A NEW PERSPECTIVE IN MEDICAL SOCIAL WORK AND ITS IMPLICATIONS FOR...
A NEW PERSPECTIVE IN MEDICAL SOCIAL WORK AND
ITS IMPLICATIONS FOR TEACHING
M. M. MIRANDA
Medical Social Work originated at the turn of the century and was institution-based. It had, as its frame of
reference, the then existing concept of health, which was limited to its curative aspect. The concept of health
has since undergone a change and has become much more comprehensive. Medical education is seeking to
move away from its clinical approach to a more holistic approach to health, while social work education has
remained static. This paper focuses on the present day contribution of professional workers and their
contribution in an evolving field. It raises issues on the direction medical social work education should take in
the future. It is meant to generate an exchange of ideas among educators, leading to perhaps a redefinition of
ideology, and revision of the existing curriculum, in keeping with present day health needs.
Dr. (Mrs.) M. M. Miranda is a member of the Faculty, College of Social Work, Bombay 400 020.
Medical social work emerged as a speciality in the profession of social work at the
turn of the last century. It was meant to fill in gaps which were perceived in the
delivery of medical care through hospitals. It had a dual origin—that of furnishing
psycho-social data which would have a bearing on diagnosis and treatment, as in the
United States, and to ensure that appropriate utilisation was made of medical care, as
in Britain. In the United States, Dr. Richard Cabot also used social workers for
"follow-up" work. Hence, medical social work was meant to take care of the
emotional, social and economic factors in the patient's life which contributed to his
illness or hindered recovery.
Medical social work is social work practised in a secondary setting, the hospital,
traditionally the domain of doctors. Till the mid-nineteenth century, medicine was pre-
occupied with the germ theory in the causation of disease. It was only in 1911 that
Grotjahn suggested that the study of medicine needed to have a wider frame of
reference, making use of sociology to analyse health problems. This was, perhaps,
the beginning of social medicine. Prior to this, environmental factors were
responsible for disease, and the various control measures were considered the
prerogative of law making bodies, which used the police to enforce the laws enacted.
Therefore, medicine and public health were considered to be two diverse disciplines,
with doctors in hospitals responsible for the former and governments (local or state)
responsible for the latter. This dichotomy still exists, but ideologically, each bends
towards the other. Public health officials, even at the beginning of the twentieth
century, widened their scope of activities to include school health services, and
maternal and child health services, which were essentially meant to cater to the
health of individuals. The term "public health" has been defined in recent times as
"the organised application of resources to achieve the greatest health for the greatest
number". (Park and Park, 1980:6) Therefore, though the chief preoccupation of public
health officials was initially only in the area of communicable diseases and sanitation,
in the present times, they view as their scope all health problems as they evolve and
442 M. M. Miranda
emerge, including environmental pollution, accidents, problems of mental health,
geriatrics, health of the industrial worker, and chronic diseases. Public health also
envisages a joint effort of the community and the government.
Medical education in the present times is moving from a rigid clinical approach to a
preventive and community-based approach, despite vested interests in the medical
profession itself. Perhaps, in the not too distant future, one can foresee preventive
and social medicine as being very much a part of the practice of the doctor in addition
to his clinical practice. And public health (or call it community health) will have come
of age, for, in its struggle for recognition it did not achieve the status of the clinician.
This paper focuses on the present day contribution of medical social workers, their
necessary contribution in an evolving field of medicine and health, the present day
teaching programmes, and the extent to which they cater to various needs. It also
seeks to examine the possibility of structural changes in present day teaching
programmes which will cater to health needs in an evolving field. The paper deals
mainly with medical social worker. It does not seek to offer any suggestions for
change or solutions to problems. Rather, it seeks to raise a few issues which can
generate deliberation and introspection on a wider scale among teachers who are
perhaps more experienced than the author, and have their own invaluable
experiences and opinions to share.
Contribution of the Medical Social Worker
The influence of the mode of working, which Mary Stewart and her contemporaries
used at the beginning of the century, is still in evidence today. Psychiatry may have
helped in achieving a deeper understanding of problem situation through the use of
such knowledge that was available to the early Medical Social Worker, but the focus
is mainly on the individual patients and their families. She may give the patient an
understanding of the disease, the course of treatment and the prognosis, motivate
and support a patient to continue with the treatment, work around his fears and
misconceptions, prepare a patient (and his family) for discharge, secure various
resources for him, and work with the family members, employers and other key
persons in his environment, so that they are supportive to the patient and follow up
the patient after he is cured and help him maintain the gains from treatment. The
medical social worker may also need to plan out rehabilitation measures for some
patients. Occasionally, a medical social worker may be involved in building up
services like a library, toy bank (for the pediatric ward), a drug bank, and
supplementary feeding programmes for certain groups of patients. She may also
make suitable referrals to other agencies and arrange for the placement of the patient
or the members of his family in various institutions and for various purposes. All this is
very time consuming, but one often hears the argument that in work with human
beings, the cost-benefit cannot be measured.
Be that as it may, there is no reason why more human beings cannot be helped with
a little more planning and change in the method of working, and in the process
increase the efficiency of the medical social worker and the contribution of the social
service department in the hospital. It is possible that medical social workers feel
more comfortable in using a traditionally used method like casework, rather than work
with groups of patients—whether to provide some aspect of health education or
information, or to provide therapy, or even recreational activities for ward patients.
A New Perspective in Medical Social Work 4 4 3
What further contributes to this position of following the beaten path, is the constant
grouse of most medical social workers against their low status in the hospital
hierarchy and the poor working conditions. This, in turn, contributes to a poor self
image which, in turn, keeps motivation and commitment at a low level. Therefore,
other functions (besides direct service to the patient), are hardly ever paid attention
to, and these include education, research, administration and community outreach.
As for her consultative function, one is never too sure where the blame lies for its
non-realisation. Of course, there are several exceptions due to their personal
motivations or positive equations with the medical profession.
The Evolving Field of Medicine and Health and the Place of Social Work in it
As mentioned before, the old perspective of medicine, as being essentially clinical, is
giving way to a newer and more dynamic one, where the role of preventive medicine
is considered (theoretically at least) of primary importance. Younger doctors and
medical students are moving out into under-privileged communities to provide
services such as immunisation, early case detection and treatment, nutritional and
family planning services, ante-natal and post-natal services, and maternal and child
On the other hand, public health today has a very broad umbrella of functions and
services, and includes medical care under its curative function. Winslow's definition
of public health* though formulated more than sixty years ago, is extremely explicit
about the functions of public health. These include, besides the curative function
mentioned earlier, prevention of disease, maintenance and promotion of health,
training of health personnel, efficient structure and administration of health services
delivery, and research for the constant evaluation of various health care
programmes and services (and identification of new areas of health needs). Today,
public health officials go beyond the physical health and include in their sphere of
activities mental health and its problems, and the various social problems which
trigger off and affect the well-being of communities. This is a holistic approach to
Traditionally, medical social work began in hospitals, and concerned itself with illness
conditions. Other aspects of health, like preventive and promotive measures, were
thought to lie in the domain of statutory services and voluntary organisations, like
community centres, which had the service of a few professional and many volunteer
social workers. The need of the social work profession today is the adoption of a more
holistic approach to health and health problems. Schools of social work, through their
training programmes, initially gave direction to professional practice. It is common
knowledge that the profession of medical social work in India was conceived in the
West in relation to Western problems, and was imported into our country and sought
to be fitted into the existing medical and psychiatric care structure. Hence, it was not
attuned to our health problems. In addition, it created a sharp dichotomy between
physical and mental health.
*"Public health is the science and art of preventing disease, prolonging life and promoting physical and mental
health and efficiency through organised community efforts for the sanitation of the environment, the control of
community infections, the education of the individual in the principles of personal hygiene, the organisation of
medical and nursing service for the early diagnosis and treatment of disease, and the development of the
social machinery which will ensure to every individual in the community a standard of living adequate for the
maintenance of health". (Simmons, 1947: 23-24).
444 M. M. Miranda
This, in turn, defined the functions in various settings and promoted a piecemeal type
of service. For example, a Psychiatric Social Worker in a school would consider as
her function mainly a counselling service and programmes to cater to behaviour,
personality or scholastic problems. She would consider a follow-up of the school
health check-up beyond her realm. On the other hand, a Medical Social Worker in a
hospital works on the basis of referrals made to her by the doctors and other members
of the hospital team. Since these referrals are very specific, she considers her job
done, once the problem at' referral is handled. A young mother experiencing
difficulties in handling a child with food fads may not be encouraged to talk about her
problem. The nomenclature ("Medical Social Worker"," Psychiatric Social Worker")
perhaps also parcels out functions.
Hence, it is time that the Schools of Social Work examined their own ideology, and
perhaps, redefined it in terms of a more holistic approach to health and its many
faceted problems. This approach could envisage inclusion of the various areas of
health—physical, mental, social (and spiritual, if sound values are seen as an essential
part of healthy living ), in their various aspects, that is, remedial (both curative and
rehabilitative), preventive and promotive (or developmental). Since a small section of
the total population is in need of remedial services, while the vast majority are either
populations at risk, or in need of help to maintain their health, the major emphasis
should be on work with the latter groups, with a lesser emphasis on the former.
The present day emphasis of the Schools of Social Work is largely on work in urban
health settings. The rationale of this is that most schools are urban-based and
enrolment is mainly of urban-based students. From this would follow the premise that
graduates would look out for urban-based jobs. This is perhaps a misconception.
Many urbanites look for at least some temporary exposure to work in rural areas.
Students from rural areas, on the other hand, generally desire what they view as
upward mobility, i.e. a secure and lucrative job with urban amenities in cities and
towns. However, unless students are given adequate exposure to the health
problems of the rural people, they will never be able to appreciate and understand
that health needs are never the same, even in a particular geographical area, but are
unique to each society; that needs evolve as societies evolve; that at any point in
time, societies can be placed on a continuum from the most primitive to the most
highly developed and their health needs predicted fairly accurately. They will never
be able to understand that urban health and rural health are two parts of the same
system and that their skills can be utilised for a more equitable sharing of resources.
But most of all, they will not have an opportunity to reach out to the largest group of
the Indian population experiencing health problems. With the government
emphasising on rural health, needs and programmes as reflected in its services and
training, professional social workers are in danger of missing the boat.
Present Day Training Programmes
Professional medical social workers are trained for practice through a two year
course—which is often a post-graduate degree. There are schools which offer
specialised courses in Medical and Psychiatric Social Work. In such programmes, the
first year course is generic for all students of all the specialisations. Therefore, the
courses are of a general nature and meant to give the students an understanding of
the various fields. These include the various methods courses, information courses
related to man and society, and electives which cater to special interests. The
A New Perspective in Medical Social Work 445
second year courses in Medical and Psychiatric Social Work are more specific to the
field. They tend to stress psychiatric analysis of individual problems rather than skills
in dealing with problem situations. They are also "institution-centred", and stress the
remedial aspects in both physical and mental health. Electives offered are diverse,
but at the same time, they do not cover the various areas in the field of health or of
groups at risk. Compulsory courses which are offered in other specialisations (e.g.
Family and Child Welfare and Community Development) cannot be taken by medical
and psychiatric social work students, though they may directly or indirectly deal with
the problems of health and methods of work with such as community organisation. In
short, it would seem that though specialisation courses equip a student to deal well
with individual problems on a one to one basis, they have not really moved away from
the early Western orientation of the profession to a more dynamic problem-centred'
approach to health involving the vast majority of people.
Field work experience is again limited to mainly institutional urban settings, and it is
expected that when students become practitioners, they will be able to transfer their
skills to other settings. This, perhaps, never really happens. The Review of Social
Work Education in India states:
There is a need to make field work more analytical and conceptual. There is a
need to encourage students to ask "why", whereas, a great deal of field
learning is apt to state the "what" and "how" in the field tasks. Students should be
assisted to perceive the totality and see the parts in relation to the whole...
The approach again is holistic rather than a specific technique or method
oriented. (University Grants Commissions Second Review Committee: 1980)
This, generally speaking, is a goal to achieve, rather than what actually happens, in
Generic courses, on the other hand, have subjects on various aspects of health, like
medical and psychiatric information and community health. While such courses help a
student to work fairly well in non-institutional settings, like a community setting, they
find that they have to supplement their classroom inputs with additional reading if
they have to function in institutional settings like the social service department of a
general hospital. More electives, on
the lines of advanced courses of the second year
specialisation course in medical and psychiatric social work, could fill in this lacuna.
Block field work, at the end of the second year, is becoming rarer. If planned well,
the block field placement can provide a student with invaluable and uninterrupted
experience of the entire social work process which is very essential in later practice
for a more holistic view of and approach to problems.
The Need for a Second Look at Training Programmes in Medical Social Work
The first issue that comes up here is whether medical social work should continue to
throw in its lot with medicine (which is remedial) or shift its frame of reference to
public health, of which medicine is today considered a part. If the latter happens,
specialisation courses in medical and psychiatric social work would be treading on
the toes of other specialisation courses, in its attempt to restructure its courses, as the
inevitable overlapping and duplication will follow. Clear demarcations between
specialisations will be more difficult to maintain, while core courses at the second
4 4 6 M. M. Miranda
year level will change. While generic courses will have better scope, they will
perhaps need to offer many more optional courses to make up for the
present lacuna, where specifics of settings may be required.
Another issue, which has to be considered if the training content has to be revised, is
what to change and how to change. This, again, can be highly debatable and can be
the subject of much controversy. Therefore, it would be best to look at the present
day areas of health needs and leave it to individual schools to consider whether they
would like to institute changes and in a manner they consider appropriate. Briefly, the
most important health needs centre around immunisation, early detection of
diseases, personal and environmental hygiene, adequate housing having small and
manageable families, adequate nutrition, safe working conditions, availability of
health care for all sections of the population, proper information on health care for the
general population, an effective health delivery system, and a system which will be
able to evaluate the existing services in relation to changing needs and identify
evolving needs. Various populations at risk (e.g. children, young mothers) will also
have to be kept in mind. Some of the strategies needed will be health education,
mobilisation and initiating the redistribution of existing health resources through
various means, building of new resources, training and supervision of other
categories of health workers, including volunteers, and especially grassroots workers,
(whom even a medical social worker in a hospital can use extremely effectively in
community out-reach work), creating horizontal and vertical links in the entire health
delivery system to enhance the present delivery of health services and in-built and
on-going research programmes. Linked with this will be the field work content, and
decisions as to what should be the entry point in relation to various problem
A third issue, and I have no doubt, a very controversial one, is whether to have a
sizable emphasis on rural health. Practical considerations, like unpreparedness of the
teaching staff for such a change, difficulties as regards field placements, and
additional costs will have to be considered. However, this is an invaluable exposure,
which has been emphasised earlier. On the practical side (as far as health delivery is
concerned), it will provide the necessary manpower for establishing social work
activities, so necessary to make health a reality to the rural population.
Banerjee, G. R.
Social Service Department in a Hospital,
Bureau of Research and
Publications, Tata Institute of Social Sciences, Bombay.
Bartlett, H. M.
Medical Social Work:
American Association of Medical Social
Bartlett, H. M.
Social Work Practice in the Health Field
Park, J. E. & Park, K.
Textbook of Preventive and Social Medicine,
M/s Banarsidas Bhanot,
Pathak, S. H.
Medical Social Work in India,
Delhi School of Social Work,
Simmons, J. S.
Public Health in the World Today,
Harvard University Press,
A New Perspective in Medical Social Work 447
"Social Work within Medical Care" Medical Social Work,
Vol. 15, No. 3, pp. 66-73
University Grants Commission
Review of Social Work Education in India,
U.G.C, New Delhi-2.
by Dr. A. S. Desai)