Introductory Guide to Medical Social Work - OnlineMSWPrograms.com
Introductory Guide to Medical Social Work
By Kaitlin Louie
Medical social workers work in hospitals, community clinics, and other healthcare settings to support patients and their families, and to assist the larger medical team in the coordination of patients’ care. They play an essential role in many of the non-medical aspects of patient care, including helping patients and their families navigate the medical system, assessing and monitoring patients’ and family members’ mental and emotional health, providing short term counseling and therapy, and communicating patient needs and concerns to the larger medical team.
Medical social workers work closely with patients and family members who are experiencing mental, emotional, family, and/or financial stressors due to their or their loved one’s medical condition. Because of the type of challenges they encounter and the fast pace of medical settings, medical social workers may find this field to be stressful and demanding. However, many medical social workers refer to the relationships they build with patients, families, and the medical team combined with the knowledge that they are helping individuals, as reasons that they entered and have stayed in the field.
Due to the demands of the profession, becoming a medical social worker typically requires that individuals earn a Master’s in Social Work (MSW) degree from a CSWE-accredited institution. Medical social workers typically combine a strong understanding of clinical social work practices and modalities (such as psychosocial assessments, crisis interventions, and psychotherapy) with knowledge of medical environments and protocols.
Medical social workers are employed in a wide range of medical settings, such as hospitals and medical centers, specialized medical clinics, and public health departments.
Inpatient Medical Social Workers
Social workers who are employed at hospitals and medical centers, providing specialized social services to patients suffering from chronic and/or acute health conditions that require hospitalization are known as inpatient medical social workers. While some inpatient medical social workers stay within one specific medical unit or department, many spread their time across several units.
Carrie Allen, LCSW works at John Muir Medical Center in Walnut Creek, California, where she supports patients in the emergency room as well as the surgical trauma and orthopedic floors. In an interview with OnlineMSWPrograms.com, she explained how social workers work throughout the Medical Center:
“At John Muir our social workers are assigned to different floors, we have 9 different social workers per day and the assignments are as follows: trauma intensive care (ICU)/(overflow) intensive care, neuro intensive care/progressive care unit, emergency room, acute rehab (physical rehab)/neuro progressive care, pediatric intensive care unit/mothers on labor and delivery/pediatrics, neonatal intensive care unit and mothers of these neonates, trauma med-surg/ortho med-surg (my floors), oncology med-surg/oncology surgeries, renal med-surg/general surgeries.”
Ms. Allen also mentioned that, though medical social workers at John Muir Medical Center tend to focus on certain units, they also have a strong understanding of the needs of the hospital as a whole.
“On the weekends there are only two social workers, and then we are also on-call for PICU and NICU to meet California Children’s Services (CCS) criteria, so though we all specialize in our floors, we all have to know how to do everything because on the weekends and on-call we have to know how to do everything.”
Depending on their academic training and professional experiences, some inpatient medical social workers may specialize in a given area within the hospital, such as geriatrics, pediatrics, or psychiatric and intensive care; these medical social workers may also work in multiple units that serve similar populations. In an interview with OnlineMSWPrograms.com, Jessica Beitch, LCSW described how she worked in several areas of pediatric intensive care at the University of California, San Francisco (UCSF) before transitioning to her current role in the pediatric bone marrow transplant service at UCSF Benioff Children’s Hospital. “I worked on the pediatric oncology service, neuro-oncology and neurosurgery service, general pediatrics ward, pediatric ICU, outpatient hematology, and was hired as an employee to the bone marrow transplant service,” she said.
Medical social workers for inpatient settings collaborate on a daily basis with many different teams and staff members. Ms. Beitch described the people on her interdisciplinary team with whom she interacts on a regular basis:
“As a medical social worker on the bone marrow transplant unit at a teaching hospital, I work with a robust team that includes attending physicians, fellows, residents, nurse practitioners, nurses, nurse coordinators, nurse administrators, patient-care advocates, dieticians, food service attendants, child life specialists, art therapists, music therapists, physical therapists, occupational therapists, speech therapists, lab techs, pharmacists, administrative assistants, medical assistants, medical interpreters, financial representatives, descendent affairs staff, national foundations, community organizations, and other social workers (I’m probably forgetting a few people!)."
Outpatient medical social workers work with patients who either do not need hospitalization but still require medical care and guidance, or who are transitioning from hospital care to outpatient care or their home. Oftentimes, these patients grapple with very similar challenges that hospitalized patients do, and therefore require similar services such resource navigation guidance, counseling, and care coordination.
Outpatient medical social workers can work at hospitals and medical centers, as well as specialty clinics. DeEtta Barnhardt, LCSW works as an inpatient social worker at Lucile Packard Children’s Hospital at Stanford (LPCHS), explained how outpatient social workers tend to focus on patient discharge planning and follow up. “We have outpatient social workers as well [at LPCHS]. I may assist a patient/family on outpatient needs if they have recently discharged but I will usually sign-out any ongoing outpatient needs to the assigned outpatient social worker,” she explained. Ms. Barnhardt also worked as an outpatient social worker at Gillette Children’s Specialty Healthcare in St. Paul, Minnesota, and explained to OnlineMSWPrograms.com how her duties were in some ways quite similar to those of her current role in inpatient pediatrics:
“When I worked at Gillette Children’s Specialty Healthcare, I was an outpatient social worker. At times I would cover inpatient if we were short-staffed but my primary role was outpatient. I worked with one other outpatient social worker and we covered all the outpatient clinics,” she recalled, “Part of our role was social work related including support and referrals to resources; however the other part was care coordination (case management) such as ordering wheelchairs, hospital beds, and enteral supplies. It was similar to my current role at LPCHS as I had to prioritize my day, never knew what each day would hold, and there was a general quickness needed to accomplish the tasks necessary each day. […] I would be paged to assess a situation, would complete an evaluation, provide appropriate resources and support, make referrals as needed and would continue to work with the patient/family on an outpatient basis.”
As Ms. Barnhardt explained, medical social workers’ responsibilities may, at times, span both inpatient and outpatient responsibilities as needed. Furthermore, some medical social work roles involve fulfilling or coordinating both inpatient and outpatient services on a regular basis. For example, in her current role in the pediatric bone marrow transplant unit at UCSF, Ms. Beitch “[covers] both the inpatient service and outpatient clinics,” and noted to OnlineMSWPrograms.com, “This is a great fit for me. I enjoy the integration of acute illness with the opportunity to establish long-term relationships with patients and their families.”
In addition to working in hospital settings, medical social workers can also work for specialized clinics that serve populations suffering from very specific conditions or diseases. These clinics differ from hospital settings in that they are serve individuals solely on an outpatient basis. Jenn Toledo, MSW works as a medical social worker for Satellite Healthcare, which is a dialysis unit in Menlo Park, CA specifically treating patients afflicted with End Stage Renal Disease. She explained to OnlineMSWPrograms.com the distinction between hospital settings and specialized clinics such as Satellite Healthcare. “Working at a dialysis clinic is different from working at the hospital because the patients at a dialysis clinic are all patients with the same chronic illness–ESRD,” she said, “Patients can require anywhere from twice a week treatment, to five times a week treatment, with each treatment running from 2-4 hours on average.” Specialized clinics such as Satellite Healthcare often receive patients through referrals hospitals and medical centers.
Medical social workers in specialized outpatient clinics often fulfill as wide a range of responsibilities as their peers who work in larger hospital settings. Ms. Toledo explained to OnlineMSWPrograms.com how she supports patients at Satellite Healthcare through a combination of resource navigation services, emotional support, guidance in logistical matters such as housing and insurance, and any other issues that affect patients’ mental, emotional, and physical well-being.
“I assist patients with adjusting to their illness, assisting in arranging dialysis while they travel, referrals to community resources, insurance support, kidney transplant referrals, transportation issues, housing and legal issues, behavior issues, complaints, encouragement of adherence to treatment regimen, and the list goes on and on. My day never looks the same as the previous day.”
Medical social workers can also work for public health programs that provide education, guidance, advocacy, and resources to patients suffering from chronic conditions. Alexa Silva, MSW, works for the Alameda County Public Health Department’s Asthma Start Program as an Asthma Coordinator. In her role, she provides education to children who have asthma and their families regarding how to detect, medicate, and manage this condition. She also conducts home visits to assess for environmental asthma triggers.
In an interview with OnlineMSWPrograms.com, Ms. Silva explained,
“[M]y responsibilities include education to families around asthma including signs and symptoms such as coughing, shortness of breath, and retractions. […] I educate families about all the medications they are using, how they work, why they are important, and how to use them properly. I always have the child demonstrate to me how they use their medications and correct them if necessary. Finally, I do a home assessment in which I address any possible triggers in the home such as mold, dust, and pests (i.e. roaches).”
Ms. Silva explained how she and her fellow social workers on the Asthma Start Program team incorporate social services into their delivery of health care services to disadvantaged asthmatic youth and their families.
“Most of our families live on one income and receive governmental support such as Medi-Cal and food stamps. Some of the issues my clients face are lack of health insurance, a medical home (by which we mean a primary clinic and doctor to manage their care), and/or poor living environments. We try to address any social issues when we go out to the home such as screening for domestic violence to issues directly affecting the asthma such as mold and working with the landlords to correct any potential deficiencies.”
Medical social workers who work for public health departments focus much more on preventative care, relative to social workers in hospital settings. “Our job is very different from that of Medical Social Workers who are in a hospital because we do not deal with emergency situations,” Ms. Silva explained, “We focus more on prevention and education. We are [also] very specialized.”
While their precise responsibilities vary depending on their work setting, medical social workers typically fulfill a number of key tasks:
Performing evaluations on mental and emotional health
Assessing social, family and/or financial circumstances
Communicating patient information to various stakeholders in patient’s health team
Providing counseling or psychotherapy to patients and families
Maintaining confidential patient records
Connecting patients and families with outside medical and non-medical resources
Coordination of patient care in collaboration with health team stakeholders
Medical social workers typically conduct psychosocial assessments of patients (and sometimes their family members) in order to determine their needs and to identify any mental or emotional distress that could exacerbate their condition. A psychosocial assessment is defined as an evaluation of a patient’s psychological and physical health, as well as any external conditions (financial hardship, family conflicts, cultural considerations, etc.) that the medical care team should factor into the care of a patient.
Upon completing this assessment, medical social workers communicate the information they have gathered to the larger medical team, which helps other team members (i.e. physicians, nurses, medical assistants, etc.) provide more effective care. Ms. Allen explained the importance of the psychosocial assessment:
“Core responsibilities include completing an interview with our patients with a full psychosocial assessment as needed. We are responsible for developing and implementing a plan of treatment to assist patients while they are in the hospital with many different psychosocial factors, such as social, emotional, financial, and environmental. We are an integral part of the treatment team, and we assess and provide treatment based on biopsychosocial information.”
The psychosocial assessments are not just essential in the development of a treatment plan; they are also important in ensuring patients receive the insurance coverage they need for certain services.
“I conduct psychosocial evaluations of every patient and family that gets admitted to the service, and insurance companies often utilize these evaluations as part of the transplant authorization.In line with general social work practice, I am constantly assessing for safety and risk, access to resources, mental health, financial concerns, and available support networks.”
Patient and Family Education, Counseling, and Therapy
Patient education is one of the most important responsibilities that medical social workers have in health care settings. Grappling with a disease, injury, or other medical condition can be confusing and deeply stressful for patients and their loved ones. Medical social workers explain to patients the causes, effects, and progression of their illness. After receiving information about patients’ treatment options from the medical team, medical social workers also communicate and discuss these options with patients and their families. They also provide updates to patients and their families regarding any changes in their treatment plan.
In describing her work with pediatric bone marrow transplant patients, Ms. Beitch described,
“I help explain to the patients with age-appropriate language the reason they are in the hospital and getting this type of treatment, and I also support the siblings. With my Child Life Specialist colleagues, we prepare patients for certain procedures and teach them strategies to reduce anxiety, depression, and stress. I help the medical team understand a family’s cultural perspective; and help a family understand the medical team’s recommendations and treatment plan.”
Medical social workers also provide emotional support and psychotherapy if needed to patients and family members who are experiencing emotional distress as a result of the diagnosis. Types of psychotherapeutic methods that medical social workers may use to support patients and their families can include supportive psychotherapy, cognitive behavioral therapy, mindfulness based stress reduction, and problem solving therapy. Ms. Beitch shares her approach to providing therapy to pediatric patients:
“In my clinical work, I utilize the techniques and spirit of motivational interviewing. My goal is to stay very patient-focused and draw on the person-in-environment model. If anxiety becomes a problem for a patient, I introduce stress-reduction techniques such as deep breathing and visualization. With parents, I encourage self-care and mindfulness activities to help with the stress and strain of hospital life. Mostly, I engage in active listening, provide emotional support and validation, and bear witness to the challenges and triumphs of our families.”
Medical social workers may also work with populations that are faced with mental health disorders and/or substance abuse. In talking about her work in the trauma unit at John Muir Medical Center, Ms. Allen noted, “Statistics show that many trauma patients who arrive do test positive for alcohol or drugs, and so the social worker does a lot of substance use counseling while the patient is admitted.” Substance abuse counseling and therapy may include methods such as harm reduction techniques, cognitive behavioral therapy, dialectical behavioral therapy, and motivational interviewing.
Medical social workers help patients and their families understand the resources that are available to them within the hospital setting as well as in the community. In her interview with OnlineMSWPrograms.com, Ms. Toledo elaborated on her work in connecting clients to the resources and services they need within and outside of Satellite Healthcare.
“I help with assuring they have the resources necessary to get to/from treatment, transportation, helping them assure their insurance is in order, applying for our financial assistance programs if they cannot afford payment of their treatments, referring them to MediCare (as an ESRD patient, they qualify for MediCare regardless of age). I help with coordinating with primary care physicians in getting referrals to physical therapy or home health safety evaluations, referring them to CalFresh food stamps, food banks, homeless shelters, low-income housing, mental health providers, vocational rehabilitation programs, and kidney transplant wait lists and evaluations.”
Through her work with the Asthma Start Program, Ms. Silva connects asthmatic children and their families to the supplies and medication they need during her home evaluations and follow-ups. “I assess any need for supplies such as dust-mite proof mattress covers or a vacuum and bring them to my next visit,” she said.
Ms. Allen also elaborated on how medical social workers connect their clients with a variety of resources according to their individual situation and needs. “[Social workers] provide counseling for adjustment to illness, and also help patients navigate the system so they can sign up for insurance and receive medical care once they are discharged,” she explained.
As she often works with patients in the trauma unit, Ms. Allen must frequently connect them to resources to help them transition upon their discharge from the hospital.
“Some of our trauma patients are elderly and suffer from falls, and then they become very sick and the social worker can help transition them to hospice if that is their wish to do so. Many trauma patients are gang-affiliated, and the social worker works with those patients to help the patient plan for a safe discharge, connect them to victim of violence resources, and connect them to our Beyond Violence program which is an outpatient program that works with our patients to stop the cycle of violence.”
Medical social workers also implement crisis interventions when necessary, helping patients and their families cope with tragedy, emergency situations, and moments of acute stress. For patients and families who are coping with a terminal illness, medical social workers provide grief counseling, therapy, and referrals to additional mental health support.
Ms. Barnhardt explained the different crisis intervention services she provides as a pediatric social worker at LPCHS:
“Many families are in crisis mode and I provide crisis intervention services which would include general support, resources, referrals to appropriate agencies or services within the hospital, specific steps to follow (like homework), suicide assessments, and even walking parents to the ED for mental health assessments if needed. At times it is important to discuss death, dying, grief and bereavement.”
In some medical settings, such as the emergency room or the trauma unit of a hospital, patients may struggle with substance abuse, severe mental health issues, conflicts with family, or domestic/sexual abuse issues upon their admittance into a hospital or other medical setting. Specific to these individuals experiencing hardships, medical social workers help patients resolve or manage these issues in the moment and over time.
“In talking about the ER, it’s difficult to write about all the different things they need us for in the ER, but here are some of things we most normally do: grief support for death, adult and child abuse, rape/sexual assault, substance use, homelessness, hospice patients, patients who are unsafe at home (frequent falls), suicidal patients, patients with mental health issues, and uninsured patients who need help with follow-up. In the ER, the main difference is that everything is crisis oriented, so you just have to focus on what needs to be done now, and what is the plan.”
All of the responsibilities described above fall under care coordination, which is defined as the effective organization and delivery of medical care to patients. By bringing patients’ mental, emotional, familial, and social concerns into their treatment plan medical social workers ensure that patients receive a more holistic, compassionate, and efficient form of care that improves overall health outcomes. Medical social workers are an integral part of the care coordination team in many medical environments.
Other care coordination duties that medical social workers fulfill include serving as a point of contact between different teams within the health care setting, ensuring that facilities adequately serve patients’ needs, and coordinating patients’ movement from different units or from one medical setting to another (ex. hospital discharges or transfers to a different ward).
Medical social work is a challenging field, as social workers must balance the needs of many patients and also manage the demands of stakeholders on the larger medical team. Ms. Barnhardt noted how one challenge of her role at LPCHS is feeling pulled in many different directions at once.
“Communication is challenging because I am working with interns, residents, fellows and attending physicians from multiple teams each day. At times it is difficult to know and understand what each team is doing and what the plan of care for the patient is. It is important to attend rounds when able, arrange care conferences as needed and seek out the medical teams for updates and information when appropriate. It is also very important that I communicate any psychosocial concerns or issues with the medical team as these issues can affect the discharge plan.”
Witnessing and helping patients work through physical, mental, and emotional trauma and hardship can also be deeply stressful, as the stakes for the patient, the family, and the medical team are high. Particularly in acute care medical settings, the work can be emotionally taxing. “Some of the most challenging aspects of my job include communication, meeting expectations, meeting administrative demands, and for me, when a patient dies,” Ms. Barnhardt noted.
Frustration with administrative and systematic barriers to patient care is also a challenge that some social workers voiced. Ms. Silva, who works with the Asthma Start Program notes challenges she has faced in helping her clients:
“[A] big challenge that we face is in dealing with landlords that do not want to take the time or spend the money on repairs that are needed in the home to make it a healthy home for people with asthma. In this case we are forced to turn to the city for further intervention. […] I would say to those looking to go into the public health department that they need to learn how to be an advocate for their clients and not be intimidated by those in power.”
The stress that medical social workers feel can also have an effect on their physical well-being. Ms. Allen shares what she believes to be the most challenging part of her role at the medical center:
“The most challenging aspect of the job is the stress of the job. Stress brings on lots of headaches, back aches, and just overall exhaustion at the end of the day. Sometimes I just have to lay down and take an hour nap when I get home before I begin with my evening because I am just so emotionally and physically exhausted. I feel as if there is no real preparation for this, and I am still honestly trying to find my own way of coping with the stress of the job.”
Many medical social workers recommend a consistent self-care plan. “It is important when working in a pediatric hospital setting to know yourself. Look into yourself and acknowledge what might produce countertransference or open old wounds,” Ms Barnhardt advised, “Remind yourself how you handle stress and determine a plan of how you would relieve stress after a challenging day. Try to remember why you wanted to be a pediatric social worker in the hospital setting.”
Medical social work, while demanding, gives individuals a unique opportunity to connect with people in deeply meaningful and at times unforgettable ways. “The rewarding aspects of my job are that I am able to follow patients and families through their experience, from diagnosis to sometimes death,” Ms. Barnhardt said of her work as a pediatric social worker, for which she won a Gold Rose Award, which is an award granted to people in helping professions for excellence in service.
“I am able to support them through the ‘roller coaster’ that is pediatric illness. I sometimes watch patients improve and go home, never to return again. Other times I see patients during each admission as they transition from being ‘intensive care’ to being ‘acute’ and then going home, only to return again in the future. And then there are the other times, where I have developed a wonderful working relationship with a family, having seen them through many obstacles, only to be at a place that is the end. This is a very difficult time, but it means so much, to be there with a family through the last steps of hope, through the grief, the loss, and the time of bereavement, knowing that I made a difference, just from being there with them during that time.”
The concrete and, at times, dramatically positive impact that medical social workers can have on their patients’ health outcomes can also be rewarding and highly motivating.
“When I first heard about this position I was excited to learn more about asthma and to work in a public health setting. One of the rewarding experiences I have had at this job includes having success with getting my clients a medical home and health insurance so they remain healthy. […] Our program has reduced ER visits and hospitalizations by more than 50 percent. This makes me proud and happy to be doing what I do. I intend on staying with the program for years to come.”
After working in the hospital since age 16 and as an EMT in the emergency room for several years, Ms. Allen decided to become a medical social worker after meeting a mother and her child who was in need of medication for a seizure disorder. “I knew that I wanted to help patients in a tangible way,” she said, “I wanted to fight with insurance companies, advocate for patients, and try to go to any length to help that mother get that seizure medication.”
Some medical social workers have very personal motivations for entering the field,
“I decided to become a medical social worker because at 16 I was diagnosed with leukemia and I had a great social worker assigned to me at UCSF. my 2.5 years of treatment she followed my case and that is where I discovered what social work was for the first time. The types of things she assisted with all appealed to my strengths and what I enjoy doing–helping people and working with kids. That is when I decided to pursue medical social work as a career and I have a very specific goal of one day working in the pediatrics oncology department of a hospital because I will be able to speak the same language as my patients and have a deeper understanding of what they are going through.”
Medical social workers recommend a combination of solid academic preparation and internships or professional experience in a medical setting for individuals interested in entering this field.
Field Placement in a Hospital
“For MSW students who are interested in medical social work, I HIGHLY recommend they do at least one of their internships in a hospital,” Ms. Allen said, “I know firsthand that it is very difficult to get hired with no hospital experience.”
Ms. Toledo similarly recommended that students actively seek field placements in medical settings:
“I definitely recommend getting a field placement in a hospital or clinic because otherwise you will not have the experience that is practically necessary to get a job as many healthcare settings will require at least a year of experience in healthcare. I also recommend volunteering with organizations related to the medical field.”
If social workers or students are unable to complete their field practicums in a medical environment, they should try to find professional or volunteer opportunities in these settings, even if they are not related specifically to social work. Ms. Allen explained to OnlineMSWPrograms.com how being familiar with medical terms and workflows is highly important:
“[T]he more medical experience the better. Because it’s not just the medical social work job a person has to learn, but they also have to learn how a hospital works, medical terminology, and how to belong on a medical team. Like when you sit down for rounds and the information says–Doe, John, 36M, fx L femur, TBI, SDH. Hx: DMII, HTN. You better know that they are saying, ‘John Doe is a 36 year-old male with a fractured left femur, traumatic brain injury, and subdural hematoma. He has a history of type 2 diabetes and hypertension.”
Research CSWE-accredited MSW Programs for Medical Specializations
Most medical social worker positions require that candidates are prepared at the master’s level, due to the intense nature of the work and the expertise required to navigate complex patient situations. Individuals interested in entering this field of social work should therefore research MSW programs that are CSWE-accredited and which provide classes on subjects that are relevant to medical environments.
Classes that prospective medical social workers should consider taking include but are not limited to courses on clinical social work methods and therapeutic modalities (such as motivational interviewing, strengths-based therapy, problem solving therapy, and substance abuse counseling), as well as courses on specific issues that medical social workers encounter on the job, such as death and dying, grief and bereavement counseling, crisis interventions, child abuse and neglect, and family dynamics.
While some MSW programs provide concentrations specifically in health care or medical social work, students do not necessarily need to concentrate in medical social work during their MSW program to qualify for roles in health care settings. “[A]t UC Berkeley we have a “health” division within the social work school, and this is where many people go to pursue medical social work,” Ms. Allen noted, “But there are many other students in children and families and mental health concentrations who end up with a second year hospital internship, and then get hired on at a hospital.”
The medical social workers whom we interviewed emphasized how individuals considering this field should work to build self-awareness, as well as strong and supportive relationships before, during, and after their graduate social work program. Ms. Beitch shares her advice on learning more about medical social work and yourself:
“My advice is to get out in the world and practice this kind of work before you really commit to it as a career. It is very taxing. Get to know yourself and your triggers and vulnerabilities before engaging in intense relationships where people’s emotions and lives are at stake. In terms of sustainability, I’ve learned that even more important than the population I work “for” is the team that I work with. My colleagues are the ones who will support me day in and day out, year after year. I trust in them completely and feel so fortunate to be on a team with them. Therapy and supervision have been so completely necessary for me emotionally and professionally. And my friends from social work school are my saviors.”
The knowledge, expertise, and commitment that medical social workers bring to their work with patients and their families help health care facilities deliver high quality and compassionate healthcare to people in need. Through sound academic preparation, internship and volunteer experiences, a strong support network, and consistent self-evaluation and self-care, medical social workers can maintain resilience and energy when tackling the daily challenges of this deeply necessary field of work.
About the Author: Kaitlin Louie is a content writer and editor who writes articles for OnlineMSWPrograms.com. She received her bachelor's and master's degrees in English from Stanford University, and aspires to be an author of fiction and creative non-fiction.