The Grey Continuum Between Specialty and Primary Palliative Care Social Work: A Podcast with Bridget Sumser

Eric: Welcome to the GeriPal Podcast! This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, I spy a couple of people in our office today.

Alex: We have a couple of people.

Eric: I mean, our studio, our studio.

Alex: Our studio. Studio office?

Eric: Studio whatever.

Alex: Office studio?

Eric: Who are these people?

Alex: We have Bridget Sumser, who’s a palliative care social worker at UCSF. Welcome to the GeriPal Podcast, Bridget.

Bridget: Thanks for having me.

Alex: And coming back for as a repeat guest host, we have Anne Kelly, who’s a palliative care social worker here at with our palliative care service. Welcome back.

Anne: Hi there. Glad to be here.

Eric: And we’re going to be talking about social workers and palliative care services and Bridget’s new book, Palliative Care: A Guide for Health Social Workers. But before we get into this topic, Bridget, do you have a song for Alex to sing?

Bridget: I do. Revolution by Tracy Chapman.

Eric: Let’s do it.

Alex: [Singing]

Alex: Yeah. I like the little assistance there.

Eric: I never know when to say that whisper.

Bridget: How do you not know where the whisper is?

Eric: Okay, I’m going to get it at the end. We’re going to play this song again. And I am-

Alex: Your cue is, it sounds …

Bridget: Like a whisper.

Alex: Like a whisper.

Eric: I thought, it sounds like a revolution.

Alex: No, we’re doing-

Bridget: The revolution sounds like a whisper.

Eric: Why did you pick this song, Bridget?

Bridget: Well, it’s really just one of my favorite songs. And there may be some subtle political undertones, which maybe we’ll talk about as we talk about the book.

Eric: Whoo, fascinating. So, why did you write a book? That seems like a big undertaking.

Bridget: Yeah. So, to be fair and clear, this book is co-edited by myself and Meagan Leimena, and Terry Altilio. And we were really fortunate to work with some incredible contributors who put a lot of time and heart and soul into this project. Over the course of five years. And we did it because in the aftermath, or in the aftertime of the Oxford Textbook of Palliative Social Work, Terry and her partner, Shirley Otis-Green, were approached about, “What’s the next project?” And so, in working with Terry at that time, we went out to figure out what the next project was, and out of that search and research, this was born.

Alex: And-oh do you have a question? No, okay, yeah, because I was going to ask who’s the target audience for this particular book?

Bridget: Yeah, so this is really a guide for health social workers. Health social workers is a huge term. It means any social worker working in the healthcare setting. And certainly has relevance for new palliative care social workers also. So, we know there’s not a lot of training opportunities for social work in palliative care, and there’s some good nuggets and gems for people practicing in specialty settings. But the heart is really for health social workers.

Anne: You guys mention in your book that there’s a lot of talk around bridging the gap between what’s considered “specialty” palliative care social work. And where there might be a overlap, or differences between what we think of as more general health social work. And I was wondering if you could say more about that, and what that process was like, and trying to distinguish between the two.

Bridget: Yeah. So we started with a really strong conviction that social work practice and palliative care practice are inherently aligned. And really at their core, congruent.And so, we started with this theoretical frame that as specialists, we could figure out how to extend our work to primary providers. And as we tried to conceptualize that over time, we realized that that split, that dichotomy, is actually pretty hard to make tangible. And partially that’s because social work practice, clinical social work skills are so similar to palliative care skills. And so, to talk about how health social workers should be integrating, or already are integrating palliative care into their practices, at some times felt a little redundant or it felt like in the process of making a specialty, and a specialty of palliative care social work, we had forgotten or moved away from all of that work that was already happening just in general social work practice.

Alex: So the comparison would be, for example, to physicians, where there’s a primary care physician or hospitalist, who’s practicing primary palliative care, might have a distinct skill set that they need to learn around communication, symptom management, et cetera. That might be really important for all doctors to know. But is a little bit, and even arguably, every doctor should know. But, and should have known already.

And maybe that’s more so … what you’re saying here is it’s more so in the case of social workers. Whereas these core palliative care principles in social work are core principles of social work.

Bridget: Yeah. Absolutely.

Eric: So is there a case for specialty-level palliative care social work? Is it so ingrained in social work and social work training that there is no need for specialty-level palliative care? Interchangeable?

Bridget: So, I think there’s absolutely a need for specialty palliative care social work. And there will continue to be.

Eric: Yeah.

Bridget: What I think we uncovered in the process of putting this book together is a resurfacing of the primary vision and values of social work practice, of health social work practice. And a reminding or reflecting back that that’s what people are doing.

Bridget: I think part of the challenge is that the health care setting in general does not ask social workers often to practice to the highest level of their license. So-

Eric: Are you suggesting this around let’s say, discharge planning?

Bridget: Possibly. And it’s not to say that discharge discharge planning is incredibly important.

Eric: Yeah.

Bridget: There are profound therapeutic components of good care plans.

Eric: And I’m saying that facetiously, that oftentimes medical centers, what they really do care about, a lot, is length of stay and getting people discharged as quickly as possible.

Bridget: Yeah.

Eric: And I feel that-

Bridget: And the concrete resource is necessary for that.

Eric: Yeah, and sometimes people’s scope of practice could be narrowly focused on this one issue.

Bridget: Absolutely. Yeah. And I would, this is maybe a political thing to say, but I don’t think most social workers get masters degrees to give taxi vouchers. I think most social workers continue on with education because they’re interested in the therapeutic dynamics to helping people in their lives.

Bridget: And I do not want to say that care planning and discharge planning can’t be a part of that.

Eric: Yeah.

Bridget: But to have your entire job really focused on getting people in and out of the healthcare center, overlooks really core qualities of social work practice.

Anne: I notice throughout the chapters, there was a lot of discussion around social work core values. And also the specific skills or interventions that are used that bring those values to life. I notice you guys gave a lot of case examples around what that might look like in real life for patients who are in a healthcare setting.

Bridget: Yeah. I think what we learned so, this book came out of a survey of health social workers, assessing their sense of competency and capacity in what we had identified as core palliative care skills and competencies. And, also, how they like to learn.And what we heard from social workers over and over and over again, is, “But what should I do? And how do I do it? And how do I name it?” And so we really wanted to ground the theory of this book in real-life examples. And articulate really clearly what we think the social worker was doing, so that that can be translated to other folks on the team. And to build the confidence in the clinical social work skills. So instead of just saying, “supportive counseling provided,” what does that mean? What did you do? How did you talk to these folks about what they are going through?

And with those case examples, we also really wanted to talk about different types of people, different types of patient populations, different disease trajectories, different settings and locations of care over different amounts of time. So that more health social workers could find themselves somewhere in the book.

Alex: I remember you split up these stories into three different levels: micro, meso, and macro. Could you talk a little bit more about why that was intentionally done throughout?

Bridget: Yeah. So there were a couple of key theoretical principles that we used throughout the book. And this idea of micro, meso, and macro, again, speaks to social work practice, which is of course, at the center for many folks as one-on-one relationship. Or the micro. And the person in their environment, who is in their life, their most immediate circle.

And then we are also thinking about interventions on more of different levels of systems. So, in the community and the biggest system being policy and healthcare at large. And we wanted to explore ways social workers could take palliative care principles and advocate, or enact them on multiple layers.

Eric: I have some non-book questions but I want to make sure we stay on this book theme for a little bit more. Any other book questions?

Anne: I’m wondering about how you and all the contributors of the book, as you guys worked on writing this and editing it and re-editing it, did this process, did you find that it changed your practice, or your attitudes in some way? How did it change you and what you bring to your work each day?

Bridget: Yeah, it’s a good question. I think just a comment on the process. This was extraordinarily laborious. In that we asked specialty palliative care social workers to write about taking what they do all day, every day, and integrate it into settings that maybe they don’t actually work. So just right there, we’ve asked them for this massive cognitive process.

Alex: You mean, for example, like somebody who does primarily outpatient social work, to write about something that’s more of an inpatient issue, or-

Bridget: Or, take a person who’s primarily on a palliative care consult team and ask them to imagine how they might apply some of what they do in a dialysis center.

Alex: Oh, okay.

Bridget: So really trying to take specialty palliative care and to imagine it in primary settings. So right there, that was challenging from the get. And then you have many many contributors writing it from about different subjects, from different locations, and you’re trying to make a cohesive statement on some level. At least not contradict yourself too much.

And so the editing process was layers and layers and layers. And we actually read the chapters out loud on conference calls over and over again.

Alex: Wow.

Bridget: And that was three of us across time zones, really with this deep commitment to making it the best book possible. So one way that it changed my practice was that I was really tired. A lot of times as we did this many nights a week for what felt like years.

But I do think really importantly, it gave me a really different appreciation for what healthcare social workers do. And I think in my own professional identity building as a specialist, had separated myself some from health social work, and re-ignited my commitment to social work as a field, most broadly.

Alex: There are chapters on a number of different topics in this book. Pain, cultural issues, spirituality, culture. So many diverse topics that really cover the whole spectrum of psychosocial and physical, spiritual distress in palliative care.

Bridget: Yeah.

Alex: So it’s interesting that you interweave all of these components. And yet, there are also chapters that are specifically about palliative care and end of life. And, about social aspects. And working through this book, I wondered if you feel like there is a core of, “This is what social work is, and this is what the main things that social workers should attend to. And then these are other things that they should be aware of, around it.” And I wonder what you would put in that center, and what you’d put around it.

Bridget: Yeah, it’s a good question. So we organized the book around the domains of palliative care as defined by the National Consensus Project. In a hope to really orient health social workers to how many people conceptualize the most important parts of palliative care. Recognizing also that while we separate them for chapters, and we separate them as domains, are really quite intertwined and overlapping. And so that’s sort of a false separation. I think social workers are for sure psychosocially oriented. And maybe you can put that right at the center. Who are your patients and families? What are the social factors influencing their experience? How are they processing psychologically, psychiatrically, emotionally? What’s happening with their relationships?

I think what we really encouraged people is to do in this book is to find things that speak to them. And to get more into it. Really, in many ways, it’s a sort of a survey course in palliative care, for health social workers, and many people are studying all of the things in this book. And spending their entire lives studying the things in this book. And so what we were hoping to encourage people is if spiritualty speaks to you, or symptom management speaks to you, or systems issues speaks to you, integrate that into your practice. And let it be a personal thing that’s really driven by what you think is important.

Eric: Moving a little into from primary palliative care in social work to specialties palliative care social work, it sounds like it’s a pretty exciting time right now. There’s a new … Anne, is that right? You just took a test yesterday?

Anne: The new certification exam is ..

Bridget: Did you take it yesterday?

Anne: I did, I took it yesterday.

Eric: What is this exam?

Anne: It’s the advanced … I know Bridget was on, you’ve been on the board to help develop it. Maybe you could speak a more a little about it.

Bridget: Yeah, so the its Advanced Practice Palliative and Hospice Social Work Certification Exam. And it was built in the lineage, or reflection of similar nursing credentials. And social work, up until this point, has been without a credentialing exam.

So, there is an NASW credential that is really just based on experience, and it was felt, and has been felt for a long time, it was really important for people to be able to prove competence.

Eric: And that just started this year.

Bridget: It did. It just launched.

Eric: Wow, that’s exciting.

Bridget: The first test was yesterday. After a lot of hard work, by a lot of people.

Eric: So why should social workers in palliative care take this exam?

Bridget: It’s a good question. I think that this is part of building a solid reputation of specialists. And really being able to prove and own, maybe less about proving, actually, but the internal process of owning expertise and capacity.

And I think there’s some hope that that equals some of the hierarchical stuff over time with nursing and physician colleagues.

Eric: There’s hierarchical issues in the healthcare system?

Anne: Never heard of it.

Bridget: Not at UCSF. Maybe at other places.

Eric: Yeah, and I think, even from a hiring perspective and developing teams, it does do something when you’re trying to develop a team to see that this person has this expertise. And is shown also by this certification. Not just, “Oh, I’m really interested in this subject, and that’s why I’m applying for this position.”

Bridget: Yeah, it certainly highlights commitment. And I think what we have heard is that employers are really excited about this certification. And because there are so few options for specialty-level palliative care social work training, this is a really important component of building out the professional identity and confidence.

Eric: And when you look in the future, let’s say the next five or 10 years, any other things that excite you as far as specialty-level palliative care social work?

Bridget: Yeah, there’s so many things. I think SWHPN in the National Organization of Social Work and Hospice and Palliative Care Network is really building membership. And the annual meeting has increasingly large groups of social workers that are really committed to this work, and to the both the clinical care and the academic component of palliative care social work.

There are more and more jobs, which means we have more and more opportunity to build our workforce, and to build some evidence base in it. And then, I think palliative care social workers are going to have an awesome opportunity, as exampled by this book to really think about how can we change healthcare? So outside of providing specialty-level care, how can we take what we do and influence how more people are cared for?

Eric: Anything you’re excited about, Anne?

Anne: I agree entirely. I think it’s wonderful just to be thinking about our discipline, the evolution of our discipline and really coming to, not only be recognized by others, but really recognizing ourselves, and being able to identify the heights of what social workers can contribute to this kind of care for people.

Bridget: Yeah. And I think to be moving away from the idea that social work and chaplaincy, but that social work is a support to physician and nurses. But actually, when we look at what is most important to people with serious illness, it’s psychosocial issues. These are the things that are actually making or breaking people’s experiences.

Eric: Ok right, so if you look at … so why do you think it is, when we look at a lot of the randomized control trials in palliative care, it’s often a, the team … we talk a lot about teams in palliative care? Oh yeah, this is a team based, palliative care’s team, team, team.

But if you look at the randomized controlled trials, a lot of them are a physician and a nurse, or a physician and nurse practitioner.

Bridget: Yeah. So why do I think there aren’t social workers on those studies?

Eric: Yeah. It seems like if we say this is so integral and important to what we do … man, there should be social workers and chaplains included in these studies.

I recognize that part of it is just funding a trial. But I think it is one of the disservices that we do, sometimes, to our literature, when we don’t actually include the core principle of what makes a good palliative care team.

Bridget: I think a huge part of that is job structure. So if you have somebody who has 100% clinical time job, is essentially running a palliative care service, or at least providing the continuity for that palliative care service, where do they get the time to be on a study?

There are very few models of social work jobs that integrate time for projects, program development, research. And that’s partially a funding issue. And that’s partially that social work jobs are generally either managerial or clinical jobs.

Alex: So, we talked a little bit about moving, looking forward and what we’re hoping for in the next five years. Could you talk about … we talked a little bit about this in the book, the history of social work and palliative care? I’m thinking now, not so much about health social workers, but about specialists, palliative care social workers.

Bridget: Mm-hmm (affirmative).

Alex: And as you mentioned in the book too, there are different ways in which they become integrated in part of the teams in different local environments. But nationally, is there a bigger sense of where we’ve come from?

Bridget: Mm-hmm (affirmative). Yeah. I have been really fortunate to be trained and mentored by Terry Altilio, who’s one of the editors on this book. Both Meagan and I have been, and that has led to a really intergenerational process in our learning, and certainly in the creating of this book.

But in many ways, we’re in a place now where there’s first generation, second generation palliative care social workers. And a lot of the first generation palliative care social workers came out of oncology care. And worked so hard, advocated so hard to have a seat at the table. That was a lot of the effort to bring social work, to feel heard, to be valued, to not be second thought.

Bridget: And now, I think there’s an opportunity, there is all the talk that this is interdisciplinary or interprofessional, we work as teams, this is important. That’s sort of an assumption. And now, we get to see what we’re going to do with that.

That said, there’s huge regional differences. So we are sitting in the Bay Area, where we’re lucky to have social workers on most palliative care teams. But, there are plenty of specialty palliative care teams that do not have social workers, or have one for 60 patients.

And so, while we’re in this place, this sort of slow change of leadership, to second generation folks, and some passing of some torches, we also have places where hospital systems are just trying to conceptualize palliative care social work for the first time. So that’s a pretty dynamic space to say, “This is where we are, and this is where we’re going.”

Alex: And a huge role for this book, then, is to educate all social workers, all health social workers in core principles of palliative care. It’s sort of a vision for, “Look at the potential of what you can do, if you have these skills.”

Bridget: Yeah. Yeah.

Eric: It’s almost like you have to create a revolution.

Bridget: Huh. Woah …

Eric: A whisper …

I don’t know the song at all, so I … those are the only two words I remember.

Bridget: Or maybe no whispering. No more whispering. I don’t know.

Anne: So Bridget, as you said, not only does teaching other people the core principles of palliative care, but I think what you’re saying is, “Hey, social workers out there, there’s a lot of this stuff that you know already. And you can apply in these different ways when we’re caring for seriously ill folks.” And it’s a call to everybody to recognize all the similarities that we share.

Bridget: Yeah. Absolutely. And I think for better or worse, in the building of a specialty, within social work practice, I think a lot of people experience a lot of turf issues. Of the palliative care social worker will do this, or won’t do that. And the medicine social worker will do this, or will not do that.

And I think, our hope with this book, and I think certainly my hope in the future, is that a), this all starts to exist on much more of a gray continuum. And that palliative care social workers can really respect and honor the deep work that primary social workers do. And that there’s much more sharing of patients. So it’s less about, “This is my specialty and this is what I do, and this is what I’m really good at.” And more collaboration.

Alex: That’s a great vision.

Eric: Yeah.

Bridget: Thanks.

Eric: Anne ruined with the last question my transition line.

Anne: I know. I saw it coming.

Eric: It’s a revolution.

Anne: I turned left.

Eric: I don’t have a good transition line anymore!

Anne: Hmm.

Eric: Yeah.

Anne: How about we say “thank you”?

Alex: That’s good.

Anne: Thank you to Bridget.

Eric: Communication techniques. Thank you, Bridget, for joining us.

Bridget: Thank you so much for having me.

Eric: It was an absolute pleasure. How about before though we leave, we end a little bit more with-

Alex: Talkin’ bout a revolution.

Eric: Talking about a revolution.

Bridget: Or singing about it.

Eric: Okay. I’m going to try to join in for the whisper.

Alex: All right, we look forward to a little whisper.

Eric: Okay.

Alex: [Singing]

Alex: That was perfect in every way.

Bridget: Totally. It always is.

Eric: Thank you again for joining us today. And thank you to all our listeners for joining us. If you have a moment, again, please take a second to rate us on your favorite podcasting software. Thank you again.

Alex: Thanks, folks.

Anne: Bye.

Eric: Like a whisper…

Bridget: Bye-bye.