You can tell a lot about a job and the people doing it by asking them to describe their best day at work. For Ali, a 28-year-old pediatric cancer social worker, that day occurred one year ago. A 17-year-old cancer patient who had been given two months to live made a bucket list. On her list were graduating from high school and getting accepted into college. So Ali and her colleagues arranged a graduation ceremony in the hospital, at which they read off a list of the colleges to which she had been accepted.
Ali and other social workers savor such opportunities to make a difference. They got to know the patient and her family well, reached out to a variety of school officials and community leaders to make the event happen, and enabled many friends and hospital employees to participate in it. Though the ultimate outcome was heartbreaking – the patient died just days after the event — Ali cherished the opportunity to stage such a meaningful event and help make a better death possible.
This is just one example of how medical social workers so often play the role of the “glue” that holds health care together. Doctors, nurses and other health professionals typically have their hands full with patients’ medical needs. My medical colleagues and I know that performing a surgical procedure or prescribing medicines for the patient is only a part of a comprehensive plan of care, and even the best medical care may fail if it is not well integrated into the patient’s life.
Caring and coordination
Medical social workers help to ensure that the psychological and social needs, or what we in the field call the psychosocial needs, of patients and families get attended to, and that all aspects of the patient’s care — inpatient, rehabilitation, outpatient, in-home and so on — are coordinated. They ensure that medicine and life work well together. For example, a patient coping with a diagnosis of cancer or dementia may need help with services as diverse as insurance, in-home health services, psychotherapy and grief counseling.
In the U.S., medical social work got started in Boston at Massachusetts General Hospital, which started a training program in 1912. Today the number of U.S. medical social workers is about 170,000. They work in a variety of settings, most commonly hospitals, patient homes and nursing facilities. Generally, a master’s degree in social work is required to enter the field, and the average annual compensation is about US$56,000.
Though employing medical social workers costs hospitals and health care organizations money, there is evidence that having social workers on staff lowers overall health care costs. They do so by ensuring that needs are responded to promptly, addressing problems before they grow larger; by helping to reduce repeat medical visits by ensuring that needs are fully met in the initial visit; and by helping to coordinate a complex system of care to ensure that its many parts are pulling together in the same direction.
Leaving the profession
Even though medical social work represents a rewarding career, many social workers, including Ali, are leaving their jobs. This is not an isolated problem. The state of Kansas recently found that it was losing one-fourth of its children’s social workers each year, and the same appears to be true in Ohio. A recent Texas report showed that social services had the highest turnover rate of all state employee categories at 25 percent.
This is a big problem. To do their jobs well, medical social workers need to know other health professionals, hospitals, social services, and patients and families well. Each time a medical social worker is lost, it takes months or even years to get a replacement up to speed. In the meantime, patients and families can end up falling through the cracks. When their relationships with medical social workers end, they must start all over again with strangers.
Factors causing turnover
So why are medical social workers leaving their jobs? One of the biggest problems, according to Ali, is large caseloads. “When each social worker is responsible for too many patients,” she says, “it becomes impossible to give each patient and family the level of care they need. Because you are stretched so thin, you end up tending only to the patients and families with the most urgent needs. You are forced to choose who not to care for, and that feels like failure.”
Ali cited the example of a family she had been working with the day we met for an interview: “They are functioning okay, financially stable, showing up on time for their clinic appointments. I know they need help, and that if I could spend with them the time they need, I would be able to provide them with much better support leading up to their child’s death. But because I am so busy tending to those with more urgent needs, I won’t know them or be able to support them well when it comes.”
Ali also worries about the amount of time she and her colleagues spend on paperwork. She estimates that, on average, for every hour she can spend working face to face with patients and families, she and her colleagues spend more than two hours filling out forms and the like.
A related difficulty is the fact that, whenever a gap in care opens up, medical social workers tend to be the ones who get called to fill it. Suppose, for example, that a family has a gap in insurance coverage. Says Ali, “Social workers have no special training in insurance, but because it is not anyone else’s job either, we are expected to take care of it. It would be so helpful if we had financial navigators who could help patients and families with that aspect of their care.”
Though dedicated to the care of others, Ali and her colleagues are often uncared for themselves. “When a patient dies,” she says, “there are systems in place to reach out to doctors and nurses, but no one thinks of the social workers, who often get to know the family just as well. It is hard, and we need space and time to talk about these things, but no one checks in on us, and with our caseloads so high, we are expected just to move on to the next patient.”
Few people know it, but Ali and her colleagues are often the last people in the hospital to see a deceased patient. “We are the ones who walk the patient out of the hospital for the last time, handing them off to the funeral director,” she says. “That might not seem like a big deal, but over time it begins to take a toll on you, especially when you have gotten to know them well over months or years. Sometimes you just need someone to talk with about it.”
When we understand better the crucial coordinating and caring role medical social workers like Ali play today, we see how vital it is that medical practices, hospitals, health care facilities and our whole health system attend to their concerns. When they do their jobs well, everyone – patients, families and other health professionals – wins. Ali and her colleagues are not asking for a raise. They are simply asking for the opportunity to provide the kind of care they would want for their own families.
Richard Gunderman, Chancellor's Professor of Medicine, Liberal Arts, and Philanthropy, Indiana University
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