Social Work; Essays on the Meeting Ground of Doctor and Social Worker

Our job, then, in taking histories – that is, in finding out how things happen that lead up to disease or misfortune – should begin by writing down the thing for which the patient comes– headache, cough, emaciation, poverty, desertion, unemployment. This is the "presenting symptom"; it should always be the first thing written down in our history, not in terms of medical diagnosis such as asthma or anemia, but in the form of a complaint. Our attempt is first to put that down, to get a starting-point, and then to weave that into a chain of evidence which we call a history. That history makes it possible to make a diagnosis and to plan treatment.

The network of events

But the particular event, the particular complaint for which the patient comes to us, is woven not merely into one chain of evidence, but into several. Let us carry out the metaphor of the chain. We must imagine many chains woven into one another like the chain-armor of the mediæval knight. Each link is a fact. But many chains of facts are interwoven in the history of one single patient. First there is the chain of medical evidence, the links (or symptoms) leading up to a diagnosis; second, the chain of social evidence, which we try to classify on our social history card. Third, we must trace the links in the chain of relationship with other people, other members of the family, with friends and fellow workers or schoolmates. Finally, the chain of heredity, of which we cannot make much at present except in relation to tuberculosis and mental disease or mental deficiency. But these studies of heredity in its bearing on character are going to be more important as the science of social work develops.

Our first attempt, then, after determining the "presenting symptom," is to find out by a series of questions how this symptom is linked up into a tissue composed of many chains of facts. Our next task which is usually difficult, and frequently impossible, is to find out why this great tissue of evidence issues just now in one particular "presenting symptom." Why did the patient come to us to-day? This question is often impossible to answer because the patient does not know, though he may think he knows. Nevertheless, the social worker must try to find out. Often it is not until we have known and liked a person for days or weeks that we find out why he came to us at this particular time. Yet the answer to this question may be the most important thing that we can find out. For two reasons it is important; first, because it furnishes the clue to all our later investigation and assistance in this case; secondly, because it may show that the individual's complaints are not of any significance at all.

I can illustrate this by a case studied at the Massachusetts General Hospital in Boston. We looked up a series of patients at their homes in order to find out if we had really been of any service. The cases were not selected, but were taken from our files in numerical order. Among others we visited a lady whose malady had been diagnosed as "sacro-iliac strain." She had been given a prescription for a belt. We wanted to find out whether she had ever bought the belt and whether it had helped her. After some difficulty the visitor finally got the following details: The lady had come from a city twenty miles distant from Boston. She had taken an early morning train, and could not get back to her home the same night. Hence she could not soon make another trip like that. She came to have her eyes examined. Now it happened that we had no eye clinic at the hospital at that time. But the lady had heard a great deal about the hospital and its efficiency. She was determined not to go home without having got something out of the hospital. So when she was told at the Admission Desk that she could get no treatment for diseases of the eye, she wandered into the medical clinic, trying to remember or imagine some symptoms for the relief of which she could be admitted to the clinic. Finally she managed to get out some sort of a story about a pain in her back; she was referred to the orthopedic division; there a diagnosis of sacro-iliac disease was made and a belt was advised. When she got home, of course, she laughed at the idea of buying a costly belt.

Now, if we could have found out in the beginning why she came to the hospital, we might have saved a good deal of bother for a good many people. It is astonishing how many patients turn out to have as little reason for coming now as this lady did. One of the things that shows the arbitrariness of choice in selecting a time for visiting the hospital, is the striking diminution in the number of patients in the week before Christmas. That suggests that there are many postponable visits. Or again, patients may come merely because somebody else from the same neighborhood is coming.

Listening and questioning

As the history-taker traces out the symptoms of the patient's illness after finding an answer to this first question, Why to-day? two opposite habits of mind must be employed, one passive, the other active. We must be sure that the patient shall feel that he has had a good listener, that his troubles have really been appreciated. But if we are constantly putting in questions, as we certainly must later, the patient does not feel that he has been listened to. We desire first of all to get his own story in his own words, passively. We may not necessarily write down a single word of it. But I have found that the patient's own way of expressing the nature of his troubles is often important and characteristic. It helps to prevent our histories from looking too much alike, which is their commonest fault. Hence we should get into them somewhere a phrase or several phrases reported passively in the patient's own words; if possible a phrase in which he describes his "presenting symptom," the thing of which he chiefly complains.

But the second stage in the process of taking a patient's history is the most important. In this part we should be active, not passive. We must attack our task with a tool in our hand, a mental tool fitted to rake out of the mass of confused ideas in his mind certain significant facts. That rake is a logical schedule of questions which you use upon him actively, not passively, and by using which you get answers either negative or positive. Whenever you think well, you think with a schedule of that kind in your mind. If you pack a trunk well, you pack it using a list, a schedule of the things that ought to go into that trunk. Our printed social face-card helps us to think and question with a schedule before us, to think in an orderly way, without forgetting our items, and thus to select what we need out of the mass of disorderly facts in the patient's memory.

In the second phase of history-taking, then, which begins after we have listened appreciatively but quietly to the patient's own version – usually catastrophic and full of fanciful theories – we lead him by questions (but not by "leading questions") along the paths which will open up a full view of the trouble, medical or social, which has been suggested to us by the patient's first statements. Suppose, for instance, one happened to know of an extraordinarily rare but curable disease, one symptom of which the patient had mentioned, "My hair comes out by handfuls." One would go on to ask, "Do you feel warmer or colder than usual this winter?" Then, "The expression of your face is not notably changed, is it, so that your friends comment on it?" "Is your skin drier or moister than usual?" "Does your tongue bother you in any way?" "Is your mind more or less active than usual?" Thus one would confirm or refute the suggestion of the disease called myxœdema, a suggestion which was given to us by the patient's first complaint – rapid loss of hair. Given one symptom in a known group, one can trace out the others as the anatomist who finds a single fishbone may be able to reconstruct imaginatively the whole fish.

I said just now that we must not ask "leading questions." If we do, we can make a patient of a very suggestible type of mind say anything. If you ask him whether he has any symptom whatsoever he may obligingly say "yes." The way to avoid this is to put our questions in the negative: "You have no headache at all, have you?" "You do not cough?" "You never spit blood?" By these negatives we can get at the positive symptoms if they are present.

Schedules of questions to be used in history-taking may be medical or social. Some of the social question-lists are suggested in later chapters of this book. A masterly account of social questioning is contained in Miss Mary E. Richmond's "Social Diagnosis" (published by the Survey Associates, New York, 1917).

I wish now to illustrate the methods to be used by social workers in questioning patients about their symptoms so as to assist the doctor in his diagnosis.

Pain: How long? For a day, a month, a year, six years? Very chronic pains are seldom serious but seldom curable. Headache that has lasted years either has no cause known to medical science, or else it means neurasthenia. In either event it is apt to be stubborn. A headache that has lasted only a day, and did not occur before, cannot possibly be due to migraine. This suggests how the length of time that a pain has lasted is very important in diagnosis. The patient will often say, "I have always had it"; but to this we should oppose a pretty strong cross-examination. The patient usually means that he has had it off and on throughout an indefinite period. We ask him then, "When did you first have it?" and then, "How much of the time – half the time, a quarter of the time, for one day a week or one day a month?"

Pain: Where? Patients rarely come to a doctor for a single point. But pain in several points is never as significant as pain in one point. One cannot learn much from scattered pains in relation to what ails the patient and what to do for him.

Pain: How bad? That is a very difficult question to get the answer to. There is no thermometer or measure for pain. I suppose every doctor has wished many times that he had one. But there are certain rough measures which are of some use in judging how bad a pain is. (1.) We ask, "Does it compel you to lose sleep?" Some headaches may be pretty severe and yet a person sleep despite the pain. It may link itself up with a dulling of consciousness leading to sleep. But most pains and even most headaches that do not keep a person awake are not as bad as those that do. (2.) We ask, "Does it prevent work?" Any one can see all sorts of limitations to the use of that criterion. A man with a rugged type of mind will work with a pain that another weaker man will give up to. Yet the question does bring out evidence of some value.

(3.) Another criterion, more subtle and not quite so useful, is this, "Do you feel the pain more when you are quiet or when you are moving about?" The pains due to organic diseases are generally worse when one moves; while the functional type of pains are apt to be better when one moves about. One forgets it. Quite often patients are very lucid and candid about this.

Pain: How aggravated? How relieved? (a) A pain may be aggravated by position – for example, when the patient is on his feet – or worse when he is lying down – a headache, for instance. Most abdominal pains are worse when the patient is on his feet. (b) A pain may be aggravated by motion. Most of the surgical injuries, sprains, strains, tears of muscle or ligament, and fractures of bones are naturally made worse by motion. Pain may be aggravated by certain particular motions, as is the case with some of the innumerable pains in the back. Lumbago is a pain characteristically described as one that comes when the patient tries to lace his boots. Especially when he tries to get up from that position, the pain is intolerable. Pains in the chest are often worse on deep breathing – pleuritic pains, for example. But other thoracic pains may also be made worse by deep breathing. (c) Pain may be aggravated by the taking of food, or by movements of the bowels.

Pain may also be relieved in any of these ways. The most important thing that one can know about a stomach pain is that it is relieved by food. The majority of all stomach pains are aggravated by food. Pains are also relieved by heat or cold or by drugs or by rest. But those are not very important points. They may be important in relation to what we do to help the patient, but not in relation to diagnosis. Some pains, whatever their cause, are relieved by cold, more by heat, and most are also relieved by rest.

Next to pain, Cough is the symptom, especially in the colder months of the year, that we have most to deal with. The question How long? is vastly the most important one about cough. One can also measure its severity by the question, "Does it keep you awake?" and to some extent by the question, "Does it prevent work?" More important is the question, "Is it dry or productive of sputum?" The patient's description of his sputa in gross, without any microscopic examination, is also of a good deal of use. There are usually three things a patient can tell us about it: either it is yellow, or it is white, or it is bloody. There are two other important questions about bloody sputa. Unless one gets these answered, the mere fact of spitting blood is not important. We must know whether there are merely streaks of blood which one often sees in the sputa of anybody who coughs hard, are of no importance, and have nothing to do with tuberculosis. But if, in contrast with this, we can really establish evidence of the spitting of blood in quantity, we have almost proved a diagnosis of tuberculosis. In ninety-nine cases out of one hundred the spitting of blood in quantity means tuberculosis. "In quantity" means a cupful or thereabouts of pure blood. If the doctor does not find tuberculosis after that he should nevertheless assume it, for it is almost always there. I should pay no attention to negative physical finding in such a case.

The next point to ask about is whether the patient's breathing is wheezy. When a horse has become broken-winded we can hear his breathing in the street as he comes along. He has become emphysematous. We find this wheezing respiration in emphysema, asthma, and bronchitis, which are diseases important for us to distinguish from tuberculosis; we almost never get it in tuberculosis.

If the patient complains of dyspnea– difficult, rapid breathing, "short breath" as we say – we shall ask about œdema or swelling of any part, especially of the legs.

In every patient who has a cough we are concerned primarily with the diagnosis of one disease, that is, tuberculosis, its presence or absence. Hence every patient who coughs should be questioned about the other symptoms of tuberculosis and especially about emaciation. A man with a chronic bronchitis or emphysema does not lose much flesh; he does not become emaciated. A person does not become thin from throat trouble. Hence emaciation, especially recent, is a helpful guide to the doctor in making up his mind. Fever we investigate for the same reason. The only disease that often causes cough and fever during a long period is tuberculosis. Unfortunately the patient's statement about fever is usually unreliable. We can believe most of what he says on the rest of these points. But he does not know whether he has fever or not.

In women we must ask also about the monthly sickness, because it is suppressed in cases of moderately advanced tuberculosis. Nephritis, anemia, heart trouble and emotional disturbances may have that same effect. It is a measure of the degree of disease, not its type.

For the purpose of dispensary consultations I do not think we should take any family histories except when we suspect tuberculosis. But when the history leads us to think that the person may have tuberculosis, the social worker can help the doctor by asking the patient questions about the possibility of the same disease in mother, father, or others who are in contact with the patient – grandfather, grandmother, or other relatives or friends living in the same house. We believe less and less in the heredity of tuberculosis, more and more in infection by contact. If separated from a tuberculous father or mother in early infancy we believe that the child does not acquire tuberculosis. But the main mode of infection is by association in the same house, over a prolonged period, with people who have tuberculosis. Often the patients do not know or will not confess that anybody in the family now has tuberculosis or has died of it. But if we can establish the fact that one of the patient's family has died after having a cough for many years, that he grew very weak, and spit blood, we have established the diagnosis without the name. Not the degree of relationship to a tuberculous patient, but the amount of time spent in the same house with a tuberculous individual– what we call the degree of "exposure" to tuberculosis —is the important thing.

Past history

After getting the patient's present symptoms, one should ask, "Were you ever sick previous to this illness? If so, what troubles have you had?" That is of use in clearing up the limits or boundaries of the present illness. The sicknesses which the patient says he has had are not of very much use to us in diagnosis because we cannot get true answers. The patient's diagnoses or his doctor's are apt to be vague or meaningless. But the questions about the patient's past history tend to make him more clear as to the date when his present illness began. Hence his answers on these points should be written down very briefly, a word or two only about each, and usually in the words used by the patient.

In our written histories in hospitals we usually take a considerable body of notes about the patient's habits. I do not advise this for social workers. But there are certain routine questions which should be asked of all patients concerning their appetite, bowels, sleep, weight, and work. The answers should be recorded in a separate paragraph, at the end of the history.

What is printed here is meant to give a sample, not a full account, of medical-history-taking. Competence in this field takes long practice. Nevertheless the intelligent social worker can learn in a few weeks to be of great assistance to the doctor by taking either in the dispensary or in the home such histories as I have sketched.

In social-history-taking there is no single order or schedule of questions agreed upon by all social workers. But there should be some order and system determined partly by the personality of the worker and partly by the nature of the trouble. If poverty or destitution is the presenting symptom, one must find out the items in the family budget, the figures of income and outgo, paying especial attention as in medical histories to the question, "How long?" How long have you paid that rent, earned that wage, been without a job, taken boarders, been in debt?

Is sickness, childbirth, alcoholism, injury a factor?

Is there any family history of tuberculosis, pleurisy, insanity, epilepsy, feeble-mindedness? Of miscarriages or of "scrofulous" children and "blood diseases"?

What previous hard times? What economic and moral high-water marks and low-water marks can we trace in the past history?

What relatives, friends, employers, doctors, teachers, neighbors, landlords, social agencies, public officials or records can be consulted for additional light on the person and his troubles?

From all these sources one arrives finally at an opinion on "what sort of person are we trying to help – what sort physically, mentally, and morally?" That is the central fact.

CHAPTER III

ECONOMIC INVESTIGATION BY THE SOCIAL ASSISTANT

It should be clear from what I have said already that the work of the social assistant may have nothing to do with poverty. Her only business in visiting a family may be to assist the doctor in his diagnosis and treatment by bringing him additional facts about the nature, seriousness, or cause of the disease and about the means by which it may be combated.

But in many, perhaps most, of the families whom the social assistant attempts to befriend, there is a call for relief, for financial assistance, for money, food, coal, and clothes. This appeal like most medical appeals is apt to take the form of an emergency. Help (we are told over the telephone) is needed at once, or disaster will follow. The family is eager for immediate relief, not for a slow and painstaking investigation of the causes which have led up to the present state of things, or of the exact nature of their present troubles. They are like the sick in this respect. Prompt relief from pain is what the sick demand, not the tedious processes of questioning and examination. They want a remedy, a pain-killer, morphine or its equivalent.

But we all know the dangers of giving morphine for the relief of pain. It never cures a disease; it only stifles a symptom. It gives delicious ease; but the need for its use soon recurs. Hence there is always danger that before long the patient will have to fight, not only the disease which originally caused him pain and made him call for morphine, but the morphine habit in addition. This is all familiar. But not every one realizes that the giving of money in case of poverty is as dangerous as the giving of morphine in sickness. Money like morphine satisfies an immediate need and hence is eagerly welcomed by the sufferer. But of money as of morphine it is true that a single dose soon makes the patient call for another, and often a larger dose; that it soon makes the patient dependent on this sort of relief, and so forms a dangerous habit. With the rarest exceptions, to give money or to give morphine does not cure. The state of things which produced the pain or the poverty is sure to recur. For (as I have said above) the patient's belief that his present troubles are an unforeseeable accident, a sudden catastrophe, is almost never true. The truth is that his pain or his poverty are but the last chapters in a long story produced by causes which can usually be traced out, and whose future action can often be foreseen. By giving money we are covering up a smouldering fire, not quenching it.

For economic bankruptcy or breakdown, like physical bankruptcy or breakdown, is generally the result of faulty organization in the system of income and expenditure. Physically a person breaks down because he has been spending more energy than he can recoup by rest, food, and recreation. Economically he breaks down because his scale of expenses exceeds his regular income. Hence it gives but temporary relief to pay the bankrupt's debts, to cancel the sufferer's pain. The operation will soon have to be done over again unless some constructive plan for increasing his income or decreasing his expenditure can be worked out. Giving creates dependence because it atrophies industrial and moral initiative, just as a crutch or a splint causes muscles to waste. Powers unused atrophy. If we support a person, except temporarily, he will soon lose the power of self-support.

But the point of view impressed upon us by the sufferer himself is apt to be quite the opposite. What he wants is something immediate and temporary for the relief of something accidental. The beggar who meets us in the street has "accidentally" lost his purse and asks of us a small sum of money to reach his home. Often I have said to such an applicant, "Meet me at the railroad station half an hour before the train leaves for your home. I will buy you a ticket and see you on board." He never comes. This is an extreme instance and involves almost always a deliberate attempt to deceive us. In home visiting it is not like this. The sufferer does not usually intend to deceive. Nevertheless his misfortunes are pictured by him as accidental and temporary catastrophes, maiming a life which needs no general reconstruction. He is so sure of this that he is apt to force the idea upon us unless we are alert, bracing ourselves to question it and to make sure that it is true. But actual experience has shown me and hundreds of others that this point of view is almost never true.

It is not chance that the family is just now poor. It is no emergency which we are summoned to meet. It could have been foreseen long before and it will certainly recur unless we can trace out its causes and prevent their acting as they have hitherto. Hence the detailed, prolonged, individual study of the family's economic state is necessary. One must find out, first of all, all the details of income and outgo. The family is likely to forget some of these, so that one must be ready to assist their memory.