1417 Northeast 42nd Street, Seattle, Washington 98105. Formerly he was Social Work Consultant, Department o f Community Medicine, University o f Kentucky Medical Center. Ms. Anderson is a graduate student at the University o f Washington School o f Social Work. The educational demonstration described in this paper was possible because o f the pioneering efforts o f Grace White and Leone Renn in initially developing a social work program in community medicine and the enthusiastic support o f Drs. Kurt Deuschle and Jesse Tapp, formerly with the department. Appreciation is also extended to the Kent School o f Social Work and the University o f Tennessee School o f Social Work for their active.participation. 7 Social Work in Health Care, Vol. 1(1), Fall 1975
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tance of interdisciplinary approaches in patient care, the reality of effective team effort has not always materialized or been optimal for the patient's benefit. Among the many factors that inhibit the full realization and potential of team collaboration, one major barrier is the relative isolation and separateness of educational and training programs in the various health professions. It is unrealistic t o expect that once health professionals have received their respective degrees collaboration with one another will automatically ensue. "If interdisciplinary learning and comprehensive care are t o become a reality, both faculty and students must have considerable insight into the background, attitudes, orientation, and capabilities of disciplines other than their own."' While "hard" evaluation results of interdisciplinary teaching are relatively scarce, two studies3q4 d o indicate the importance of enrly exposure among health profession students. Several have reported favorable student responses t o interdisciplinary work on community health projects. Social work and medicine have given primany focus in their training programs t o the needs of individual patients and clients despite the knowledge of how important social and environmental forces are t o the maintenance of health and social functioning. Prepaxing tomorrow's health team professionals for expanded preventive work means providing students with the skills for community health diagnosis8 and social change intewentions. Social workers have always taught in general terns that the community affects the client: "The student's success in learning t o look beyond the individual case t o others with similar characteristics and to relate needs and resources depends to a considerable degree on their instructor's success in revealing the social forces at work and the technique by which their effects may be ppedickd, analyzed and ameliorated or c ~ n t r o l l e d . " ~ The training demonstration described in this paper sought to sheLure a systematic way t o provide students with an in-depth look at the community forces that impinge on individual and family health. Students who participated in this project and lived for 6 weeks in Appalachian communities did not need an instructor t o "reveal" the social forces affecting health. Instead, student and instructor alike concentrated their mutual leaming efforts in analyzing social conditions m d environmental hazards and developing with clients and community groups appropriate strategies of prevention and/or amelioration. ORGANIZATIONAL SETTING FOR STUDIEMT COLEABORATHON Initiation of the joint student demonstration project in community hedth came about in response to requests from medical
Neil F. Bracht and Inge.Anderson
9
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faculty in the Department of Community Medicine for more interdisciplinary exposure for medical students during their 6-week community medicine field clerkship. The faculty social work consultant in the department (who was also a member of the hospital social service department) developed the demonstration project in collaboration with faculty and students in community medicine. The social work program including - the role of the social work consultant. has been described elsewhere in detail.
University of Kentucky Medical Center
F y 1y1
DEPARTMENT OF COMMUNITY MEDICINE
Social Work Consulton t
I
1
f
SOCIAL SERVICE DEPARTMENT
I L
SENIOR MEDICAL STUDENTS IN CLERKSHIP PROGRAM -
UNIVERSITY
~~
I
COMMUNITY ASSIGNMENT
I COMMUNITY ASSIGNMENT
GRADUATE SOCIAL WORK STUDENTS IN FIELDWORK UNIT
SCHOOL COMMUNITY ASSIGNMENT NO. 3
SOCIAL
FIGURE 1. Organizational structure of teaching components allowing for student collaboration in the community.
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SOCIAL WORK IN HEALTH CARE
Basically, the social worker serves as a family and community health consultant t o medical students, traveling t o various sites in the state where students are placed. The department itself is representative of many disciplines, providing models of multidisciplinary collaboration in its many teaching, research, and community projects. During the pilot year (1967),medical and social work students working in pairs studied together in Kentucky communities completing family and clinical studies, community health surveys, and research projects. Three of these community-based field placements between medical and social work students are described in this paper. In total, six students (three senior medical students and three 2nd-year social work students) participated in the pilot training project and its evaluation. The organizational structure of teaching units involved in the training program is shown in Figure 1. The hospital's social service department gave high priority t o innovation in field instruction for social work students. Departmental social work staff were actively involved in the training of a wide variety of health profession students in addition to social work students at the medical center. The social work director's strong community orientation t o the state's health problems, including social, cultural, and economic factors, was supportive of community-based educational efforts for students. Students from both disciplines were familiarized with the communities prior t o the time they actually took up residence and worked in the communities t o which they were assigned. During the 6 weeks, students were requested t o keep daily diaries of their activities, and social work students, in addition, were involved in pre- as well as postevaluative examinations regarding their knowledge of community services, demographic and economic factors, community political and decision-making structure, and the organization of health services.
PLACEMENT OF MEDICAL AND SOCIAL WORK STUDENTS IN THE COMMUNITY Community Case Illustration 1 A rural community with a population of 10,000, not far from the medical cente~,was selected for the first collaborative educational venture between medical and social work students. The social work student, who was on a "block" placement, was assigned to the community's local public health department, and the medical student was placed with a local general practitioner, as is customary in the community medicine clerkship. Both students lived in the community during the assignment. The public health department had never before employed a social worker on its staff, and the opportunity to pioneer the use of a social worker was a challenge to the student.
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Neil F. Bracht and Inge Anderson
The major focus of the two students' joint endeavor was a community health and welfare survey, in which they conducted a comprehensive social and health study of the community. Later, upon their return to the medical center, they presented their conclusions and findings to the medical faculty as well as the staff of the social service department. This focus on the community provided immediate cooperative interactions between the students. In order to get the job done, each needed the help and knowledge of the other. Making a community diagnosis. In conducting a community inventory and health assessment, it was expected that social welfare content would be emphasized in the social worker's report and health needs in the medical student's. Exchange of ideas and information was accomplished through joint visits to health and welfare institutions by the students, where both would ask questions and gather pertinent community data. Each was exposed to the way of thinking and approach of the other. Close collaboration took place when the students had to pool their information and combine their data into one community survey report. During the time in the field, faculty members visited regularly with the students and provided consultation both on their community study as well as their clinical work. The students' presentation of their community findings to the faculty was both insightful and creative in its approach. The students decided to use specific cases of rheumatic heart disease in children as a way of assessing the variety of services, personnel, and programs in the rural community under study. This was accomplished by the two students tracing the course of the disease and relating major community services to particular patient needs and resources. For example, the medical student 'first described how through early detection the disease was diagnosed by the family physician. Using this introduction, the student then discussed the quality of hospital and physician services in the community. Picking up on the theme, the social work student described the effects of the disease on the child's educational progress which then led to a broader discussion of the total community's educational system and services provided for the educationally and physically handicapped. In discussing the general question of control and prevention of diseases, the students presented findings from their evaluation of the health department's chronic disease control program. The medical student discussed the "poor" record of local physician referral to the public health department for such services. The social work student found the health department's patient follow-up registry grossly inadequate and made suggestions for its improvement that were adopted while he was still in the community. When students also live in the community to which they are assigned, the educational experience takes on added meaning and quality. There is more time for an informal exchange of ideas as well as broader contact with citizens and local groups. One medical student commented that "2 days in the field equals 10 in the classroom." During their time in the field, the medical and social work students visited a wide range of community, social, and governmental institutions and discussed local problems with community groups and leaders. The social work student's final report included: (a) demographic analysis; (b) history of the community; (c) assessment of political systems; (d) general social and economic factors; (e) evaluation of private and public welfare services; and (f) information on the financing and organization of health and educational services. Both students agreed in their final report that the nonaccredited status of the local hospital and its financial difficulty were serious problems confronting the community. The social work student stated in his report: "The hospital administra-
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tor, concerned about the budget deficit, is making an effort to admit only those patients who can pay either through individual resources or through the medical care program provided by the state. There are no licensed nursing homes in the county which will accept patients who must rely on public assistance grants. There are no services in the county for the emotionally ill." The medical student stated the problem this way: "There is a lack of health leadership in attempting to deal with some of the very real health and social problems which exist in the community. Of the 23 reasons given for nonaccreditation of the local hospital, 21 were directly related to physician actions or omissions." Working with patients. With students living in the community, close follow-up on discharged hospital patients can be undertaken. In one case, the social work student was able to continue counseling with a psychiatric patient he had known at the medical center. Observing directly the patient's environment significantly increased the scope of the student's knowledge of the problems involved for this patient and increased his understanding of the inadequacy of past discharge plans. The student worked directly with the patient's local physician assisting in a plan of regular counseling follow-up visits between the patient and her local physician. The physician involved in this case was also the medical student's sponsor in the community, so there was three-way consultation on this case between the physician, the social work student, and the medical student. Casework treatment was enhanced as a result, and the interdisciplinary learning and cooperation that took place could be transferred to future practice situations. The public health department became familiar with the professional services of the social worker for the first time and consequently began to use the social work student to assist family members of patients being seen by the health department. In one case, the social work student helped a father with his concerns over birth control pills for his wife, while the medical student saw the wife (who had been referred by the local physician to the family-planning clinic at the health department). Both students learned a great deal about the organization and staffing of the local health department and were able to critically examine several m a s of program effectiveness. Evaluation. Wior to his community experience, the social work student was quizzed regarding his knowledge of community organization, health and welfare services, local government, current federal and state legislation, demography, and concepts of prevention in social work. He was also asked to predict certain attitudes of community leaders. Following the community experience, the student was reexamined in these areas with the following results: 1. Knowledgelskill increased in: (a) the use of demographic and census data; (b) knowledge of governmental stlructu~ein local communities; (c) medical care organization- within the community; (d) the ability to formulate diagnostic impressions of a total community situation; (e) better understanding of current legislation and its impact upon the community; and (f) more realistic interpretation of the attitudes of community leaders towmd public health and social services. 2. KnowPedge/skill did not expand in: (a) general illness patterns among the aged; (b) understanding of the preventive potential of social work in public health practice; and (c) how medical care sewices are financed. One difficulty that the social work student encountered in the community was the necessity to continually clarify his role since he did not have the usual support of a traditional social work agency to fall back on. While both students were on unfamiliar "turf," the social work student, in particular, had to search out for
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Neil F. Bracht and Inge Anderson
himself new ways to interpret contributions of social work at the broader community level. While this problem was frequently discussed by the student in supervisory conferences, it tended to diminish as the student progressed in his field placement and became more skillful in community analysis and demonstrated his clinical competence in cases. Supervisory conferences were frequently conducted in the health department with a focus on the student's progress in his community survey work as well as consultation on casework practice. Supervision was facilitated through review of the daily log kept by the student. Summary. In this first community placement of medical and social work students, the emphasis was on a joint community survey and diagnosis of health and social problems. Interdisciplinary work with patients and families took place between the students, and on one occasion three-way consultation occurred when the local general practitioner was involved with the students in follow-up planning for a patient. The public health department became the locus of the two students' clinical work and also provided a base for their joint research efforts on chronic diseases. In order to complete their comprehensive community survey they needed to rely on the skill and expertise of each other and learn quickly how to pool their information and synthesize findings.
Community Case Illustrafion 2 An eastern Kentucky mountain community of 15,000 inhabitants, with a half-million dollar antipoverty program, was the second setting used in collaborative work between medical and social work students. The social work student was assigned to a rural community action center to evaluate the effectiveness of a federally sponsored program in this Appalachian region. The medical student camed out his regular clerkship duties under the sponsorship of a local physician. The working relationship between the medical student and the social work student on their community survey was strained in the beginning because of negative attitudes on the part of both the medical student and local physician regarding the activist-oriented community action programs. The conflict situation provided for a real test of early interdisciplinary exposure of students representing different backgrounds and professions. The social work student found himself immersed in a heated community controversy about "outside agitators" taking over local initiative and control. In discussions with the medical student and local physician, the social work student pointed out that his findings revealed that many local citizens were being employed by the project and that initially a widely representative local citizens' group had specifically requested federal funds. The medical student was exposed to perspectives different from those of his sponsoring physician and local medical society, and the social work student was forced to back up his impressions with facts and describe in more detail the community's leadership structure and decision-making processes. Joint family studies. In planning a joint family clinical and social study, the social work student reported some reticence on the part of the medical student to work collaboratively. "This family I am going to visit doesn't have any social problems," was the remark of the medical student. As it turned out, the medical student was correct. But the joint inteniew in which the social worker did a brief social history and current social functioning assessment revealed to the medical student how important an understanding of cultural factors was to the success of a particular health education program that was of interest to the medical
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student. (A sex education program was being implemented at a local teenage social center, but this family would not let their daughter attend because dances were held there, and dancing was contrary to their religious beliefs.) In outlying rural community centers, the social work student was able to apply beginning community organization skills in work with groups of families experiencing common health problems. He conducted health education programs and worked with the administrative staff of several community centers in planning early childhood and tutoring programs. His attendance at community conferences of political and business leaders was helpful in assessing change and resistance forces in the community. The medical student provided new information to the social work student regarding one of the most serious health problems confronting the community, namely, contaminated water wells. The students were able to present their concern in this area to civic groups. Evaluation. This community placement was specifically designed for the social work student's educational needs and his stated future career interest in rural community action. The medical student was assigned to the area primarily because of his interest in the type of general practice provided by the local physician. The social work student's firsthand contact with an activist organization brought him face-to-face with relevant community concerns and conflicts. He had direct experience in selected aspects of community organization work and was able, with the help of the supervisor, to relate his practical experience to recent classroom theory on community organization. He had a beginning experience in problems of interdisciplinary communication. The work and setting of this placement were most interesting to the social work student, and he returned to this county on weekends (a drive of some 150 miles from his home in Louisville) to participate in weekend activities at one of the rural community centers. The experience also provided the student with an opportunity to work with and assess new types of paraprofessionals in social service programming.
Community Case Illustration 3 With the experience of two interdisciplinary field placements to draw upon, the final collaborative community assignment was structured so as to create maximum variation between the three community assignments. Hence, a more traditional assignment of the social work student to the local hospital was used in this field placement. There was one difference, however, in that this community hospital had never had a social service department, and the student's main task during his community assignment was to assess the need and document the areas for social work services in the hospital. The medical student was assigned to a local physician in the community, which is a semi-industrial area in northeastern Kentucky. The physician was also medical director of the local hospital. The students focused much of their clinical collaboration on referred patients seen in the hospital. Through the help of the local physician, the social work student gained high visibility and understanding about the purpose of his work at the hospital. Prior to going to the community, the social work student had developed a survey questionnaire and was able to explain exactly what it was he wanted to study at the hospital. His survey included: (a) number and type of patients in need of social services; (b) recognition of the need for social services by the medical staff and community; and (c) knowledge of hospital resources by community groups. Within a week after the social work student started work at the hospital, the
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Neil F. Bracht and Inge Anderson
medical staff expected and asked for primarily diagnostic and evaluative information concerning patients and families. The social worker was included as a member of the treatment team and was given a voice in planning for referred patients. Many of the specialists on the staff became more concerned about emotional involvement of their patients following surgery. In his final report to local physicians at the hospital, the social work student documented the kinds of patients most in need of services, what kind of services would be required, and the adequacy and inadequacy of local community resources to assist in the provision of such services. The medical and social work students also presented findings regarding their community survey to the medical staff. Community diagnosis. As opposed to the experiences students had in Community Case Illustration 2, there was little evidence of strong citizen action for change in the community presently under discussion. Both the social work and medical students found many solvable social and health problems but little effort by community groups to break away from the inertia that seemed to pervade the community. Severe air pollution from a nearby charcoal factory was probably the most frequently discussed problem among citizens, yet no successful effort had been made to deal with this problem. Both students agreed that the recent employment of a young, competently trained public health officer in the local health department would be a major force for change in the community. The students worked closely with the public health officer, and he was helpful to them in analyzing many of the community problems needing resolution. Evaluation. This final collaborative field placement, which occurred some 4 months after the first joint field placement described in Community Case Illustration 1,was structured so as to more nearly parallel a traditional practice setting (hospital) for the social work student. The students worked together in the local community hospital and collaborated on a comprehensive community survey. The social work student was challenged by his fieldwork responsibility for studying and demonstrating the need for social work in a small rural community hospital. The student was above average in competence and quickly gained the respect of local physicians and other health personnel. His study was directly useful to the hospital, and later a full-time social worker was hired at the hospital. Using student competence to pioneer in the development of social work services is a strategy that could be more frequently employed in community field instruction sites.
DISCUSSION Cooperation between students of different backgrounds and professional disciplines can be an exciting endeavor when students work and live together in the community. Even though students share a common human service orientation, there are nevertheless underlying value differences among the disciplines, and examples of this are reported in this demonstration. Historically, both social work and medicine have focused teaching and learning experiences on the more narrow concerns of individual clients or patients. For medicine, this has meant an emphasis on the biophysical functions of the body, while social work for a number of years concentrated more on the psychological functioning of man. In this demonstration, the educational goal
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SOCIAL WORK IN HEALTH CARE
was to break away from narrow restrictive models of intervention in order to help each student better understand the interrelationship between psychological and physiological aspects of the individual and, in addition, expose students to the larger perspective of the individual in his environment and, more specifically, his immediate community. By focusing on the total community as the "patient," students were generally in unfamiliar "territory." In many respects, this situation made the students rely on the skills and knowledge of each other to complete comprehensive community surveys and work with difficult to reach families. Living in the midst of deplorable health and social conditions, students were forced to recognize the professional's responsibility as a change agent. aple students did not always see eye-to-eye on the methods for achieving change, but by living together in the same town, numerous informal opportunities occurred to discuss traditional professional views and stereotypes. These discussions gave rise t o new concerns and insights and/or provided questions for faculty consultants when they visited the students in the field. The kinds of interactions reported by students in all of the communities seemed t o faculty involved in the project t o be typical of future professional relationships, and perhaps these early patterns of communication would serve as some basis for continuing interdisciplinary work in the future.
IMPLICATIONS OF THE TRAINING PROJECT When students from different disciplines work together in a community, cooperation is not a "Lheoretical" nicety but rather a hard reality and necessity if identified health problems axe t o be worked on and resolved. Early interdisciplinary experiences outline for students the need for an active social concern as future professionals and residents of communities. This experiment showed that hospital social work training programs can be modified in such a way as to provide a balanced learning experience between hospital as well as community-based needs and sewices. The results of the students' common efforts in studying and working in the community made, in some instances, a significant and tangible contribution to the improvement of health and social programs in the community. Ovemll, this demonstration supports exlier findings about the value of early intercPisciplinany cooperation between students from different health professions.
REFERENCES 1. Sanazaro, Paul, and Bates, Barbara. "A Joint Study of Teaching Programs in Comprehensive Medicine." Journal o f Medical Education 4 3 (1968):779-780.
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Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
Community Fieldwork Collaboration Between Medical and Social Work Students a
Neil Bracht MA, MPH, ACSW & Inge Anderson
b
a
Associate Professor and Assistant to the Dean for Health Affairs, School of Social Work, University of Washington, Seattle, WA 98105 b
Grad Student, School of Social Work, University of Washington Published online: 26 Oct 2008.
To cite this article: Neil Bracht MA, MPH, ACSW & Inge Anderson (1975) Community Fieldwork Collaboration Between Medical and Social Work Students, Social Work in Health Care, 1:1, 7-17, DOI: 10.1300/ J010v01n01_03 To link to this article: http://dx.doi.org/10.1300/J010v01n01_03
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
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COMMUNITY FIELDWORK COLLABORATION BETWEEN MEDICAL AND SOCIAL WORK STUDENTS Neil F. Bracht, MA, MPH, ACSW Inge Anderson, BA
ABSTRACT. This article describes an educational demonstration in interdisciplinary community field experiences between social work and medical students at the University o f Kentucky Medical Center at Lexington. The joint training effort involved collaboration between the medical school, the hospital social service department, the school o f social work, and community social and health agencies. The pilot program in which students from different professions lived for 6 weeks in outlying rural communities served by the medical center, provided an opportunity: (a) to study the feasibility o f combining a broad community health study experience with casework services in a hospital-based educational program and (b) to assess the benefits o f early interdisciplinary community and clinical work between future doctors and social workers. Students saw the advantages o f cooperatiue teamworlz in studying community problems, pnd were able to apply classroom theory about community organization to real community situations. The organizational structure and staff resources required to carry out such a demonstration are described, and the implications of the training project are discussed.
INTERDISCIPLINARY EDUCATION Modem health profession education has embraced the concept of the interdisciplinary health team as necessary t o the provision of high-quality comprehensive health care.' The number of professionals on today's health team has risen markedly in the past 2 decades, posing problems of communication, organizational efficiency, and role differentiation. While lip service has been given t o the imporMr. Bracht is Associate Professor and Assistant to the Dean for Health Affairs, School o f Social Work, University o f Washington, 1417 Northeast 42nd Street, Seattle, Washington 98105. Formerly he was Social Work Consultant, Department o f Community Medicine, University o f Kentucky Medical Center. Ms. Anderson is a graduate student at the University o f Washington School o f Social Work. The educational demonstration described in this paper was possible because o f the pioneering efforts o f Grace White and Leone Renn in initially developing a social work program in community medicine and the enthusiastic support o f Drs. Kurt Deuschle and Jesse Tapp, formerly with the department. Appreciation is also extended to the Kent School o f Social Work and the University o f Tennessee School o f Social Work for their active.participation. 7 Social Work in Health Care, Vol. 1(1), Fall 1975
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tance of interdisciplinary approaches in patient care, the reality of effective team effort has not always materialized or been optimal for the patient's benefit. Among the many factors that inhibit the full realization and potential of team collaboration, one major barrier is the relative isolation and separateness of educational and training programs in the various health professions. It is unrealistic t o expect that once health professionals have received their respective degrees collaboration with one another will automatically ensue. "If interdisciplinary learning and comprehensive care are t o become a reality, both faculty and students must have considerable insight into the background, attitudes, orientation, and capabilities of disciplines other than their own."' While "hard" evaluation results of interdisciplinary teaching are relatively scarce, two studies3q4 d o indicate the importance of enrly exposure among health profession students. Several have reported favorable student responses t o interdisciplinary work on community health projects. Social work and medicine have given primany focus in their training programs t o the needs of individual patients and clients despite the knowledge of how important social and environmental forces are t o the maintenance of health and social functioning. Prepaxing tomorrow's health team professionals for expanded preventive work means providing students with the skills for community health diagnosis8 and social change intewentions. Social workers have always taught in general terns that the community affects the client: "The student's success in learning t o look beyond the individual case t o others with similar characteristics and to relate needs and resources depends to a considerable degree on their instructor's success in revealing the social forces at work and the technique by which their effects may be ppedickd, analyzed and ameliorated or c ~ n t r o l l e d . " ~ The training demonstration described in this paper sought to sheLure a systematic way t o provide students with an in-depth look at the community forces that impinge on individual and family health. Students who participated in this project and lived for 6 weeks in Appalachian communities did not need an instructor t o "reveal" the social forces affecting health. Instead, student and instructor alike concentrated their mutual leaming efforts in analyzing social conditions m d environmental hazards and developing with clients and community groups appropriate strategies of prevention and/or amelioration. ORGANIZATIONAL SETTING FOR STUDIEMT COLEABORATHON Initiation of the joint student demonstration project in community hedth came about in response to requests from medical
Neil F. Bracht and Inge.Anderson
9
Downloaded by [University of Toronto Libraries] at 18:46 05 January 2015
faculty in the Department of Community Medicine for more interdisciplinary exposure for medical students during their 6-week community medicine field clerkship. The faculty social work consultant in the department (who was also a member of the hospital social service department) developed the demonstration project in collaboration with faculty and students in community medicine. The social work program including - the role of the social work consultant. has been described elsewhere in detail.
University of Kentucky Medical Center
F y 1y1
DEPARTMENT OF COMMUNITY MEDICINE
Social Work Consulton t
I
1
f
SOCIAL SERVICE DEPARTMENT
I L
SENIOR MEDICAL STUDENTS IN CLERKSHIP PROGRAM -
UNIVERSITY
~~
I
COMMUNITY ASSIGNMENT
I COMMUNITY ASSIGNMENT
GRADUATE SOCIAL WORK STUDENTS IN FIELDWORK UNIT
SCHOOL COMMUNITY ASSIGNMENT NO. 3
SOCIAL
FIGURE 1. Organizational structure of teaching components allowing for student collaboration in the community.
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Basically, the social worker serves as a family and community health consultant t o medical students, traveling t o various sites in the state where students are placed. The department itself is representative of many disciplines, providing models of multidisciplinary collaboration in its many teaching, research, and community projects. During the pilot year (1967),medical and social work students working in pairs studied together in Kentucky communities completing family and clinical studies, community health surveys, and research projects. Three of these community-based field placements between medical and social work students are described in this paper. In total, six students (three senior medical students and three 2nd-year social work students) participated in the pilot training project and its evaluation. The organizational structure of teaching units involved in the training program is shown in Figure 1. The hospital's social service department gave high priority t o innovation in field instruction for social work students. Departmental social work staff were actively involved in the training of a wide variety of health profession students in addition to social work students at the medical center. The social work director's strong community orientation t o the state's health problems, including social, cultural, and economic factors, was supportive of community-based educational efforts for students. Students from both disciplines were familiarized with the communities prior t o the time they actually took up residence and worked in the communities t o which they were assigned. During the 6 weeks, students were requested t o keep daily diaries of their activities, and social work students, in addition, were involved in pre- as well as postevaluative examinations regarding their knowledge of community services, demographic and economic factors, community political and decision-making structure, and the organization of health services.
PLACEMENT OF MEDICAL AND SOCIAL WORK STUDENTS IN THE COMMUNITY Community Case Illustration 1 A rural community with a population of 10,000, not far from the medical cente~,was selected for the first collaborative educational venture between medical and social work students. The social work student, who was on a "block" placement, was assigned to the community's local public health department, and the medical student was placed with a local general practitioner, as is customary in the community medicine clerkship. Both students lived in the community during the assignment. The public health department had never before employed a social worker on its staff, and the opportunity to pioneer the use of a social worker was a challenge to the student.
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The major focus of the two students' joint endeavor was a community health and welfare survey, in which they conducted a comprehensive social and health study of the community. Later, upon their return to the medical center, they presented their conclusions and findings to the medical faculty as well as the staff of the social service department. This focus on the community provided immediate cooperative interactions between the students. In order to get the job done, each needed the help and knowledge of the other. Making a community diagnosis. In conducting a community inventory and health assessment, it was expected that social welfare content would be emphasized in the social worker's report and health needs in the medical student's. Exchange of ideas and information was accomplished through joint visits to health and welfare institutions by the students, where both would ask questions and gather pertinent community data. Each was exposed to the way of thinking and approach of the other. Close collaboration took place when the students had to pool their information and combine their data into one community survey report. During the time in the field, faculty members visited regularly with the students and provided consultation both on their community study as well as their clinical work. The students' presentation of their community findings to the faculty was both insightful and creative in its approach. The students decided to use specific cases of rheumatic heart disease in children as a way of assessing the variety of services, personnel, and programs in the rural community under study. This was accomplished by the two students tracing the course of the disease and relating major community services to particular patient needs and resources. For example, the medical student 'first described how through early detection the disease was diagnosed by the family physician. Using this introduction, the student then discussed the quality of hospital and physician services in the community. Picking up on the theme, the social work student described the effects of the disease on the child's educational progress which then led to a broader discussion of the total community's educational system and services provided for the educationally and physically handicapped. In discussing the general question of control and prevention of diseases, the students presented findings from their evaluation of the health department's chronic disease control program. The medical student discussed the "poor" record of local physician referral to the public health department for such services. The social work student found the health department's patient follow-up registry grossly inadequate and made suggestions for its improvement that were adopted while he was still in the community. When students also live in the community to which they are assigned, the educational experience takes on added meaning and quality. There is more time for an informal exchange of ideas as well as broader contact with citizens and local groups. One medical student commented that "2 days in the field equals 10 in the classroom." During their time in the field, the medical and social work students visited a wide range of community, social, and governmental institutions and discussed local problems with community groups and leaders. The social work student's final report included: (a) demographic analysis; (b) history of the community; (c) assessment of political systems; (d) general social and economic factors; (e) evaluation of private and public welfare services; and (f) information on the financing and organization of health and educational services. Both students agreed in their final report that the nonaccredited status of the local hospital and its financial difficulty were serious problems confronting the community. The social work student stated in his report: "The hospital administra-
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tor, concerned about the budget deficit, is making an effort to admit only those patients who can pay either through individual resources or through the medical care program provided by the state. There are no licensed nursing homes in the county which will accept patients who must rely on public assistance grants. There are no services in the county for the emotionally ill." The medical student stated the problem this way: "There is a lack of health leadership in attempting to deal with some of the very real health and social problems which exist in the community. Of the 23 reasons given for nonaccreditation of the local hospital, 21 were directly related to physician actions or omissions." Working with patients. With students living in the community, close follow-up on discharged hospital patients can be undertaken. In one case, the social work student was able to continue counseling with a psychiatric patient he had known at the medical center. Observing directly the patient's environment significantly increased the scope of the student's knowledge of the problems involved for this patient and increased his understanding of the inadequacy of past discharge plans. The student worked directly with the patient's local physician assisting in a plan of regular counseling follow-up visits between the patient and her local physician. The physician involved in this case was also the medical student's sponsor in the community, so there was three-way consultation on this case between the physician, the social work student, and the medical student. Casework treatment was enhanced as a result, and the interdisciplinary learning and cooperation that took place could be transferred to future practice situations. The public health department became familiar with the professional services of the social worker for the first time and consequently began to use the social work student to assist family members of patients being seen by the health department. In one case, the social work student helped a father with his concerns over birth control pills for his wife, while the medical student saw the wife (who had been referred by the local physician to the family-planning clinic at the health department). Both students learned a great deal about the organization and staffing of the local health department and were able to critically examine several m a s of program effectiveness. Evaluation. Wior to his community experience, the social work student was quizzed regarding his knowledge of community organization, health and welfare services, local government, current federal and state legislation, demography, and concepts of prevention in social work. He was also asked to predict certain attitudes of community leaders. Following the community experience, the student was reexamined in these areas with the following results: 1. Knowledgelskill increased in: (a) the use of demographic and census data; (b) knowledge of governmental stlructu~ein local communities; (c) medical care organization- within the community; (d) the ability to formulate diagnostic impressions of a total community situation; (e) better understanding of current legislation and its impact upon the community; and (f) more realistic interpretation of the attitudes of community leaders towmd public health and social services. 2. KnowPedge/skill did not expand in: (a) general illness patterns among the aged; (b) understanding of the preventive potential of social work in public health practice; and (c) how medical care sewices are financed. One difficulty that the social work student encountered in the community was the necessity to continually clarify his role since he did not have the usual support of a traditional social work agency to fall back on. While both students were on unfamiliar "turf," the social work student, in particular, had to search out for
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himself new ways to interpret contributions of social work at the broader community level. While this problem was frequently discussed by the student in supervisory conferences, it tended to diminish as the student progressed in his field placement and became more skillful in community analysis and demonstrated his clinical competence in cases. Supervisory conferences were frequently conducted in the health department with a focus on the student's progress in his community survey work as well as consultation on casework practice. Supervision was facilitated through review of the daily log kept by the student. Summary. In this first community placement of medical and social work students, the emphasis was on a joint community survey and diagnosis of health and social problems. Interdisciplinary work with patients and families took place between the students, and on one occasion three-way consultation occurred when the local general practitioner was involved with the students in follow-up planning for a patient. The public health department became the locus of the two students' clinical work and also provided a base for their joint research efforts on chronic diseases. In order to complete their comprehensive community survey they needed to rely on the skill and expertise of each other and learn quickly how to pool their information and synthesize findings.
Community Case Illustrafion 2 An eastern Kentucky mountain community of 15,000 inhabitants, with a half-million dollar antipoverty program, was the second setting used in collaborative work between medical and social work students. The social work student was assigned to a rural community action center to evaluate the effectiveness of a federally sponsored program in this Appalachian region. The medical student camed out his regular clerkship duties under the sponsorship of a local physician. The working relationship between the medical student and the social work student on their community survey was strained in the beginning because of negative attitudes on the part of both the medical student and local physician regarding the activist-oriented community action programs. The conflict situation provided for a real test of early interdisciplinary exposure of students representing different backgrounds and professions. The social work student found himself immersed in a heated community controversy about "outside agitators" taking over local initiative and control. In discussions with the medical student and local physician, the social work student pointed out that his findings revealed that many local citizens were being employed by the project and that initially a widely representative local citizens' group had specifically requested federal funds. The medical student was exposed to perspectives different from those of his sponsoring physician and local medical society, and the social work student was forced to back up his impressions with facts and describe in more detail the community's leadership structure and decision-making processes. Joint family studies. In planning a joint family clinical and social study, the social work student reported some reticence on the part of the medical student to work collaboratively. "This family I am going to visit doesn't have any social problems," was the remark of the medical student. As it turned out, the medical student was correct. But the joint inteniew in which the social worker did a brief social history and current social functioning assessment revealed to the medical student how important an understanding of cultural factors was to the success of a particular health education program that was of interest to the medical
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student. (A sex education program was being implemented at a local teenage social center, but this family would not let their daughter attend because dances were held there, and dancing was contrary to their religious beliefs.) In outlying rural community centers, the social work student was able to apply beginning community organization skills in work with groups of families experiencing common health problems. He conducted health education programs and worked with the administrative staff of several community centers in planning early childhood and tutoring programs. His attendance at community conferences of political and business leaders was helpful in assessing change and resistance forces in the community. The medical student provided new information to the social work student regarding one of the most serious health problems confronting the community, namely, contaminated water wells. The students were able to present their concern in this area to civic groups. Evaluation. This community placement was specifically designed for the social work student's educational needs and his stated future career interest in rural community action. The medical student was assigned to the area primarily because of his interest in the type of general practice provided by the local physician. The social work student's firsthand contact with an activist organization brought him face-to-face with relevant community concerns and conflicts. He had direct experience in selected aspects of community organization work and was able, with the help of the supervisor, to relate his practical experience to recent classroom theory on community organization. He had a beginning experience in problems of interdisciplinary communication. The work and setting of this placement were most interesting to the social work student, and he returned to this county on weekends (a drive of some 150 miles from his home in Louisville) to participate in weekend activities at one of the rural community centers. The experience also provided the student with an opportunity to work with and assess new types of paraprofessionals in social service programming.
Community Case Illustration 3 With the experience of two interdisciplinary field placements to draw upon, the final collaborative community assignment was structured so as to create maximum variation between the three community assignments. Hence, a more traditional assignment of the social work student to the local hospital was used in this field placement. There was one difference, however, in that this community hospital had never had a social service department, and the student's main task during his community assignment was to assess the need and document the areas for social work services in the hospital. The medical student was assigned to a local physician in the community, which is a semi-industrial area in northeastern Kentucky. The physician was also medical director of the local hospital. The students focused much of their clinical collaboration on referred patients seen in the hospital. Through the help of the local physician, the social work student gained high visibility and understanding about the purpose of his work at the hospital. Prior to going to the community, the social work student had developed a survey questionnaire and was able to explain exactly what it was he wanted to study at the hospital. His survey included: (a) number and type of patients in need of social services; (b) recognition of the need for social services by the medical staff and community; and (c) knowledge of hospital resources by community groups. Within a week after the social work student started work at the hospital, the
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medical staff expected and asked for primarily diagnostic and evaluative information concerning patients and families. The social worker was included as a member of the treatment team and was given a voice in planning for referred patients. Many of the specialists on the staff became more concerned about emotional involvement of their patients following surgery. In his final report to local physicians at the hospital, the social work student documented the kinds of patients most in need of services, what kind of services would be required, and the adequacy and inadequacy of local community resources to assist in the provision of such services. The medical and social work students also presented findings regarding their community survey to the medical staff. Community diagnosis. As opposed to the experiences students had in Community Case Illustration 2, there was little evidence of strong citizen action for change in the community presently under discussion. Both the social work and medical students found many solvable social and health problems but little effort by community groups to break away from the inertia that seemed to pervade the community. Severe air pollution from a nearby charcoal factory was probably the most frequently discussed problem among citizens, yet no successful effort had been made to deal with this problem. Both students agreed that the recent employment of a young, competently trained public health officer in the local health department would be a major force for change in the community. The students worked closely with the public health officer, and he was helpful to them in analyzing many of the community problems needing resolution. Evaluation. This final collaborative field placement, which occurred some 4 months after the first joint field placement described in Community Case Illustration 1,was structured so as to more nearly parallel a traditional practice setting (hospital) for the social work student. The students worked together in the local community hospital and collaborated on a comprehensive community survey. The social work student was challenged by his fieldwork responsibility for studying and demonstrating the need for social work in a small rural community hospital. The student was above average in competence and quickly gained the respect of local physicians and other health personnel. His study was directly useful to the hospital, and later a full-time social worker was hired at the hospital. Using student competence to pioneer in the development of social work services is a strategy that could be more frequently employed in community field instruction sites.
DISCUSSION Cooperation between students of different backgrounds and professional disciplines can be an exciting endeavor when students work and live together in the community. Even though students share a common human service orientation, there are nevertheless underlying value differences among the disciplines, and examples of this are reported in this demonstration. Historically, both social work and medicine have focused teaching and learning experiences on the more narrow concerns of individual clients or patients. For medicine, this has meant an emphasis on the biophysical functions of the body, while social work for a number of years concentrated more on the psychological functioning of man. In this demonstration, the educational goal
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was to break away from narrow restrictive models of intervention in order to help each student better understand the interrelationship between psychological and physiological aspects of the individual and, in addition, expose students to the larger perspective of the individual in his environment and, more specifically, his immediate community. By focusing on the total community as the "patient," students were generally in unfamiliar "territory." In many respects, this situation made the students rely on the skills and knowledge of each other to complete comprehensive community surveys and work with difficult to reach families. Living in the midst of deplorable health and social conditions, students were forced to recognize the professional's responsibility as a change agent. aple students did not always see eye-to-eye on the methods for achieving change, but by living together in the same town, numerous informal opportunities occurred to discuss traditional professional views and stereotypes. These discussions gave rise t o new concerns and insights and/or provided questions for faculty consultants when they visited the students in the field. The kinds of interactions reported by students in all of the communities seemed t o faculty involved in the project t o be typical of future professional relationships, and perhaps these early patterns of communication would serve as some basis for continuing interdisciplinary work in the future.
IMPLICATIONS OF THE TRAINING PROJECT When students from different disciplines work together in a community, cooperation is not a "Lheoretical" nicety but rather a hard reality and necessity if identified health problems axe t o be worked on and resolved. Early interdisciplinary experiences outline for students the need for an active social concern as future professionals and residents of communities. This experiment showed that hospital social work training programs can be modified in such a way as to provide a balanced learning experience between hospital as well as community-based needs and sewices. The results of the students' common efforts in studying and working in the community made, in some instances, a significant and tangible contribution to the improvement of health and social programs in the community. Ovemll, this demonstration supports exlier findings about the value of early intercPisciplinany cooperation between students from different health professions.
REFERENCES 1. Sanazaro, Paul, and Bates, Barbara. "A Joint Study of Teaching Programs in Comprehensive Medicine." Journal o f Medical Education 4 3 (1968):779-780.
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