2001 Publications

Erickson K., Schmidt L., Santesso D.L., Schulkin J., Gregory K., Hobel C. Obstetrician-gynecologists' knowledge and training about antenatal corticosteroids. Obstetrics & Gynecology. 97(1):140-6, 2001 Jan.

Objective: To characterize the clinical decisions, knowledge, opinions, and education of obstetricians and gynecologists about antenatal corticosteroids. Methods: Questionnaires mailed to 1020 ACOG Fellows included items on demographics, knowledge, clinical practice patterns, and educational background regarding antenatal corticosteroids. Results: The survey response rate was 47.8%. Almost all respondents (94%) reported administering antenatal corticosteroids, with reduction of respiratory distress syndrome (82%) as the primary reason for antenatal corticosteroid administration. Most (59.2%) were unaware of newly recognized associations between multiple administrations of corticosteroids and fetal growth restriction. In hypothetical clinical situations, responses by physicians who completed their residency training before 1970 indicated less likelihood to administer corticosteroids when administration is relatively indicated per National Institutes of Health (NIH) and ACOG guidelines than those trained later (P <.001). Only 8% of the entire sample rated their knowledge of antenatal corticosteroids as comprehensive; most (68%) rated it as adequate. Respondents rated residency training as a much better source of antenatal corticosteroid knowledge than medical school. Conclusion: Most obstetrician-gynecologists reported using antenatal corticosteroids; however, in general, many were not aware of more recent information regarding potential risks. This survey suggests that a multipronged educational approach is warranted to update obstetrician-gynecologists about antenatal corticosteroids.

Jones J.L., Dietz V.J., Power M., Lopez A., Wilson M., Navin T.R., Gibbs R., Schulkin J. Survey of obstetrician-gynecologists in the United States about toxoplasmosis. Infectious Diseases in Obstetrics & Gynecology. 9(1):23-31, 2001.

Background: Although the incidence of toxoplasmosis is low in the United States, up to 6000 congenital cases occur annually. In September 1998, the Centers for Disease Control and Prevention held a conference about toxoplasmosis; participants recommended a survey of the toxoplasmosis-related knowledge and practices of obstetrician-gynecologists and the development of professional educational materials for them. Methods: In the fall of 1999, surveys were mailed to a 2% random sample of American College of Obstetricians and Gynecologists (ACOG) members and to a demographically representative group of ACOG members known as the Collaborative Ambulatory Research Network (CARN). Responses were not significantly different for the random and CARN groups for most questions (p value shown when different). Results: Among 768 US practicing ACOG members surveyed, 364 (47%) responded. Seven per cent (CARN 10%, random 5%) had diagnosed one or more case(s) of acute toxoplasmosis in the past year. Respondents were well-informed about how to prevent toxoplasmosis. However, only 12% (CARN 11%, random 12%) indicated that a positive Toxoplasma IgM test might be a false-positive result, and only 11% (CARN 14%, random 9%) were aware that the Food and Drug Administration sent an advisory to all ACOG members in 1997 stating that some Toxoplasma IgM test kits have high false-positive rates. Most of those surveyed (CARN 70%, random 59%; chi2 p < 0.05) were opposed to universal screening of pregnant women. Conclusions: Many US obstetrician-gynecologists will encounter acute toxoplasmosis during their careers, but they are frequently uncertain about interpretation of the laboratory tests for the disease. Most would not recommend universal screening of pregnant women.

Power, M.L., Holzman, G.B., Sculkin, J. A survey on the management of nausea and vomiting of pregnancy of obstetrician-gynecologists. Primary Care Update for OB/GYN, 8:69-72, 2001 Mar.

Our objective was to survey obstetrician/gynecologists concerning their management of nausea and vomiting in pregnancy. We mailed a survey on nutrition during pregnancy to the 230 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a control sample of 800 non-Network Fellows. Results presented here are for the questions concerning prevalence and management of pregnancy-induced nausea. A total of 488 surveys (47.4% response rate) were analyzed. Respondents reported that on average, 51.4% of patients complain of nausea during pregnancy, and 9.2% complain of severe or prolonged nausea with vomiting. Respondents reported that on average, 2.4% of patients require hospitalization because of hyperemesis gravidarum. Treatments recommended by a majority of respondents for moderate nausea were eating frequent small meals (95.5%), snacking on soda crackers (88.5%), avoiding strong odors (75.6%), taking a prescribed antiemetic (71.3%), taking ginger (51.8%), and eliminating iron supplements (50%). Women physicians were more likely to recommend ginger and less likely to prescribe an antiemetic. For severe and sustained nausea with vomiting, with additional symptoms such as dehydration or weight loss, intravenous hydration (88.7%) and antiemetics (74.0%) were the most common treatment options. Almost half (48.8%) of respondents would hospitalize such patients. We conclude that obstetrician/gynecologists appear to be knowledgeable concerning current opinion on managing nausea and vomiting of pregnancy. Improvements in the management of nausea during pregnancy are more likely to come from further research, not education of physicians.

Cain, J.M., Schulkin, J., Paresi, V., Power, M., L. Holzman, G.B., Williams, S. Effects of Perceptions and Mentorship on Pursuing a Career in Academic Medicine in Obstetrics and Gynecology. Academic Medicine, 76:628-634, 2001 Jun.

Purpose: To understand the perceptions of residents and Fellows in obstetrics and gynecology about the impacts of race or ethnicity, gender, and mentorship experiences on pursuing careers in academic medicine.  Method: Two surveys were administered: one to a sample of 2,000 Fellows of the American College of Obstetricians and Gynecologists, and one to the 4,814 obstetrics and gynecology residents taking the 1998 in-training examination. The questionnaires asked about demographics, perceptions about careers in academic medicine, and residents' experiences with mentorship.  Results: Response rates were 96.8% for residents and 40.6% for Fellows. Of the residents, 26.1% indicated they would not consider a career in academic medicine. First-year women residents were more inclined to pursue careers in academic medicine than were first-year men (p = .042), but their interest declined during residency. Women residents (43%)-especially minorities-felt that men were mentored and recruited more for faculty positions, while men (38%) felt that women were mentored and recruited more. Fellows' reports of recruitment did not differ by gender. Most white residents did not perceive racial or ethnic bias in mentoring or recruiting, while most non-white residents did. Almost one third of non-white women residents felt that supervisors were more likely to condescend to women and minority individuals.  Conclusions: It is likely that neither men nor women residents in obstetrics and gynecology receive adequate mentorship for careers in academic medicine. Perceptions of bias are a serious barrier to developing racial, ethnic, and gender diversity in leadership positions.

Erickson K., Thorsen P., Chrousos G., Grigoriadis D.E., Khongsaly O., McGregor J., Schulkin J. Preterm birth: associated neuroendocrine, medical, and behavioral risk factors. Journal of Clinical Endocrinology & Metabolism. 86(6):2544-52, 2001 Jun.

Increased CRH secretion by the placenta of pregnant women has been associated with preterm birth. Certain indices of risk, both medical and psychosocial in nature, have been linked to preterm delivery. Levels of total, bound, and free CRH, CRH-binding protein (CRH-BP), and cortisol were measured prospectively in a large sample of pregnant Danish women who delivered preterm and term infants. Measures of maternal serum hormones were taken at 7--23 and 27--37 weeks gestation and, for those who delivered at term, at 37--43 weeks gestation. At 7--23 weeks gestation, maternal levels of total CRH (P = 0.01), bound CRH (P = 0.03), and CRH-BP (P = 0.01) were higher in the preterm than in the term group. At 27--37 weeks gestation, levels of total CRH (P < 0.0001), bound CRH (P < 0.0001), free CRH (P < 0.0001), and cortisol (P < 0.0001) were all higher in the preterm than the term group, whereas levels of CRH-BP (P < 0.0001) were lower in the preterm than in the term group. The best medical and behavioral factors associated with preterm delivery were, respectively, previous preterm delivery (P < 0.0001) and engagement in certain risk-taking behaviors (P = 0.008). The positive relations between preterm delivery and various adverse medical and socioeconomic variables with increases in placental secretion of CRH suggest that the latter may participate in the pathophysiology of preterm delivery.

Defoe D.M., Power M.L., Holzman G.B., Carpentieri A., Schulkin J. Long hours and little sleep: work schedules of residents in obstetrics and gynecology. Obstetrics & Gynecology. 97(6):1015-8, 2001 Jun.

Objective: To investigate residents' work schedules and their attitudes toward limiting their hours. Methods: An anonymous survey regarding resident work hours and call schedules was administered to the 4674 obstetric-gynecologic residents who took the year 2000 Council on Resident Education in Obstetrics and Gynecology in-training examination. Results: A total of 4510 surveys were analyzed (96.5%). Three of four (75.5%) respondents reported working between 61 and 100 hours each week. Most (71.3%) reported sleeping less than 3 hours while on night call. Eight of ten reported having postcall clinical responsibilities. The reported number of hours on call declined and the reported number of hours of sleep increased with year of residency. Three of four residents wanted limits on their work hours. Residents who reported longer on-call hours or less sleep during night shift were significantly more likely to want a restriction on work hours. Fatigue was the most commonly selected reason (77.6%) followed by "need more personal time" (76.3%), and "fear of compromising quality of care" (59.8%). Women were more concerned about fatigue than were men. Among residents who did not want work hour restrictions, "additional surgical experience" was the most commonly selected reason (69.0%). Conclusion: Residents in obstetrics and gynecology report working long hours, and experiencing periods of little sleep. Most want their work hours to be limited. Fatigue is a major concern among residents that want their hours limited. A sizable minority worries that such limits might also limit their experience.

Hill L.D., Erickson K., Holzman G.B., Power M.L., Schulkin J. Practice trends in outpatient obstetrics and gynecology: findings of the Collaborative Ambulatory Research Network, 1995--2000. Obstetrical & Gynecological Survey. 56(8):505-16, 2001 Aug.

Historically, obstetrics and gynecology has been a medical/surgical specialty focusing on women's health and reproductive concerns during the childbearing years. Newer responsibilities-for example, in primary care, gerontology, and genetics-require Ob-Gyns to draw upon a base of medical knowledge that traditionally was not considered germane to their practices. Ob-Gyns are increasingly providing more primary care services to their patients; consequently, the field has expanded considerably. The Collaborative Ambulatory Research Network (CARN) was created in 1990 as a vehicle for investigating issues pertinent to women's health and to the practice of obstetrics and gynecology in the outpatient setting. This article summarizes the findings of CARN studies from 1995 to 2000, covering a range of topics related to women's health across the life cycle, including, but not limited to perinatal care. Topics include nutrition, infectious disease, hormone replacement therapy, psychosocial issues, and genetic testing in obstetric and gynecologic practice. Each study produced a picture of current practice patterns and knowledge of the physicians surveyed. Findings on knowledge, attitudes, and practices varied widely. Overall, Ob-Gyns were knowledgeable and consistent in more traditional areas of practice. Conversely, inconsistencies were observed in newer areas. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to define what the Collaborative Ambulatory Research Network (CARN) involves, describe how CARN obtains its data, and summarize some of the findings of CARN from the years 1995 to 2000.

Floyd, L., Delodoff, B., Sidhu, S., Schulkin, J. Obstetrician gynecologists screening for tobacco and other drug use during pregnancy.  Prenatal and Neonatal Medicine, 6:201-207, 2001 Aug.

Objective: This survey was conducted to assess the knowledge, beliefs and practice behaviors of obstetrician–gynecologists concerning their patients' prenatal use of tobacco and other drugs. Methods: We developed a 32-item questionnaire which the American College of Obstetricians and Gynecologists mailed to a sample of 1000 members throughout the USA. A total of 604 questionnaires were returned (60%). Descriptive statistics, prevalence rates and prevalence rate ratios were calculated, and stratified analyses were performed in some cases in order to control for the possible confounding effects of age and gender. Results: Most respondents (98%) reported questioning their prenatal patients at the first visit about tobacco use, with only one in nine asking at each prenatal visit. Ninety-five per cent of respondents reported that they discussed adverse effects and advised cessation for patients who screened positive for smoking; 38% reported always providing self-help materials; and 22% reported referrals to cessation workshops. Fewer respondents (87%) reported asking their patients about drug use. Among women reporting other drug use, 97% of clinicians discussed adverse effects, and 95% advised abstinence. Forty-five per cent reported that they referred patients for treatment, and one-third reported performing periodic drug screens. Respondents graduating after 1989, female clinicians and clinicians who judged their medical school training on substance use as excellent or very good were more likely to adhere to current practice guidelines on smoking and illicit drug use. Conclusions: While screening of prenatal patients for tobacco use and other drug use was reported by survey respondents, providing or arranging for interventions for those screening positive was less often reported.

Hill, L., Greenberg, B., Holzman, G.B., Schulkin, J. Obstetrician-gynecologists attitudes toward premenstrual dysphoric disorder and major depressive disorder.  J. of Pscyhosomatic Obstetrics and Gynecology.  22:241-250, 2001 Dec.

Nine hundred ninety-seven fellows of the American College of Obstetricians and Gynecologists were surveyed by mailed questionnaire regarding their attitudes toward the conceptualization, diagnosis and treatment of premenstrual dysphoric disorder (PMDD) and major depressive disorder (MDD). Hypothesized differences in attitudes based on age, gender and professional identity as a primary care provider versus non-primary care provider were examined. Comparisons between attitudes toward PMDD and MDD were also investigated. Approximately 36% of the questionnaires were completed and returned. Overall attitudes toward PMDD versus MDD were found to be significantly different. Roughly one in three respondents disagreed with statements indicating responsibility for and confidence in their ability to treat MDD, but not PMDD. When significant differences were found for age, gender and professional identity, younger physicians, women physicians and those who self-identified as primary care providers reported attitudes that may be more likely to be associated with diagnosis and treatment of MDD and PMDD in gynecologic practice. For example, about 41% of self-identified non-primary care providers and 14.8% of primary care providers disagreed with the statement 'treating depression is my responsibility as a gynecologist'. Differences in gynecologists' attitudes toward MDD versus PMDD may be associated with under-treatment of MDD in gynecologic practice.


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