The integration of gender in medical research and education-obstacles and possibilities from a Nordic perspective

Research on women's issues in medicine was developed in the Nordic countries from the beginning of the 1980s. The theoretical developments led to a change of concepts from women's health to gender research, within which the structurally organised relations between men and women are analysed. Over the last decades, gender research has slowly been established in medical faculties, as a result of a strong political commitment for increased research and integration of gender issues in the university curriculum in Sweden. The government has made substantial investments in order to stimulate gender research and education in different disciplines, with special focus on medicine. Academic medicine has responded to this development with different strategies, including resistance and redefining concepts. Gender research has slowly become integrated into both research and teaching within Nordic academic medicine, although the pathway has not been easy. Gender research has had political support but there is a risk of backlash. Medical students' reactions to gender education can be compared with academic medicine's reactions towards gender research. Obstacles and possibilities are described in relation to teaching gender in schools of medicine. Most important is to recognise the risks for increased gender stereotypes and increased essentialism among the students, unless gender is taught from a theoretical perspective.

The Balanced Budget Act of 1997 and the financial health of teaching hospitals

BACKGROUND

We wanted to evaluate the most recent, complete data related to the specific effects of the Balanced Budget Act of 1997 relative to the overall financial health of teaching hospitals. We also define cost report variables and calculations necessary for continued impact monitoring.

METHODS

We undertook a descriptive analysis of hospital cost report variables for 1996, 1998, and 1999, using simple calculations of total, Medicare, prospective payment system, graduate medical education (GME), and bad debt margins, as well as the proportion with negative total operating margins.

RESULTS

Nearly 35% of teaching hospitals had negative operating margins in 1999. Teaching hospital total margins fell by nearly 50% between 1996 and 1999, while Medicare margins remained relatively stable. GME margins have fallen by nearly 24%, however, even as reported education costs have risen by nearly 12%. Medicare + Choice GME payments were less than 10% of those projected.

CONCLUSIONS

Teaching hospitals realized deep cuts in profitability between 1996 and 1999; however, these cuts were not entirely attributable to the Balanced Budget Act of 1997. Medicare payments remain an important financial cushion for teaching hospitals, more than one third of which operated in the red. The role of Medicare in supporting GME has been substantially reduced and needs special attention in the overall debate. Medicare + Choice support of the medical education enterprise is 90% less than baseline projections and should be thoroughly investigated. The Medicare Payment Advisory Commission, which has a critical role in evaluating the effects of Medicare policy changes, should be more transparent in its methods.

Saving nurses, saving patients: responses to the labor crisis

While numerous task forces have spent enormous time and energy studying the size and scope of the nursing shortage, other organizations have been hard at work solving the difficulties faced by nurses and reducing the effects of the labor shortages on patient care. These efforts range from national legislative activities to grassroots innovations. Many of these efforts have already produced tangible results and take the form of major investments in professional development and improvements to the workplace environment. Physicians play an important role in the hospital work environment and can affect teamwork, a clear driver of nurse satisfaction.

Child welfare knowledge transmission, practitioner retention, and university-community impact: a study of Title IV-E child welfare training

This paper describes the implementation of a Title IV-E child welfare training program in Louisiana. A collaborative arrangement between the state child welfare agency and seven state university social work programs provides for student monetary stipends in return for child welfare training and work as public child welfare employees upon graduation. On a test of child welfare knowledge, students in MSW and BSW programs scored higher following child welfare training; BSW student stipend recipients made greater gains than non-recipients when controlling for initial scores. MSW students' results appear to approach significance; they may not be significant due to low power of the statistical analysis. Child welfare agency retention of the stipend student graduates is considered good by the agency.

A follow-up of a Title IV-E program's graduates' retention rates in a public child welfare agency

OBJECTIVE

Examine retention rates of a Title IV-E program's graduates in a public child welfare agency.

METHOD

The sample consisted of all workers (N = 266) hired between June 1994 and June 1997. Subjects were followed until 12/31/99 in order to ascertain employment status. Data for study were abstracted from agency personnel files.

FINDINGS

Title IV-E trained social workers had longer periods of tenure than non-IV-E trained employees (p < .057). Other predictors that were significant or approaching significance included Spanish speaking (p < .007), having an MSW (p < .0245), being rehired by the agency (p < .052), and being promoted to social from Income Maintenance (p < .061).

CONCLUSIONS

The retention finding is encouraging because it may mean child welfare agencies may improve their human capital through programs like IV-E. Recruiting Spanish speaking social workers or upgrading existing workers' language skills may increase retention in child welfare. Promoting from within coupled with upgrading skills through training programs like IV-E may also be a solution to the staffing crisis.

Factors influencing the retention of specially educated public child welfare workers

Although public child welfare has historically been a major employer of professional social workers, within the last twenty years MSW graduates have shunned public social services for the private sector. Using Title IV-E funds, universities have responded to this shortage by providing financial and educational incentives for graduate social work students to work with the diverse and complex cases in public child welfare. As a result, the numbers of graduate social workers seeking employment in public child welfare have increased, but questions remain about the extent to which professional social workers remain employed in public child welfare agencies beyond their employment payback period. This paper reports the results of one research study on the factors that affect the retention of these master's level child welfare workers.

Career paths and contributions of four cohorts of IV-E funded MSW child welfare graduates

For the last decade the federal government has provided financial support through Title IV-E of the Social Security Act to schools of social work to provide professional education in child welfare. This study looks at the first four cohorts of graduates who received IV-E funding from one school of social work. Data on MSW graduates from 1993-1996 (N = 73), as well as survey responses (N = 32), were analyzed to ascertain dimensions of their career development in, and contributions to, child welfare social work. Results indicate that the vast majority of graduates funded by IV-E dollars became employed in and stayed in child welfare focused social work, with a strong percentage in public child welfare services, and that these social work-educated social workers are actively involved in shaping the practice, policies and administration of child welfare services.

Examination of racial imbalance for children in foster care: implications for training

Concerned with the high number of African American children in out-of-home care in an East Texas county, the regional administrator of a state public child welfare agency asked its IV-E partnered university to examine the kinds of training the agency might need to address the problem. A semi-annual time-series model from January 1997 to June 1999 was constructed to track the proportion of African American children at three critical case junctures: investigation, case opening, and removal of the child to out-of-home care. In addition, the study analyzed characteristics of the county's population, including racial changes and poverty. The study found that African American children were referred to public child welfare at twice the rate of Anglo children, with the ratio increasing during case progression. The study also found a higher proportion of African American children in the community and a higher poverty rate, particularly for African American children, than what was previously understood. The study not only provided details of racial distribution over time and over case disposition, but also highlighted the importance of understanding problems within a community and organizational context. The study further suggests that training include generalist and advanced generalist social work education, considering practice with systems of all sizes, to assess, prevent, treat and evaluate interventions designed for the safety, permanency and well-being of children.

Evaluating federally-funded child welfare training partnerships: a worthwhile challenge

This article assesses the state of evaluation research on federally-funded child welfare training, including both Section 426 and Title IV-E partnerships. The article discusses the need for stronger evaluations of child welfare training and describes some factors which may have impeded past evaluation efforts. It recommends strengthening evaluations of federally-funded child welfare training through well-targeted questions, strong research designs, strong research methods, innovative methods, and theory-driven studies. The article concludes by promoting the development of child welfare research and training centers.

Facing the challenge of a changing system: training child welfare workers in a privatized environment

The state of Kansas' implementation of a privatized child welfare system is arguably an ambitious shift in child welfare service delivery. In an attempt to drastically improve services to vulnerable families, privatization resulted in intended and unintended consequences for the child welfare workforce. Some of these consequences, including the influx of inexperienced new workers, high worker turnover, and managing relationships with multiple partners, are issues that affect training needs of child welfare professionals. The following paper offers one approach to addressing these needs as well as identifying the challenges involved in training in a privatized environment.

Tracking process and outcome results of BSW students' preparation for public child welfare practice: lessons learned

A Texas university/agency partnership program to prepare social work students for public child welfare conducted an exploratory study of the process and outcome results of the program's efforts from 1989-99 and offers recommendations to other university/agency programs. The evaluation plan was multi-faceted, and the evaluation included both process and outcome components from the perspectives of each stakeholder-the agency, the university, the students, the clients, and the taxpayers. The paper concludes with recommendations for the future. The partnership acknowledges that these evaluation results have limitations and are not generalizable beyond this specific partnership. The lessons learned in this university/agency partnership are first steps in developing better partnerships to prepare students for public child welfare practice.

[Is continuing medical education under suspicion of corruption? Contribution to the discussion by the Committee for Quality Preservation of the Swiss Society of Gynaecology and Obstetrics]

The requirements laid down by law and by the medical profession itself with regard to continuing medical education have recently been tightened. The cost of good training is high, both in time and money. Sponsoring, especially by the pharmaceutical industry, has helped to keep costs down for individual participants. The question of a tariff system for the payment of compulsory training is now being raised. Rates have been set to ensure that, in the future, indirect costs are covered. In the event of a full tariff-based payment of costs being introduced, various disadvantages could be expected both for participants and the quality of the training. Changes in Swiss criminal law and the new medicines act do not forbid sponsoring, but they do call for rules of professional ethics and of personnel law in public hospitals governing behaviour in respect of funding by sponsors. Various sponsoring models are conceivable with differences in allocation to organizers, individual participants or distribution via a pool system. There are strong arguments in favour of continuing the existing practice of mixed funding by participants and sponsoring, provided that it is subject to certain rules of transparency. What is lacking to date is a political decision on the issue of funding for continuing medical education.

The effects of the 1997 Balanced Budget Act on family practice residency training programs

BACKGROUND AND OBJECTIVES

This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residency training programs in the United States.

METHODS

We surveyed 453 active family practice residency programs, asking about program closures and new program starts (including rural training tracks), changes in the number of residents and faculty, and curriculum changes. Programs were classified according to their urban or rural location, university or community hospital setting, and rural and/or urban underserved mission emphasis.

RESULTS

A total of 435 (96%) of the programs responded. Overall, the impact of the BBA was relatively small. In 1998 and 1999, nationwide, there were 11 program closures, a net decrease of only 82 residents, and a net increase of 52 faculty across program settings and mission emphasis. The rate of family practice residency program closures increased from an average of 3.0 per year between 1988-1997 to 4.8 per year in the 4 years following passage of the BBA.

CONCLUSIONS

The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue.