2000 Publications

Wilkins-Haug L. Erickson K., Hill L., Power M., Holzman G.B., Schulkin J. Obstetrician-gynecologists' opinions and attitudes on the role of genetics in women's health. Journal of Womens Health & Gender-Based Medicine. 9(8):873-9, 2000 Oct.

Our objective was to describe gynecologists' current practice patterns and opinions on genetic screening and their perceived importance of genetic screening within individual practices. A questionnaire survey was sent to 1248 American College of Obstetrics and Gynecology (ACOG) Fellows, of whom 564 (45%) responded. Results from the 428 respondents providing genetic screening for heritable diseases or disorders are reported. Forty-four percent of respondents believe advances in the treatment of genetic diseases are likely in the next 10 years. Currently, however, genetics in gynecological practice receives infrequent attention. Twenty-four percent of respondents do not routinely review family histories at gynecological visits, 39% rate genetic issues as last among priorities in the office, and only 14% obtain consent for the DNA tests that they initiate. Although 21.3% identified themselves as sole providers of genetic information and counseling to their patients, most (65.4%) note they are not confident of their knowledge of genetics, particularly concerning breast and ovarian cancer. For obstetrician-gynecologists to keep pace with the rapid changes in genetics, further education and assimilation of genetics into the routine office practice will need to occur. Not currently viewed as a priority among practitioners, issues of genetic knowledge, ethics, and test interpretation will soon need attention. National organizations, continuing medical education, and existing genetic centers will need to meet these recognized demands.

Power M.L., Holzman G.B., Schulkin J. Knowledge and clinical practice regarding folic acid among obstetrician-gynecologists. Obstetrics & Gynecology. 95(6 Pt 1):895-8, 2000 Jun.

Objective: To assess obstetrician-gynecologists' knowledge of and clinical practice concerning folate. METHODS: We mailed surveys on nutrition during pregnancy to the 230 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a random sample of 800 Fellows who are not members of the Network. Our results focus on questions concerning folate. RESULTS: We analyzed 488 surveys (a 47.4% response rate). Approximately two thirds of respondents screen their pregnant patients for folate intake. Fewer (53%) screen their nonpregnant patients of childbearing age. Those who screened their patients for folate intake were more likely to counsel pregnant patients about diet. They also were more likely to believe that nutritional counseling would improve pregnancy outcomes (70.0% versus 56.5%) and overall patient health (77.5% versus 66.5%). Most Fellows were aware that macrocytic anemia was a manifestation of folate deficiency (90.4%) and that folic acid supplementation during preconception and the early prenatal period helps protect against neural tube defects (96.5%). They were aware that alcoholics (91.4%), smokers (61.3%), and lactating women (53.5%) are at increased risk of folate deficiency. They were less aware of other consequences of low folate intake, such as increased serum homocysteine (20.3%). Respondents who screen their pregnant patients for folate intake correctly answered more of the knowledge questions about folate than physicians who do not screen. CONCLUSION: Obstetrician-gynecologists are generally aware of the link between folate intake and neural tube defects, but are less aware of other aspects of folate metabolism.

Schulkin J. Decision sciences and evidence-based medicine--two intellectual movements to support clinical decision making. Academic Medicine. 75(8):816-8, 2000 Aug.

Two recent intellectual pursuits, Decision Science and Evidence Based Medicine have linked clinical decision-making to the results obtained from sound scientific research. The aim of incorporating science in medical decision-making is several hundred years old. These two recent additions can inform clinical judgement and provide intellectual tools to render medical decision-making more scientific.

Horan, D.L., Hill L.D., Schulkin, J. Childhood sexual abuse and adverse pregnancy outcomes in adulthood: an endocrinological hypothesis. Journal of Women's Health, 10:27-33, 2000.

Anecdotal reports link adverse pregnancy outcomes, such as preterm delivery, to women with histories of childhood sexual abuse (CSA). Although little research has been conducted on this subject, we provide an overview of known health effects of violence against women and posit a biological explanation for adverse pregnancy outcomes among survivors of CSA.

Diekman S.T., Floyd R.L., Decoufle P., Schulkin J., Ebrahim S.H., Sokol R.J. A survey of obstetrician-gynecologists on their patients' alcohol use during pregnancy. Obstetrics & Gynecology. 95(5):756-63, 2000 May.

Objective: to examine knowledge, attitudes, current clinical practices, and educational needs of Obstetricians/Gynecologists (OB/GYNs) regarding substance use during pregnancy, with an emphasis on alcohol use. Methods: A 26-item, self-administered questionnaire on prenatal alcohol, tobacco, and illicit drug use was sent to 1,000 active ACOG Fellows, with a response rate of 60%. Responses were analyzed using univariate and multivariate statistical techniques. Results: The majority of respondents ask their prenatal patients about alcohol use (97%), tobacco use (100%), and illicit drug use (89%). When a patient reports substance use, the majority of respondents reported that they always discuss adverse effects and always advise abstinence. Respondents were more likely to refer a pregnant woman to treatment if she reported heavy alcohol use (61%) than if she reported tobacco (22%) or illicit drug use (45%). Twenty-two percent of the respondents indicated that to prevent the four major outcomes associated with prenatal alcohol abuse (spontaneous abortions, birth defects, CNS impairment and Fetal Alcohol Syndrome) pregnant women should completely abstain from alcohol use during pregnancy; 22% were unsure about thresholds associated with the conditions; and 6% reported that consumption of 8+ drinks per week or 5+ drinks per occasion posed no risk to the pregnancy or the outcome of that infant. Barriers most often reported as affecting alcohol use assessment and management in clinical practice were time limitations (70%), patient sensitivity (65%), need for additional training to enhance ascertainment skills (65%), and lack of referral sources (50%). When asked to identify resources needed to improve alcohol use assessment in clinical practice, respondents identified information on thresholds for adverse reproductive outcomes (83%), referral sources for patients with alcohol problems (63%), training and consultation in assessment and counseling (44%), and reimbursement by insurance and providers for screening and assessment (44%). Conclusion: Almost all OB/GYNs ask their prenatal patients about substance use and most discuss the adverse effects and advise their prenatal patients to abstain. However, knowledge about thresholds at which alcohol consumption can cause adverse pregnancy outcomes is inconsistent. OB/GYNs identified barriers to alcohol use assessment and management, as well as resources needed to improve assessment. Efforts should be made to provide OB/GYNs with updated information concerning the adverse effects of substance use during pregnancy, as well as effective methods for screening and counseling women regarding prenatal use.

Wilkins-Haug, L., Hill, L.D., Power, M.L., Holzman, G.B., Schulkin, J. Gynecologists' training, knowledge and experience in genetics: A survey study.  Obstetics and Gynecology, 95:421-424, 2000.

Objective: To explore gynecologists' genetic knowledge, training, and practice experience with genetic screening and DNA-based testing. Methods: A questionnaire survey was sent to 1248 ACOG Fellows, of whom 564 (45%) responded. One hundred thirty-four respondents (24%)reported that they do not order DNA based tests or take family histories to screen for heritable diseases or disorders. Results from the 428 respondents who provide genetic screening services are reported. Results: Most physicians (90%) knew that genetic tests are informative when used in conjunction with family history. Gynecologists gave more correct responses regarding genetic testing for breast and ovarian cancers than they did for colon cancer and other adult onset diseases. Sixty-five percent of the respondents had not received formal training in DNA-based testing in gynecologic practice. Older physicians were less likely to have had training. Younger physicians generally gave more correct responses on the knowledge portion of the survey (r = -.165, P < .01). Physicians who had formal training in genetics gave more correct answers. Physicians who order DNA-based tests scored higher than those who do not and had no formal training, but not higher than those who had formal training and do not order DNA-based tests. Conclusion: Gynecologists were more knowledgeable about genetic issues pertaining to breast and ovarian cancer than to other cancers or certain adult-onset disorders. Training appeared to increase knowledge. Increased training and affiliation with genetic specialists and others could improve gynecologists' ability to use genetic screening in clinical practice.

Contact:

Jay Schulkin, PhD
jschulkin@acog.org
 
Mike Power, PhD
mpower@acog.org
 
Greta Raglan
graglan@acog.org
 
Katherine Jones
kjones@acog.org