Research Department Publications 2014

Anderson, B.L., & Schulkin, J (eds.). (2014). Numerical reasoning in judgments and decision making about health. Cambridge: Cambridge University Press.

Every day thousands of individuals need to make critical decisions about their health based on numerical information, yet recent surveys have found that over half the population of the United States is unable to complete basic math problems. How does this lack of numerical ability (also referred to as low numeracy, quantitative illiteracy or statistical illiteracy) impact healthcare? What can be done to help people with low numeracy skills? Numerical Reasoning in Judgments and Decision Making about Health addresses these questions by examining and explaining the impact of quantitative illiteracy on healthcare and in specific healthcare contexts, and discussing what can be done to reduce these healthcare disparities. This book will be a useful resource for professionals in many health fields including academics, policy makers, physicians and other healthcare providers.

Anderson BL, Urban RR, Pearlman M, Schulkin J (2014). Obstetrician-gynecologists’ knowledge and opinions about the United States Preventive Services Task Force (USPSTF) committee, the Women’s Health Amendment, and the Affordable Care Act: national study after the release of the USPSTF 2009 Breast Cancer Screening Recommendation Statement. Preventive Medicine, 59, 79-82.

Objective: Investigate the knowledge and opinions of obstetrician and gynecologists (ob-gyns) regarding the USPSTF committee and statement, and to assess their reactions to healthcare legislation.
Methods: A national cross-sectional survey study of ob-gyns was conducted six months after a controversial USPSTF recommendation statement was released in November 2009. Ob-gyns' opinions about the Women's Health Amendment (WHA) and the Affordable Care Act (ACA) were also assessed.
Results: A total of 54% of ob-gyns knew that the USPSTF recommendations do not represent the position of the U.S. government and 40% knew that the USPSTF is not comprised of federal employees. A majority (60%) thought that the USPSTF was influenced by potential costs more than guidelines should be. When examining ob-gyns opinions about new national health policies, 88% support the mammography coverage provided by the WHA but support for the ACA varied.
Conclusion: This study provides a snapshot of ob-gyns' knowledge and opinions about the USPSTF and breast cancer screening guidelines at a controversial point in time. Our findings are a unique contribution to larger efforts to understand health and political policy as the culture of medicine continues to evolve.

Anderson BL, Gigerenzer G, Parker S, Schulkin J.  (2014). Statistical literacy in obstetrics and gynecologyJournal for Healthcare Quality, 36(1), 5-17.

Physicians’ numeracy, the ability to use and understand numbers, has been overlooked.  We assessed physician numeracy skills on tasks that are relevant to their practice.  Physicians did poorly on the questions about numerical facts (e.g. number of women living with HIV/AIDS), better on questions about statistical concepts (e.g. incidence, prevalence) and best on questions about numerical relationships (e.g. convert frequency to percentage).  Almost all could translate between frequency and probability formats. About half were able to calculate the positive predictive value of a mammography screening test. 

Atanasov P, Anderson BL, Cain J, Schulkin J, Dana J. (2014). Comparing physicians personal prevention practices and their recommendations to patients. Journal of Healthcare Quality, epub ahead of print.

Background: Hypothetical choice studies suggest that physicians often take more risk for themselves than on their patient's behalf.
Objective: To examine if physicians recommend more screening tests than they personally undergo in the real-world context of breast cancer screening.
Design: Within-subjects survey.
Participants: A national sample of female obstetricians and gynecologists (N = 135, response rate 54%) from the United States. In total, they provided breast care to approximately 2,800 patients per week.
Measure: Personal usage history and patient recommendations regarding mammography screening and breast self-examination, a measure of defensive medicine practices.
Results: Across age groups, female physicians were more likely to recommend mammography screening than to have performed the procedure in the past 5 years (86% vs. 81%, p = .10). In respondents aged 40-49 this difference was significant (91% vs. 82%, p < .05), whereas no differences were detected for younger or older physicians. Among respondents in their 40s, 18% had undergone annual screenings in the past 5 years, compared to 48% of their colleagues above 50. Respondents were as likely to practice breast self-examination (98%) as to recommend it (93%), a pattern that was consistent across age groups. A logistic regression model of personal use of mammography significantly predicted recommending the procedure to patients (OR = 15.29, p = .001). Similarly, number of breast self-examinations performed over the past 2 years positively predicted patient recommendations of the procedure (OR = 1.31, p < .001).
Conclusions: Obstetricians and gynecologists tended to recommend early mammography screening to their patients, though their personal practices indicated later start than their own recommendations and lower frequency of screening than peers in recent studies have recommended.

Benn, P., Chapman, A.R., Erickson, K., DeFrancesco, M.S., Wilkins-Haug, L., Egan, J.F.X., & Schulkin, J. (2014). Obstetricians and gynecologists’ practice and opinions of expanded carrier testing prenatal testing. Prenatal Diagnosis, 34(2), 145-152.

Objective: The objective of this study is to assess the opinions of Fellows of the American College of Obstetricians and Gynecologists on expanded carrier testing (molecular detection of >100 genetic diseases of variable severity) and noninvasive prenatal testing (NIPT).
Methods: A survey conducted between March and August 2012, assessed current use of testing, provision of genetic counseling, types of disorders that should be identified, preferences for future use, ethical aspects, and views on regulatory oversight.
Results: Expanded carrier testing was offered to all patients by 15% of the responders and 52.1% upon patient request. Most (67.3%) favored testing only for mutations of known significance. In this study, 79.1% supported the use of NIPT as a screen for Down syndrome for all women with 47.9% viewing NIPT as a complete substitution for invasive testing. Most supported expansion to other aneuploidies (97.5%) and severe early-onset Mendelian disorders (90.4%) but not for adult-onset disorders (29.8%) or nonmedical sex identification (15.7%). A majority (73.2%) believed that NIPT would increase pregnancy terminations for mild disease states. Respondents favored a role for professional societies in providing regulatory oversight.
Conclusion: Rapid incorporation of new genetic technologies may be limited by the availability of genetic counseling, concerns regarding inclusion of clinically mild disorders, results of unknown significance, and costs.

Coleman-Cowger V, Anderson BL, Mahoney J, Schulkin J (2014). Smoking cessation during pregnancy and postpartum: Practice patterns among obstetrician-gynecologists. Journal of Addiction Medicine, 8(1), 14-24.

Objectives: To assess current obstetrician-gynecologist (ob-gyn) practice patterns related to the management of and barriers to smoking cessation during pregnancy and postpartum. Conclusions: Compared with findings from a similar study conducted in 1998, physicians are less likely to adhere to the 5 A’s smoking cessation guideline at present. As we know that brief intervention is effective, it is imperative that we work toward addressing practice gaps and providing additional resources to address the important public health issue of smoking during pregnancy and postpartum.

Domjahn B, Hlavsa MC, Anderson BL, Schulkin J, Leon J, Jones JL. (2014). A Survey of U.S. Obstetrician-Gynecologists’ Clinical and Epidemiological Knowledge of Cryptosporidiosis in Pregnancy. Zoonoses and Public Health, epub ahead of print.

Although cryptosporidiosis is frequently diagnosed in the U.S., there has been very little assessment of obstetrician-gynaecologist knowledge about this disease. In 2010, we surveyed U.S. obstetricians about the diagnosis, treatment and epidemiology of cryptosporidiosis. Among other results, only 44.4% of respondents correctly identified that prolonged, intermittent diarrhoea would lead them to consider cryptosporidiosis in a differential diagnosis. The low level of knowledge among obstetrician-gynaecologists about cryptosporidiosis showed in this study indicates a need to develop resources for physicians about all aspects of cryptosporidiosis, particularly on diagnosis, treatment and prevention strategies.

Donnelly, J.C., Raglan, G.B., Bonanno, C., Schulkin, J., & D’Alton, M.E. (2014). Practice patterns and preferences of obstetricians and gynecologists regarding thromboprophylaxis at the time of cesarean section. The Journal of Maternal-Fetal & Neonatal Medicine, epub ahead of print.

Objective: Our survey aimed to identify knowledge and application of guidelines in the United States by assessing practicing obstetricians and gynecologists (OBGYN) use of thromboprophylaxis, preferred methods, and whether their type of practice influenced their choices. Conclusion: Awareness of the risk of thromboembolism around delivery by cesarean section is high amongst OBGYN practitioners. Broadening guidelines to encompass all deliveries, not only caesareans, with a focus on identifying the patient at risk, would likely be successful.

Ekert LO, Anderson BL, Gonik B, Schulkin J. (2014).  Reporting Vaccine Complications: What do obstetricians and gynecologists know about the Vaccine Adverse Event Reporting System? Infectious Disease in Obstetrics and Gynecology, Article ID: 285257, epub ahead of print.

Background. Obstetrician-gynecologists are increasingly called upon to be vaccinators as an essential part of a woman's primary and preventive health care. A national Vaccine Adverse Event Reporting System (VAERS) is a well-established mechanism to track adverse events, and this study examined obstetrician-gynecologist familiarity and use of this system. Conclusions. Obstetrician-gynecologist familiarity with VAERS is lacking. Only when the obstetrician-gynecologist is completely knowledgeable regarding standard vaccine practices, including the availability and use of programs such as VAERS, will providers be functioning as competent and complete vaccinators.

Farrow, V.A., Lawrence, H., & Schulkin, J. (2014). Women’s healthcare providers’ range of services and collaborative care. Journal of Healthcare Quality, 36(2), 39-49.

Physician shortages and healthcare reform are important topics in the healthcare field today. The utilization of the skills and professional competencies of nonphysician healthcare providers, as well as collaboration between physicians and nonphysician healthcare providers may in part provide a solution to some current healthcare concerns. The purposes of this study were to describe the range of services provided by nonphysician women's healthcare providers (WHCPs), and to begin to explore the collaborative relationship between obstetrician-gynecologists (ob-gyns) and WHCPs. Questionnaires were sent to ob-gyns, certified nurse-midwives, certified midwives, nurse practitioners (NPs), and physician's assistants (PAs) with questions regarding the types of services WHCPs provide, as well as collaboration between ob-gyns and WHCPs. Overall, 62.1% of ob-gyns employ WHCPs. NPs are the most common type of WHCP employed in our sample. WHCPs are more likely to be younger than ob-gyns, and an overwhelming majority of WHCPs in our sample are female. Most reported that they are anticipating an expansion in the roles and services they provide over the next 5 years. In an era of healthcare reform, WHCPs may in part provide a solution to the growing physician shortage. Collaboration between ob-gyns and WHCPs is a key aspect of the changing healthcare environment.

Gaissmaier W, Anderson BL, Schulkin J. (2014). How do physicians provide statistical information about antidepressants to hypothetical patients? Medical Decision Making, 34(2), 206-15.

Background: Little is known about how physicians provide statistical information to patients, which is important for informed consent. Conclusions: Most physicians did not provide complete and transparent information. Clinicians who presented consistent information to different patients tended to present complete information, whereas those who varied what information they chose to present appeared more prone to nudging.

Goldenberg RL, Farrow V, McClure EM, Reddy UM, Fretts RC, Schulkin J. (2013). Stillbirth: Knowledge and practice among U.S. obstetrician gynecologists. American Journal of Perinatology, 30(10), 813-20.

Objective: To determine knowledge of U.S. obstetrician-gynecologists (OBGYNs) and individual and institutional practices regarding stillbirth. Conclusions: OBGYN knowledge and institutional practice regarding stillbirth could be substantially improved. Residency programs need improved education regarding stillbirth. Hospitals and their OBGYN departments should focus more on stillbirth through continuing education programs and grand rounds and develop stillbirth management protocols and standardized order sheets to appropriately evaluate stillbirths. Audits that evaluate cause of death and preventability with a feedback loop focused on improvement in care should be considered.

Jones, K., Schmidt, L.A., Schulkin, J. (2014) Shyness. PSYCHOLOGY 5:244-254.

Decades of research on the study of introversion and extraversion have allowed researchers to distinguish among individual differences on each of these dimensions. Research indicates that shyness, a rather common personality trait, is a construct that is related, but not identical, to introversion. Once regarded as a unitary construct, modern day personality theorists propose that shyness is based on a number of orthogonal dimensions. Empirical evidence suggests that distinct subtypes of shyness develop as a result of differences in social approach and social avoidance behaviors. Temperamental shyness is a risk factor for behavioral and affective problems, as well as more severe psychological problems. This article focuses on the phenomenon of shyness by reviewing its subtypes, psychosocial correlates, and efficacious treatment interventions.

Leddy, M., Farrow, V., Schulkin, J. (2014) Obstetrician-gynecologists’ knowledge, attitudes, and practice regarding elder abuse screening. Women’s Health Issues 24: e455-e464.

Background: Elder abuse is a prevalent and growing social problem with significant consequences on victims’ mental and physical health. Unfortunately, many cases of elder abuse go unreported. Elderly women are at increased risk for abuse and, as such, obstetrician-gynecologists (OB/GYNs) are in a unique position to screen for and report abuse. This study intended to determine OB/GYNs’ knowledge, attitudes, and practice regarding elder abuse.

Methods: Two hundred Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists (ACOG) received a survey. Analysis was completed with SPSS 20.0. In addition to descriptive statistics, c2 analyses were used to determine differences between groups.

Findings: In total, 122 fellows responded (61%). Abuse screening rates differed by abuse type. Few “always” screen for abuse, with half assessing only when it is suspected. Most (81%) had never reported a case of abuse. Younger males reported different clinical practice patterns than other groups. Generally, OB/GYNs were knowledgeable about risk factors and facts about elder abuse, but several knowledge gaps were identified. Most reported that elder abuse screening is within their professional purview. Half of the respondents cited time constraints as a barrier to screening. Conclusions: Greater education about elder abuse screening is needed. Specifically, training regarding available valid and brief screening tools, local abuse reporting laws, and available community resources. This study identified the potential need to target younger male OB/GYNs for additional training.

Luchowski A, Anderson BL, Power M, Raglan GB, Espey E, Schulkin J. (2014). Obstetrician–Gynecologists and Contraception: Practice and Opinions about the use of IUDs in Nulliparous Women, Adolescents, and Other Patient Populations. Contraception, 89(6), 572-577.

Objectives: This study examined obstetrician-gynecologists’ practices and opinions about the use of IUDs in adolescents, nulliparous women, and other patient groups, as well as for emergency contraception. Conclusions: Although most obstetrician-gynecologists offer IUDs, many exclude appropriate candidates for IUD use, both for emergency contraception and for longterm use despite evidence-based recommendations. Implications: This study shows that obstetrician-gynecologists still do not offer IUDs to appropriate candidates, such as nulliparous women and adolescents, and rarely provide the copper IUD as emergency contraception.

Luchowski A, Anderson BL, Power M, Raglan GB, Espey E, Schulkin J. (2014). Obstetrician–Gynecologists and Contraception: Long-Acting Reversible Contraception Practices and Education. Contraception, 89(6), 578-583.

Objectives: This study examined obstetrician-gynecologists’ knowledge, training, practice, and beliefs regarding LARC methods. Conclusions: Barriers to LARC provision could be reduced if more obstetrician–gynecologists received implant training and provided same-day IUD insertion. Continuing education will likely increase implant provision. Implications: This study shows that obstetrician–gynecologists generally offer IUDs but fewer offer the single-rod contraceptive implant. Recent continuing education strongly predicted whether obstetrician–gynecologists inserted implants and was also associated with other practices that encourage LARC use.

Power ML, Schulkin J. (2013). Maternal regulation of offspring development in mammals is an ancient adaptation tied to lactation. Applied Translational Genomics, 2, 55-63.

The developmental origins of health and disease (DOHaD) is a paradigm for understanding metabolic diseases of modern humans. Vulnerability to disease is linked to perturbations in development during critical time periods in fetal and neonatal life. These perturbations are caused by environmental signals, often generated or transduced by the mother. The regulation of mammalian development depends to a large extent on maternal biochemical signals to her offspring. We argue that this adaptation is ancient, and originated with the evolution of lactation. Lactation evolved earlier than live birth and before the extensive placental development of modern eutherian mammals. Milk contains a host of signaling molecules including nutrients, immunoglobulins, growth factors and metabolic hormones. As evidenced by marsupials, lactation originally served to supply the biochemical factors for growth and development for what is essentially a fetus to a weanling transitioning to independent existence. In placental mammals maternal signaling in earliest life is accomplished through the maternal–placental–fetal connection, with more of development shifted to in utero life. However, significant development occurs postpartum, supported by milk. Mothers of all taxa provide biochemical signals to their offspring, but for non-mammalian mothers the time window is short. Developing mammals receive maternal biochemical signals over an extended period. These signals serve to guide normal development, but also can vary in response to environmental conditions. The ancient adaptation of lactation resulted in a lineage (mammals) in which maternal regulation of offspring development evolved to a heightened degree, with the ability to modify development at multiple time points. Modern metabolic diseases may arise due to a mismatch between maternal regulation and eventual circumstances of the offspring, and due to a large proportion of mothers that exceed past evolutionary norms in body fat and pregnancy weight gain such that maternal signals may no longer be within the adaptive range.

Raglan, G.B., Lawrence III, H., & Schulkin, J. (2014). Obstetrician/Gynecologists care considerations: Practice changes in disease management with an aging patient population. Women’s Health, 10(2), 155-160.

Demographic changes across the country are leading to an increased proportion of older Americans. This shift will likely lead to changes in the patient population seen by obstetrician/gynecologists (ob/gyns), and practices may need to adapt to the needs of older women. This paper looks at mental health, sexual health, bone loss, cardiovascular disease, and cancer as areas in which ob/gyns may experience changes with the increasing age of patients. While this is by no means a comprehensive list of changing areas of practice, it offers a guide for reflecting on the future of ob/gyn training, and the importance of considering the needs of older patients in practice.

Raglan, G.B., Margolis, B., Paulus, R.A., & Schulkin, J. (2014). Electronic health record adoption among obstetrician/gynecologists in the United States: Physician practices and satisfaction. Journal for Healthcare Quality, epub ahead of print.

Background: This study aimed to explore the experiences of obstetrician/gynecologists (ob/gyns) with regard to the use of electronic medical record (EMR) systems in practice. Results: The majority of ob/gyns who used an EMR reported being satisfied with that system (59.5%). The most commonly reported impediments to EMR use were time needed, ineffective templates, note quality, interference with patient interactions, and expense. The most commonly cited positive were e-scribing, efficiency, and ease of access to notes including legibility. Conclusions: In spite of increased adoption of EMR systems, more work is needed to improve ob/gyn satisfaction with EMR systems.

Schulkin, J. (2014) Pragmatic naturalism and Social Cooperation. Journal of Speculative Philosophy 28: 52-78.

A profound sense of biological explanations and social nature of our species were appreciated by Chauncey Wright and American classical pragmatists. Inquiry was understood in the context of social cooperation. One achievement in the evolution of cephalic function is the development of social cooperative behaviors, the cornerstone of our cultural productivity. Classical pragmatism is linked to an expanding sense of human capability, tied to the depending of human experience. While pragmatism is open-ended, the limits of human function put our advances into a perspective in which the evolution of function is just as apparent as the devolution of function.

Vink J, Anderson BL, Fuchs K, Schulkin J, D'Alton ME. (2013). Opinions and practice patterns of obstetricians-gynecologists regarding amniocentesis in twins. Prenatal Diagnosis, 33(9), 899-903.

Objective: Accurate amniocentesis-related pregnancy loss (ARL) rates for twin gestations remains elusive because of varying ARL definitions in the literature. We examined how OB/GYNs define/counsel women carrying twins about ARL. Conclusion: Various definitions/ARL rates are used when counseling about ARL in twins. Further studies using a widely accepted definition of ARL are necessary to improve the counseling of women considering amniocentesis for prenatal diagnosis in twins.

Wright J, Silver R, Bonannno C, Gaddipati S, Lu Y, Simpson LL, Schulkin J, D’Alton M. (2013). Practice patterns and knowledge of obstetricians and gynecologists regarding placenta accreta. The Journal of Maternal-Fetal and Neonatal Medicine, 26(16), 1602-1609.

Objective: We surveyed obstetricians to determine their knowledge, patterns of care and treatment preferences for women with placenta accreta. Overall, 20.4% referred women to the nearest tertiary center, and 7.1% referred to a regional center. Delivery was recommended at 34–36 weeks by 41.2%. Adjuvant interventions including ureteral stents (26.3%), iliac artery embolization catheters (28.1%), and balloon occlusion catheters (20.1%) were used infrequently. Six or more units of blood were crossed for delivery by only 29.0% of practitioners. Conclusion: There is widespread variation in the care of women with or at risk for placenta accrete.



Jay Schulkin, PhD
Mike Power, PhD
Greta Raglan
Katherine Jones