Finding Patients and Building up the Visiting List—Increasing the
Visiting List—Social Workers—Dispensaries—Patients’ Family and
Friends—Nurses’ Cases—Physicians.
=Finding Patients and Building up the Visiting List.= The first thing
for a nurse to do when she begins her work in a new community is to find
the patients she is to instruct and care for. And the question naturally
arises; how are these patients to be discovered?
The campaign of propaganda concerning the need of tuberculosis work has
aroused the interest of people of all classes. The funds to support the
nurse are evidence of this. But the people who pay the bills are not
those who can produce the patients. To get in touch with the patients,
it is necessary to approach people of another class, those whose work
brings them in contact with the very poor. For, as a rule, in beginning
tuberculosis work, it is only patients of the poorest class who find
their way to the nurse’s visiting list. Later, as the work becomes more
firmly established, and better known and understood, her visiting list
will include not only the poor, but those in well-to-do and comfortable
circumstances.
The Board of Managers of the new association may interest themselves in
finding the patients, but in the end it is the nurse herself upon whom
this responsibility rests. Upon her initiative and ability depends the
success of the work. Her first step, therefore, should be to call upon
all those who can in any way be of service, and who can direct her to
the patients she is anxious to reach. She should call upon the
physicians of the community, the dispensaries and hospitals (if there
are any), social workers, such as the agents of charitable associations;
priests, clergymen, and all those who come into contact with the
suffering and the destitute. Her visits should be made in person, since
a personal interview makes a stronger appeal to the memory of the busy
man than the most convincing letter or the most eloquent report. This
involves one great reason why the nurse should be thoroughly equipped in
character and training; the colourless, uneducated, unconvincing woman
carries with her no conviction, and inspires no confidence either in
herself, or in what she proposes to do. A physician may well hesitate
about turning over his patients to a woman who is unable to put her case
before him.
It may be that considerable time will thus have to be spent in calling
upon all those likely to know of tuberculous patients, and therefore
able to furnish the nurse with the necessary names and addresses. That
the response is not great should cause no discouragement. As we have
said elsewhere, the tuberculosis death-rate, multiplied by five, will
give a conservative estimate of the number of tuberculous individuals in
a community. It is the nurse’s duty to unearth them. They exist—she must
find them, and the greater the obstacles, the greater the incentive to
overcome them. The total result of a two or three weeks’ campaign may be
a mere handful of cases reluctantly handed over by a few physicians, and
a few undiagnosed suspects, reported by an earnest priest. In this way
the visiting list is begun.
=Increasing the Visiting List.= To increase the visiting list—that is,
to bring under her care an increasingly larger proportion of the total
number of tuberculous patients, even though the list becomes so large
and unwieldy that she cannot manage it, should be the ambition of every
tuberculosis nurse. At present, in every city in the country, there is
so much undiscovered and unreported tuberculosis, that the failure of
the nurse to increase the visiting list is an indication of poor work,
not an indication that a full round-up has been made of all those
suffering from this disease. This is especially true in a new community;
a small or stationary visiting list is a sure sign, not necessarily of
lazy or unconscientious work, but at least that the undertaking is being
managed by someone who does not know how.
To illustrate this: A nurse is sent to a certain house, to see a
specified patient. She does her work well—gives him a bed-bath, shows
the family what to do, and makes considerable impression along lines of
general hygiene. As far as it goes, her work is satisfactory and good.
Another nurse, however, sent into this same house, would not only do all
these things equally well, but, in addition, she would discover that the
patient’s wife was coughing and probably infected, while his old mother,
retired in the chimney-corner, was in even worse plight than the patient
himself. These suspects, therefore, she sends to the dispensary, where
her suspicions are confirmed by the doctor’s findings. Thus, if a
community possesses a nurse of the first type, it may rejoice to find
the amount of tuberculosis so small. If, on the other hand, it has a
woman of the second type, it will become alarmed and anxious at the
increasing number of patients who need care and control.
Nothing should diminish the enthusiasm for gaining new patients. The
mere fact that a nurse has more than she can manage should never deter
her from continually trying to find more. More patients, more patients,
and even then, more patients, should be her constant aim—and then the
chances are that she has not found all that exist. In Baltimore, when
pioneer work was begun under the Visiting Nurse Association, that
organization had a visiting list of some 1700 consumptive patients,
divided among five nurses. As five nurses represented the largest number
the Association could support, and as 1700 patients was only about
one-fourth of those who needed care and attention, some other method of
caring for the latter had to be devised. It was at this critical moment
that the Health Department was persuaded to assume the tuberculosis work
of the private association, and to incorporate it as part of the city
machinery. If the need for this transfer had never been proved, it is
hardly possible that the change would have been made. If the first
nurses had confined their visits to the patients they could reasonably
manage, and had refused to accept others, it would have been impossible
to prove how great the number of infectious patients was, and how
inadequate the care given them by the five struggling nurses of the
private association. Therefore, each community which undertakes
tuberculosis work should endeavour to unearth all the cases that exist,
if for no other reason than to show the size of the problem, and the
necessity of adequate measures for handling it. New patients, positive
and suspicious, should be sought for from every possible source. This is
better policy than to confine the work to the conscientious care of a
handful of manageable cases.
=Social Workers.= The agents of the Charity Organization Society, or
similar associations, continually come across cases of tuberculosis. The
new nurse should canvass all these agencies, and ask that all cases of
this kind be referred to her. If a case is not positively diagnosed,
that should be no drawback to reporting it; while the agents of these
associations are laymen and therefore not able to make diagnoses,
laymen, nevertheless, are able to make very shrewd guesses. It is the
nurse’s duty to take charge of these doubtful cases, and get them
examined and diagnosed by the proper agencies. The mere fact that a
patient presents suggestive symptoms makes it all the more urgent that
he be examined as soon as possible, and lack of positive diagnosis
should be no reason for the agent to withhold, or for the nurse to
refuse to take charge of, such a case. To visit a suspect does not
necessarily classify him as a consumptive, while not to visit him might
be to deprive him of assistance at a most critical time.
In finding cases, extensive co-operation should be invited; almost every
one whose work brings him into contact with numbers of people, knows one
or two among them who are tuberculous. Thus settlement workers, school
teachers, school attendance officers, juvenile court officers,
clergymen, Salvation Army workers, and so forth, are all people whose
aid and interest should be solicited. It makes no difference whether or
not the case is positively diagnosed—any sick person, with the symptoms
of a consumptive, is a person whose case should be looked into. It is
the nurse’s business to obtain the diagnosis.
=Dispensaries.= If there is a hospital or dispensary (not necessarily a
tuberculosis dispensary), the nurse should visit these institutions and
ask to have all positive and suspicious cases referred to her. Since the
patients who come to these places are usually those of the poorer
classes, the doctors will not be likely to object to giving their names
to the nurse. Indeed, they may be glad to accept the assistance she
offers. One visit to these institutions, however, is not enough. Every
week or two the nurse must present herself and renew her request for
patients—she must not trust to the busy physician to report them by
letter or telephone. Even when tuberculosis work is conducted on a large
scale, as in Baltimore, it is always part of the nurse’s duty to visit
these institutions regularly, to remind the doctors of their existence
and of their unquenchable desire for more patients.
=Patients’ Families and Friends.= After the nurse is well established,
and her position in the community recognized and assured, she will find
that a certain number of new cases are referred to her through the
families and friends of those already on her visiting list. This is a
high tribute, and should be valued accordingly. She should not rely
entirely upon this voluntary assistance, however, but from time to time
should question her patients, and find out whether they have any friends
who are ill, who would like to be visited. Surprising revelations often
follow. There was in Baltimore one old coloured woman who took special
pride in discovering patients, and who made an indefatigable agent in
hunting up cases in the neighbourhood. The accuracy of her diagnosis was
wonderful—her son had died of tuberculosis, so she knew all the
symptoms, and she did not refer us to a single case, which, upon
examination, failed to be tuberculous. We must remember that while in
its early stages tuberculosis is difficult to detect, when it is so
advanced that a layman can recognize it, in nine times out of ten he is
right. And as these advanced cases are the chief distributors of the
disease, the alert nurse should be keen to learn of these patients
through any source that presents itself. Of course many calls from such
sources send one on mere wild-goose chases, but it is better to go on a
dozen fruitless errands, than to overlook one real case of tuberculosis.
=Nurse’s Cases.= A large proportion of her cases will be unearthed by
the nurse herself. In Baltimore, the nurses themselves discover nearly
thirty-three per cent. of the cases under supervision. Thus, on being
sent to see a certain patient, before her visit is over the nurse may
discover one or two others of the family whose condition is such as to
call for immediate examination. The nurse should look with suspicion
upon every member of a household which has been exposed to tuberculosis.
The prolonged and intimate contact which is necessary for the
transmission of this disease has unfortunately, in most families,
existed for months before her arrival. The nurse should be particularly
keen in questioning the parents of tuberculous children since it is from
the parents that most children contract this disease.
=Physicians.= In considering the various sources from which patients are
recruited, we have purposely left until the last that which most people
would have deemed the first and most important source of all, namely,
the physicians of a community. While the medical profession has blazed
the way, and has indicated the paths along which the work must be
carried on, it is unfortunately only the greater men in the profession
who have done this. The others, through ignorance, through indifference,
or through that spirit which according to Dr. Cabot makes medicine “the
greatest profession, the meanest of trades,” have succeeded in placing
effective if temporary barriers in the path of the anti-tuberculosis
worker. The rigid adherence to the old Hippocratic oath, by which the
physician was sworn to keep inviolate the confidence of his patient, and
to place foremost the welfare of the individual, has for the most part
been very nobly lived up to. This oath, however, antedates our knowledge
concerning infectious and communicable disease. With the knowledge as to
the nature of transmissible diseases, there has come a change in medical
ethics, a change manifested by laws in which the welfare of the
community is placed above that of the individual. We see this reflected
in the regulations governing diphtheria, smallpox, scarlet fever, and so
forth—diseases which are distinctly the concern of the community, as
well as of the patient himself. But with tuberculosis, which has but
recently become recognized as a communicable disease, we find a halting
reluctance to consider anything but the rights of the individual. This
feeling is particularly strong among physicians of an older generation,
hold-overs from a passing régime. To such as these the nurse is nothing
less than an impertinence. Even if physicians of this sort are unable to
see their patients oftener than once or twice a year, or know them to be
in need of supplies which the nurse will gladly furnish, they refuse to
call upon her, and consider her advent as intolerable.
Again, there are physicians who do not object to the nurse on this
score, but who resent her as a subtle menace to their practice. They
feel that if a layman is able to preach rest, fresh air, and food, and
distribute prophylactic supplies, that the ground will be cut out from
under them, and that they will lose a chronic and fairly lucrative class
of patients. As a matter of fact, the physician who preaches this simple
doctrine has nothing to fear from the tuberculosis nurse—if her words
echo his they only add force.
There are other physicians, however, who have received an inferior
medical education; they are neither sure of themselves, nor able to
diagnose tuberculosis until it is in an advanced state. These object to
the nurse on the ground, implied rather than expressed, that she is
supervising and criticizing their work, and this self-consciousness
often takes the form of a violent antagonism. It is always the badly
trained physician who fears the well-trained nurse.
Furthermore, there are certain practitioners who frankly exploit their
patients. They may be competent enough but they are in medicine to make
a living, and are often brutally unethical as to how this is done. If
through self-interest it seem best to them to withhold from the patient
the nature of his disease, they do not hesitate to do so, regardless of
the danger to which others may be exposed. By a strange paradox, the
same profession which gives us the noblest, the most unselfish workers
in the interests of public health, also gives us its most implacable
enemies.
However, the new nurse must call upon all the physicians of the
community, and endeavour to obtain their assistance and support. But,
for the reasons mentioned, she must not be discouraged if she is not
always cordially received by them. There will always be among them many
who are enlightened and progressive, and who will assist generously in
the anti-tuberculosis campaign. If a community can boast of only one or
two such men, even, success is assured. And later on, as the nurse
progresses quietly in her work, she will come into contact with other
doctors, who promise her aid, but ignore their promises because they
think she is trying to steal away their patients. As it gradually dawns
on them that this is not the case, their opposition will wear off. To
conquer this prejudice as soon as possible is part of the nurse’s work.
Furthermore, the community itself should not be daunted if the
physicians as a body do not endorse the prospect of a tuberculosis
nurse. This prejudice against public health nursing is the common
experience in all cities where visiting work has been established, but
it gradually wears off as the nurse is able to demonstrate her value.
Little by little the doctors are won over, as they begin to realize that
she is not a rival but an assistant. In Baltimore, our experience has
been that those physicians who were at first our worst opponents have
now become our staunchest and warmest friends.