I‘ h" . q'ngyg'l" -'- .... m Jig"? w-‘VI; -v —v 5 u «-_a, > i“. Y; . .Vv g. y 7"?" '37: A w v QJ.'JJ"‘L“‘ 1:. p. .‘¥ 0 ‘ Q rt. ‘ {a " .w. ;.~— 9m 5 :1« ‘. ‘ . . i 3‘.» ..:.u. at»? 5 - . .3 16 u'. ‘41 . . ' 'wbkfi 'l.’ “'" n.5,, P \J i O o o . E ' 4‘5- ""‘ '3’?" '0'— }‘l' in: '45 ?' ."“' ‘ 9 {ab w..- «5 :‘V‘N “I 1. _ . helium-immacudmmmmnA f. p21. 9! 'O V Ill-Ill I'lllllllllllll n1 CISCEfifoES AGAINST }i~]f;-IC_;;L PI'VICE INGHAH SiYLiQE 1949 - 1951 By Rachel Faufie Wood A PaniCI REPORT Submitted to the Department of Social Service, Michigan State College, in Partial Fulfillment of the Requirements for the Degree of MASTER OF fi“LS 1952 ;«‘;‘,‘§",'\ . . \, £ ,. '1‘." . I t MSU LIBRARIES 1"" 7"” 1 TH ESII RET' 'QNING MA'I -—.——- P‘ '~ in boot r 3. thi" = ncqm, 7._ .— —, “__ ———-—- ‘k ACKNOWLEDGEMENT I would like to express my appreciation for the help and encouragement given me by Mr. Bernard Ross, of the Social Service Department, advisor on this project. Grateful acknowledgement is also made to Mr. Manfred Lilliefors of the State Department of Social Welfare for his considerate aid in the statistical analysis, to Phyllis Wilkie, Vocational Counselor at Ingham Sanatorium in helping to gather facts from the medical records, to Ruth C. Lowell, Michigan TUberculosis Association, in proofreading the content of this study and to Janet Carpenter in typing the charts. Last, but certainly not least, acknowledgement is made of the co— operation of Dr. C. J. Stringer in allowing the use of records at Ingham Sanatorium, for without them, this study could not have been made. II III IV VI VII VIII IX XI TABLE OF CONTENTS Introduction Methodology Limitations of Methods Legal Authority for Tuberculosis Control in.Michigan Definitions of "Against Medical Advice" Reasons for Leaving Against Medical Advice .Family Pressures Rehabilitation Services Available at Ingham Sanatorium Summary and Conclusions Appendix Bibliography Page 10 15 18 25 IX INTRODUCTION Each year, throughout the country, thousands of patients leave tUberculosis sanatoriums against medical advice. The reasons given are various. "He couldn't adjust to hospital life." "He was emotionally disturbed.” "His family put too much pressure on him.“ But few studies have been made to discover why a patient is willing to gamble with his own life and that of others, rather than stay a little longer. In checking the records of Ingham Sanatorium, it appeared that al- though discharges against medical advice were lower than in many sanatoria, they were still too high. There seemed to be many different figures that could be used in de- termining what percentage of patients left without sanction of the hOSpital a uthorities. If one considered the total number of patients in Ingham I Sanatorium over this three-year period, 1949-51, an approximate 6% left against advice. Of the total number of discharges, it was slightly higher - around 8%. In some sanatoria, walkouts of 25% to 75% of the discharged patients are reported. (1) In the beginning, it appeared that there were several factors which might be considered. For example, within the age group 20 - 29, adjustment seemed most difficult, family problems most pressing. Those under 19 and over 60 were not so apt to leave before they should. It was assumed that those with.more advanced disease might become more easily discouraged and wish to leave. Those who had been hospitalized before and those who had built up a pattern of leaving against advice - going from one sanatorium (l) Tollen, Wm. "Spotlighting the Patient and his Family? Decreasing_Dis- charges Against Medical_gdvice, Nat'l TB Assoc. 1949 -1- to another in search of better conditions or treatment - — also seemed to form a Specific group. Many patients are some distance from home and this a ppeared to be a factor. Enforced bedrest for those who had had an active occupation might be a difficulty. And, of course, there is always the family and the part they play in the patient's life. METHODOLOGY There has been little research into the problem of the patient who walks out against advice. A few articles such as "Why Do Patients go AWOL' by Wm B. Tollen, the I'Unruly Patient PrOblem Reviewed" by Rebert D. Johnson, M.D. and “Patients are PeOple" by Harry‘Wilmer, M.D. give mainly the writer's opinions and conclusions. A comparison of discharges from two Michigan sanatoria for a six.months period, Octdber 1949 through March 1950 showed that approximately 70% from one sanatorium and 48% from the other either left against advice or abscounded. There were no reasons given. (2) Because there was so little data, it was felt necessary to go ahead with this study in the way which appeared best to those working with it. The discharge summary in the medical chart includes the reason for the patient going out against advice as seen by the doctor who was disctating it. The case record did not always give a reason for the actual leaving. However, it did cite prOblems which ha d arisen a nd included the patient's feelings on his cure, the hoSpital and his own family problems; 'Where it was possible, the worker talked with patients either when home call was made, when the patient returned for check-up or in some instances when he was rehospitalized. Because there was such a large percentage who had (2) Study made by Michigan Department of Health in 1950. moved or gone into other sanatoria, there were many on whom we had no present address. It was not deemed advisable, therefore, to try to interview all patients at this time. Many of the conclusions drawn in this study are necessarily from facts stated in medical and case records. To get an adequate sample, it was decided to use a three-year period, 1949-50-51. Discharges against advice for this period are limited to those who left after an actual diagnosis of tuberculosis. The control group con— sisted of those discharged during the same period excluding only, those who were not tuberculous, those whose stay was too short to make actual daig- nosis and those who were hospitalized for a very short interfal for treat- ment (gastric washing, phrenic, bronchogram, etc.) ibis control group of 267 patients regularly discharged was chosen instead of all patients hos- pitalized because the latter group was too large - approximately 1700 patients- and lack of time necessitated a smaller group. Sanatorium monthly lists, showing admittances and discharges were checked on all 377 patients ( both.A.M.A . (3)and those regularly discharged) and in- formation'regarding name, condition of disease on discharge; and date of discharge was Obtained. A schedule was drawn including, name, age,sex,_home locale (rural,nrban, etc.) position in family, occupation, daignosis, number of readmittances, admittance date, discharge date, number of months in the sanatorium, previous A.M.A.'s,-reasons for leaving and present situation. This information was taken from the medical chart, on the 110 patients who left against advice. Also taken from the medical charts was information as to age and amount of time spent in the sanatorium of the 267 patients. (3) A.M.A . - Against Medical Advice. _ 3 ; The case records were then checked for name, age, home locale, oc- cupa tion and reason for leaving the sanatorium on the 110 patient which comprised the walk-out group. In the beginning, it had been planned to interview each patient who was out against a dvice, if possible. However, as we could not make in- dividual interviews on all in the time allotted and because there many that had moved and there was not time to trace their present address, this was eliminated. It was noted that in only two cases was the information in the case record given by anyone other than the patient himself. It is possible that afteer a lapse of time, different reasons might be given, had the patient been interviewed now. Because it was believe that that group of patients in the 20-30 a ge group seemed to have the meet famiiy prdblems, it was decided the age classifications should be as follows: 0-19, 20 - 29, 30 - 39, 40 - 59 and 60 and over.' Marital status was also broken down in an effort to show the difference between the patient with family problems and the one with only himself to think of. Thus the classificatio.s: single, married without children, parent with children and in a single classification, those widow- ed, separated or divorced. The classification of months spent in the sanatorium was chosen on the basis of the sanatorium rules governing the taking of x—rays and criteria for discharge. X-rays and consideration of the patient in staff conference are every three months. The minimum basic requirements for discharge are two unchanging x-ra ys (6 months) and completely negative tests for six months period. It was therefore decided to use 0 — 5 months, 6 — 11 months, 12 - 17 months and over 18. With the total time of hOSpitalization de— creasing, fewer patients are remaining for over the 18 months period than heretofore. LIMITATION OF METHODS It is felt that these methods are somewhat limited. There are records which are very sketchy a s to reasons given for leaving such as the one citing: “J. was having trouble with his family and decided it was to his best advantage to leave.” Or such as the one which stated, “Mr. B. left against advice after an argument.‘I Knowledge of whether the argument was with friends, roommates, family, sta ff or personnel, whether it was over his own prdblems, disagreement as to policy or many other things would have been most helpful. Actually there may be four reasons for each discharge against advice. Egggj” that given in the hospital (medical) records. Second, that given in the case record. .zgggg, what the patients say. This may include roommates, friends or even the reason given by the one who is leaving. Fourth, the real reason. 'Many time the underlying facts are such that the patient either does not realize the events and feelings leading up to his walkout or does not wish to discuss them. Another variation of data would include the change in conditions in the sanatorium from day to day. As long as a study is dependent on human beings and human relationships, there will always be change. I'Consideration of differences or similarities in employment opportu- nities, welfare department policies, turnover in medical and nursing per- sonnel and many other apparently a ncillary factors which may influence the behavior of current patients must be considered." (4) (4) Holland Hudson cit. Appendix VI A patient may feel different from day to day. His feelings about his physical condition may differ and the person he comes in contact with as he becomes more worried, may aggravate him, worry him or help him. His home situation may also change. The family may visit and cheer him up or worry him. They may not visit at all. New problems may arise which he thinks only he can Care for. The family may try to keep prob— lems from him and thus make him worry more than ever. The lunch or dinner menu may not include his likes in food and uhe has never had such poor meals“. The steak or chicken may please him and the meals are exe cellentl' His roommate may talk when he wants to sleep or vice versa. There may be personality difficulties of which the staff is not aware until too late. All of these limit the comparison from one area to anothcr and are a means of rendering such comparisons statistically invalid. BeCause of lack of factual data as above discussed, there is little to compare. In reality, any data which could be comparable would be al— most impossible to obtain until such time as there iS'a unified defini- tion of ”Against Medical Advice." LEGAL AUTHORITY FOR TUBERCULOSIS CONTROL IN MICHIGAN Under Public Act 341, 1927, a mended by Act 93, P.A. 1937, Act 240, P.A. 1941 and Act 249, P.A. 1949, "An act to protect the people from tur berculosis, to provide for the care, treatment, isolation and hospitali— zation of persons afflicted therewith, to provide for the commitment of certain persons afflicted with tuberculosis, to provide for their Care, custody and discharge and to prescribe penalties for the violation of this act,‘' those with active cases of tuberculosis are hospitalized. Tuberculosis is declared in the above acts to be a communicable disease dangerous to public health. Because of this, anyone with a known case of a ctive tuberculosis is to be hospitalized until such time as they cannot endanger the public. According to Section 2a. “If he (health officer or state commissioner of health) shall find that any such person is a menace to others, he shall petition the probate court of the county in which such a person resides or is found, for an order directing the admission of such person to any ap- proved hospital or institution established for the care of persons suffer- ing from tuberculosis.I Thus, for that person who is a public health menace, compulsory hospitalization may be effected. In few cases, how- ever, is this significant to the person who leaves against advice, as it includes only kppwn active cases, and this term is usually used when the Sputum is proved positive. Therefore, the patient who has improved so that he has converted his sputum to negative but who has not yet stabiliz- ed his disease, is not usually brought back under court order, nor can that patient who has not given or will not give Sputum for laboratory tests be forcibly hOSpitalized. 'When the patient, who is hospitalized under court order, leaves the sanatorium against advice, he usually leaves the state immediately and thus Cannot be returned. The hospitalized patient with.a family who is under court order will seldmm leave without them and as this may be difficult, will usually stay. However, psychologi- Cally, the effect of being forcibly restrained may be so disturbing that it is usually used only when other means fail. Because it is impossible to enforce hospitalization and expect a medically indigent patient to pay for it and because cure for tuberculosis requires long periods of bedrest, this same law provides for free care. - 7 - This includes not only hospitalization but all treatment as well and “shall be considered expenditures for the protection of the public health and not as moneys advanced in the nature of welfare or relief. No person shall be under legal obligation to make reimbursement for such expense so incurred unless the state commissioner of health and the county of settlement, after reasonalbe notice and Upon fair hearing under rules of procedure to be de- termined by the state commissioner of health, shall have found that the person so hospitalized or treated, or the person or persons legally liable for his SUpport, are possessed of sufficient income or estate to enable them to make such reimbursement in whole or in part without materially af- fecting their reasonable economic security . . . .' (Section 3a) DEFINITIONS OF ”AGAINST MEDICAL ADVICE” As above mentioned, one of the difficulties in comparison of data stems from the fact that "Against Medical Advice'' may have almost as many different definitions as the number of sanatoria involved. At Ingham Senatorium, a patient is discharged after he has success- fully completed the course of treatment as recommended by the medical staff, after optimum home conditions have been effected for each indivi- dual patient and approval of his local health department has been secured. In cases where there is no county or city health department, the situation is worked out as satisfactorily as possible between the patient and the social worker. Any patient who leaves before these conditions have been met, is termed out “against medical advice.‘ The patient who leaves to meet an emergency at home, becomes dissatisfied or lea ves because of other pressures is ”out against advice.” - 8 - One administrator may report as against advice, those patients who do not wait for home investigations, while another only those who have before their term of treatment is completed. One may count disciplinary discharges as AMA'while another does not. One sanatorium may discharge patients who are negative by slide, another require negative slide, culture, guinea pig and gastric. To leave before complete conversion would be con- sidered, “against advice.“ Some sanatoria use the definition "against ad- vice" for those who have not fulfilled all requirements for discharge bum leave after advising the staff of their intentions and the term "abscounded" for those who leave without notifing anyone. Thus, here too, the absence of any uniform criteria is one of the main difficulties in any inquiries that may be made. The same absence of criteria as to programs and classifications and/ or standards of personnel makes it impossible to compare one sanatorium to another, one program or everlfacilities and resources within the sanatoria. A shortage pf personnel or those with inadequate training and/or understand- ing of the situation may increase the number of early discharges. While a trained social worker may help the patient analyze his reasons for wanting to leave, a sanatorium where there is no social worker or where he is in» adequately trained may find that the patient leaves earlier because he cannot observe his prOblem clearly. The sanatorium which has adequate, well-trained personnel will meet patient needs better than that Operating with a reduced number of workers. The services provided also vary with the number of workers and the type of ‘work done. Outside of the medical and nursing staff, that sanatoriun ‘which can help fill the waking hours of the patient with such activities as occupational therapy, bedside teaching , homemaking and library, present-' ed and supervised in such a way as to be meaningful and interesting, will find fewer walk-outs than those without these services. Those patients who can discuss home prdblems with a social worker, worry over future jObs with a vocational counselor and feel that a plan of action will be forthcoming will usually do so and not try to carry the entire burden themselves. Rules and actibity allowed are both important in considering the patieht who will not or can not wait to complete his full term of treat- ment. For the inveterate smoker a "no smOking‘ rule may become an in- surmountable difficulty. The very active business man, athlete or teen- ager may find it impossible to adjust in a sanatorium where he is kept on. complete bedrest for a long period of time, but in that sanatorium where they are given more freedom, may be better able to adjust. The fact that some sanatoriums send their patients home when they are up for one meal a day and bathroom priveleges (as they do at Ingham) and other keep them until they are on several hours work activity, also makes a difference in the willingness of the individual to stay until discharged. REASONS FOR LEAVING AGAINST MEDICAL ADVICE There are as many reasons for leaving against medical advice as there are patients who leave. No two situations are ever the same and as in everything else, the situation depends on the individual and the adjust- ment he has been able to make towards life. The hOSpital, itself, and the life a patient must lead there breeds dependency. He is told when to get up in the morning, when to wash, brush - 10 - his teeth, eat, see people sleep. From the time he was an infant, he has been taught the opposite. He has been taught independence, that he should learn to care for himself and his family, He will get ahead by his use of initiative. Little wonder he is now thrown into a world of conflict. When it becomes so great he Can no longer resolves his worries, he returns to his own life or becomes psychotic. Usually a patient will leave before he becomes so emotionally disturbed. nEmotional instablity" is a nebulous term depending often on the defi- nition by the person who is writing the history. In one case, it may be the family pressures or other difficulties which.make the patient unable to adjust to his disease and hospitalization. In another, it may be the disease'whtch acflentuates the family pressures. Often the threat of sur- gery or the vagueness of tuberculosis is far too difficult for the patient~ who has not already learned to adjust to life. He may withdraw to the point where he will no longer have anything to do with his roommates, may Spend his time sullenly staring out the window. He may work rapidly, sel- dom taking a break, paying no attention to his rest periods. He may com- plain constanily about many petty things. He may be known as "making a poor adjustment.‘ At all times we try to remember the statement by Emil Frankel, ”Sta- tistics are people. The patient upon admission becomes an individual with a broken body and disturbed mind and not just a pair of lungs sent in for repairs.‘ (5) And also that by Harry a'Wilmer, M.D., ”It's more important ' to know what kind of a fellow has the germ than what kind of germ has the fellow." (6) (5) Frankel, Emil, "The Changing Scene in the State TB Sanatorium Field", The'Welfare Reporter, N.J. Dept. Institutions & Agencies (Dec.'51) (6) Wilmer, Harry M.D. "Patients are PeOple' The Crusader, (1951). -11.. Often lack of prOper interpretation of rules or reasons for doing things may increase discontent. These may be purely unintentional or it may be an actual lack. A patient wishes to talk to a staff member but a busy schedule does not allow it as soon as the patient believes it should. A patient may not realize the red tape necessary or the time involved to carry through an Operation which he believes should be done immediately. Many times hoSpital personnel cannot get co0peration from other necessary agencies, particularly within a specified time. Mrs. W. was recommended for discharge. A low family income and poor home conditions worried her. Her county of residence, in Spite of the law, re- fused to pay for out-patient treatment and did not immediately complete home investigation. Mrs. W. left rather than wait until the situation was straightened out. Food is always a reason for "griping". The patient forgets that eating food prepared by the same people may become tiresome, whether at home, in a particular restaurant or in the hospital. Other patients play a large part in the A.M.A. discharges. Al- though we try to place patients according to age and interests as well as the amount of disease, there may be a clash of personality. The roommate or friend is all too often ready and willing to "give advice”. He will frequently discuss tuberculosis, treatment, surgery, rules, etc. This is not always with the best understanding and may create discontent or fear in the new patient. Fear of the disease, itself, is a large factor in early leaving. Often when the patient is told he has tuberculosis, it comes as a shock, he does not realize the other things that are told him at that time. He does not realize the disease is discussed as is his;po5pitalization. Too often, he is told by his own physician that there is something in his lung and he had'better come in for a couple weeks observation. He may have a far-advanced case which will necessitate months of bedrest and treatment bum is not properly'prepared so he can make arrangements at home. Mrs. B., the 25 yea r old mother of 4 small child- ren ranging from 2 to 6 years was found to have far- advanced, bi-lateral pulmonary tuberculosis. In an effort to hurry hOSpitalization, pressure was effected and she was admitted two days later. She had been the strongest member of a very weak household, yet had been so worried about her condition that she had done no pla nning for the family. Froblems came, one after a nother. The hquand was unable to hold a job; there was no one to Care for the babies continnusly. Bob, the 6 year old having no supervision was seriously hurt while playing with.matches. Five weeks after ad- mission, Mrs. B. left against advice. In this family, who found it difficult to maintain themselves under ordinary circumstances, the trauma of having the mother leave immediately without taking time for prOper planning was far too difficult. ‘When she improved physically to the point where she Spent most of the time worry- ing over what was happening to the children, she realized some changes must be made. The accident to the child only accelerated her walkout. _ 13 - Often proximity to friends and family make a difference in the length of the patient's stay. In our particular hospital, only about 40% are from Ingham County. The rest may be some distance from home. However it is found that usually the individual and his family are the deciding point, not how often they visit. One patient may leave becuase he has had no visitor, another because the visitor worried him. Mr. F., a laborer, in his late forties who had never been.more than three miles from his elderly parents and never away from his wife and 7 children, now found himself hospitalized 150 miles from them. They were financially unable to come to see him and be worried constantly as to how they were getting along withs out him although he knew his wife had always handled all the money and made all decisions. After about 8 weeks, he left to get back to them. On the other hand, we have Mr. B., whose wife visited several times a week and took every Opportunity to discuss the minutest business detail with him. He had owned a grocery store before his admittance and felt no one could take care of it as well as he. He finally became disturbed over his business and left. In both of these cases, the social worker had discussed the situations and a series of interviews had been arranged. The former had deep seated fears dating back to childhood and a complete dependency on the mother figure. In the latter, Mrs. R. felt totally inadequate to deal with the new responsibilities and refused referral to a case- work agency. It was felt that the problem could only be resolved by her cooperation. FAMILY PRESSURES Members of the family are always important in any decision made by an individual but it is apt to be that age group with.young children which seems to worry most. The mother is usually wondering how her children are cared for and if everything is going all right at home. The father about his incapacity with loss of his job and how the family is getting along. Mrs. C.W., 29 year old mother of three children had a difficult time adjusting to hoSpitalization. She had trouble with her mother-in—law who was Caring for the children and when her husband called and told her she must come immediately, she left at once. George D. worried constantly about his 17 year old wife and infant daughter and how they would be able to live on public assistance. He felt that he was not assuming his responsibilities in staying in the sanatorium and letting her work. When almost ready for diScharge, he finally left, against advice._ In the former case, the social worker had been trying to help the patient understand why it was necessary her cure come first and how she would eventually be helping her family if she first regained her health. Although she discussed the matter intelligently, she left at once when he; emergency came. In the latter, the young patient had no training for regular work and was under a prOgram planned by the patient and the vocational counselor so - 15 - that he would eventually be self supporting. The demands made by an im- mature wife, playing on his ego made him also walk out even though he knew he unable physiCally to work at that time. Members Of both sexes seem to be under pressure from their spouse to “leave now or else . . . ." Often there is not a close enough relation- ship between husband and wife to withstand separation and each is fearful that the other partner of the marriage will leave them. Often this is based on'a sense of inadequacy, stemming from fear of the disease. The patient knows it is chronic, reoccurring, contagious. He knows he must always live with the fact that he may break down and infect others. He may have to return to the sanatorium. He knows his friends and even relatives may fear him and he is not always sure of his wife's ability to stand with him against public Opinion. The patient usually makes adjustment to hospitalization much as he does to life. If he becomes upset over minor things, he will find much.wrong with the hosyital, his treatment and his new way of living. If he is a mature individual with a mature outlook on life, he will eventually find positive features in hospitalization no matter how disturbed he Was when the diagnosis was first made. For one who has left several sanatoriums against advice, it is much easier to leave the next time. If one is always striving for UtOpia, no combination of factors will completely satisfy and after once finding that he Can be hospitalized at another Sanatorium, the chronic walk-out will continue his search from hospital to hOSpital. It is believed that often the occupations of the patient made ad- justment difficult. For instance: J.J. had been an oil worker and Spent most of his adult life in hard physical labor in the oil fields. He had had little education, had worked hard, played hard. Complete bedrest with383. accuse muo v.3 mmu 30 N3 N3. mum got 988.. n u. u u m s u.» pl»... u u u w u m fmw beacons...” o u u o m o uh bu E. m on is use cyanogen ow Eugen. any? dongs sen gonna... 8b“ a on panama 9E couns- CE? and 96803.3 nought. so. H E banana 925.5 ms» ud v.3 mam v.3 MB. W3 goo“. cocoons m m u m a U 94 E; u w u e. u m 93 successes . m a c m n 2. 98 we 3 u on it use panacea!» on flanges. 33% usage BE «assumes... 3.5 u on «assume ooh—o. cones. Ci»... can 9632503 “70“ spawns: seen 518 C O P Y NATIONAL TUBERCULOSIS ASSOCIATION 1790 Broadway New York 19, N.Y. ‘ Tel. Circle 5-8000 Mrs. Rachel F. Wood Director, Rehabilitation Dept. Ingham Sanatorium Lansing 9,.Michigan DearIMrs.'Wood: Other than a study by the Veterans Administration, entitled "Irregular Discharge: The Problem of Hospitalization of the Tuber- culous', the great difficulty about inquiry into the subject of discharge a gainst medical advice is the absence of any uniform criteria among hospital administrators. Accordingly, when one looks into the problem, it is necessary to ascertain (often by field work) how the term was applied; for example in contiguous counties one administrator reports as AMA each discharge wherein the patient has not completed a full term of treatment recommended by the physician, while his colleague reports as irregular discharge cases in which the patient or his family forced~ the consent of the physician which.was reluctantly given in view of the fact that sputum conversion had been Obtwined. There are also variations in the item of disciplinary discharge, - some administrators report it as AMA and others separately. However, one of the most thorough inquiries into city and county in- stitutions was done by the Department of Institutions and HOSpitals for New Jersey. I think a line to Dr. wm.A. DOppler, Executive Officer, New Jersey Tuberculosis League, 15 East Kinney Street, Newark 2, N.J. might obtain a better citation than I can give you.at the moment. This leads up to the suggestion that while reports from other areas may be interesting, comparisons are seldom statistically valid. Even when one compares AMAS in an institution for one year with the record of the preceding year, interpretation should be preceded by a consideration of differences or similarities in employment opportunities, welfare depart— ment policies, turnover in.medical and nursi g personnel and many other apparently ancillary factors which may influence the behavior of current patients. As one rehabilitation worker to another, always represent the rehabil- itation program as gag of the means by which patients may be successful in adjusting to hospitalization. Very sincerely yours, Holland Hudson Director Rehabilitation Service eh VI moUonHw ammo wow mumwwmwm om Hmoowmm I >3» wmdwmoam ._ mmm nose womwwwoo zmsm mmx md HoomHo . H: ooosvmdwob UHmmuOmHm womaswadmboo mwmomm. meHHM AomepHuw was. memowm. .30m. . wdmd. mnemonm wow Hmm