2004 Publications

Power ML. Kilpatrick S. Schulkin J. Diagnosing and managing thyroid disorders during pregnancy: a survey of obstetrician-gynecologists. Journal of Reproductive Medicine. 49(2):79-82, 2004 Feb.

Objective: To document the knowledge and clinical practice of obstetrician-gynecologists regarding their diagnosis and management of thyroid disorders during pregnancy. Study Design: We surveyed 1,392 practicing obstetrician-gynecologists about their knowledge and clinical practice of treating thyroid disorders during pregnancy; 569 of the surveys were returned. Of those, 441 respondents treated pregnant women and completed the entire survey. Results: A majority of respondents had treated patients for hypothyroidism (88.7%) and hyperthyroidism (60.5%) within the previous year. In general, respondents appeared to be well versed in the symptoms of hypothyroidism and hyperthyroidism. Most respondents correctly predicted the likely results for thyroid-stimulating hormone, free thyroxine and total thyroxine for pregnant euthyroid, hyperthyroid and hypothyroid women, but about 50% appeared uncertain of the meaning of free thyroxine index. A majority (53.1%) of respondents considered their training during residency concerning thyroid disorders during pregnancy to be adequate, but few (7.5%) considered it to be comprehensive, and the remainder considered it barely adequate at best. Self-assessment of training and confidence regarding diagnosing and managing thyroid disorders during pregnancy were in concordance (r = .462 and r = .464, respectively; P < .001 in both cases). Conclusion: Thyroid disorders are commonly treated by obstetrician-gynecologists, and in general their practices for diagnosis and management conform to accepted practices. A sizable minority of responding obstetrician-gynecologists indicated that they considered their training to be inadequate and their confidence in diagnosing and managing thyroid disorders to be low.

Bettes BA. Chalas E. Coleman VH. Schulkin J. Heavier workload, less personal control: Impact of delivery on obstetrician/gynecologists' career satisfaction. American Journal of Obstetrics & Gynecology. 190(3):851-7, 2004 Mar.

Objective: Obstetrician/gynecologists' career satisfaction with certain work-related activities was examined among clinicians who perform deliveries and clinicians who do not. Study Design: A questionnaire was sent to 1500 member-fellows of the American College of Obstetricians and Gynecologists; 842 members (56%) responded. The questionnaire was designed to distinguish between obstetrician/gynecologists who perform deliveries and clinicians who do not in the areas of satisfaction with specific aspects of career and work-related activities. Data were examined initially by multivariate analysis of variance and subsequently by univariate analysis of variance if the multivariate test was found to be significant. Results: Workload and personal control were the primary factors for which there was a significant difference in satisfaction between clinicians who perform deliveries and clinicians who do not (P<.001). Obstetrician/gynecologists who do not perform deliveries reported working significantly fewer hours per week (P<.001) and had more satisfaction with their work activities than the delivery group overall. Despite lowered satisfaction with certain career aspects among the delivery Group, the highest positive disposition ratings that was given by respondents were for surgery, vaginal delivery, and planned cesarean delivery, with gender differences observed in the level of disposition for these particular activities. The most negative rating was reported for on-call/in-hospital time. Conclusion: Although positive disposition is associated with the activity of vaginal and cesarean delivery overall, 2 primary contributing factors of dissatisfaction that were identified among obstetrician/gynecologists who perform deliveries were increased workload and decreased personal control.

Bettes BA. Strunk AL. Coleman VH. Schulkin J. Professional liability and other career pressures: impact on obstetrician-gynecologists' career satisfaction. Obstetrics & Gynecology. 103(5 Pt 1):967-73, 2004 May.

Objective: To investigate the impact of career pressures on career satisfaction and satisfaction with job-specific activities among obstetrician-gynecologists. Methods: A questionnaire was sent to 1,500 member-Fellows of The American College of Obstetricians and Gynecologists in June 2001. The analyses were designed to examine the relationship between career pressures in 3 domains on clinicians' professional satisfaction. Results: Overall career satisfaction and satisfaction with job-specific activities were both inversely related to the perceived impact of career pressures. The major impact reported was that liability insurance costs would shorten the duration of the members' careers. Managed care had less impact than liability, with moderate concern surrounding the limitation of diagnostic and treatment options. Obstetrician-gynecologists were less satisfied with their careers and job-specific activities if they believed the cost or time of obtaining continuing medical education requirements to be a burden. Conclusion: Career pressures produced by liability insurance costs have more negative impact on clinicians' satisfaction with their professional lives and job-specific activities than managed care and requirements for continuing medical education.

Gabbe SG. Gregory RP. Power ML. Williams SB. Schulkin J. Management of diabetes mellitus by obstetrician-gynecologists. Obstetrics & Gynecology. 103(6):1229-34, 2004 Jun.

Objective: To compare practice patterns of the American College of Obstetrician and Gynecologists (ACOG) Fellows for the diagnosis and treatment of gestational diabetes mellitus (GDM) and type 1 diabetes mellitus with current ACOG recommendations and prior published series. Methods: We sent a questionnaire to 1,398 practicing ACOG Fellows and Junior Fellows, 398 of whom comprise the Collaborative Ambulatory Research Network. Responses were evaluated by age and sex to assess differences in practice. Results: Younger physicians were more likely to treat pregnant patients. Ninety-six percent of obstetricians routinely screen for GDM, nearly all by using a 50-g glucose 1-hour oral test. Nearly 60% of respondents establish the diagnosis of GDM using the National Diabetes Data Group criteria. In addition to medical nutrition therapy, almost 75% of respondents recommend exercise for patients with GDM. Approximately 60% of respondents reported that all of their patients with GDM self-monitor their blood glucose. When medical nutrition therapy is ineffective for their patients with GDM, 82% of respondents initially prescribe insulin, whereas 13% begin with glyburide. Nearly 75% of respondents routinely perform a postpartum evaluation of glucose tolerance in the patient with GDM. Most obstetricians manage the glucose control of their patients with type 1 diabetes mellitus themselves. Conclusion: Practicing obstetrician-gynecologists have incorporated recent recommendations into their practice patterns for both GDM and type 1 diabetes mellitus, including patients' self-monitoring of blood glucose, exercise, and postpartum testing in GDM. LEVEL OF EVIDENCE: III

Holzman GB. Downing SM. Power ML. Williams SB. Carpentieri A. Schulkin J. Resident performance on the Council on Resident Education in Obstetrics and Gynecology (CREOG) In-Training Examination: years 1996 through 2002. American Journal of Obstetrics & Gynecology. 191(1):359-63, 2004 Jul.

Objective: This study was undertaken to evaluate the Council on Resident Education in Obstetrics and Gynecology (CREOG) In-Training Examination scores for significant trends. Study Design: The percent-correct scores for each of the 6 published examination objectives from 7 consecutive years were analyzed. The data set was analyzed by multivariate analysis of variance using gender, examination year, and postgraduate year as categorical variables, and each year was analyzed separately by gender and postgraduate year. Scores of residents who took the examination for 4 consecutive years were analyzed by using repeated measures analysis of covariance. Results: Variation by examination year appeared random, although scores monotonically increased with postgraduate year for all objectives and all years. The mean relative scores of women were higher than men on the primary/preventive care objective, but the reverse was true for the general considerations objective. Conclusion: The CREOG In-Training Examination appears to be a dependable measure of residents' improvement in cognitive knowledge.

Cleary-Goldman J. Morgan MA. Robinson JN. D'Alton ME. Schulkin J. Multiple pregnancy: knowledge and practice patterns of obstetricians and gynecologists. Obstetrics & Gynecology. 104(2):232-7, 2004 Aug.

Objective: We sought to assess knowledge and practices of obstetricians regarding multiple gestation. Methods: A questionnaire investigating knowledge and practice patterns pertaining to multiple gestation was mailed to randomly selected American College of Obstetricians and Gynecologists (ACOG) Fellows and Junior Fellows in January 2003. Fifty-one percent (589/1,146) of the surveys were returned. Results: Statistical analysis included the responses from 430 practicing obstetricians. More than 60% rated their training regarding management of multiples as adequate. Men (56.5%) were older and had been in practice longer than females. Sixty-two percent of general obstetrician-gynecologists managed twins without input from a maternal-fetal medicine specialist. An understanding of chorionicity was less than anticipated. The majority of practitioners managed twins according to recent ACOG educational materials. They did not use prophylactic cerclage, home uterine-activity monitoring, or tocolytics. Fort-six percent encouraged prophylactic bed rest. The management of breech second twins varied. Conclusion: Most obstetricians manage multiples according to current ACOG educational materials independent of maternal-fetal medicine specialists. This survey identified knowledge gaps, specifically in chorionicity, indicating the need to develop educational strategies addressing these insufficiencies.

Morgan MA. Driscoll DA. Mennuti MT. Schulkin J. Practice patterns of obstetrician-gynecologists regarding preconception and prenatal screening for cystic fibrosis. Genetics in Medicine. 6(5):450-5, 2004 Sep-Oct.

Objective: To assess practices of obstetrician-gynecologists regarding carrier screening for cystic fibrosis (CF). Methods: A questionnaire investigating practice patterns and opinions pertaining to CF screening was mailed to 1165 members of the American College of Obstetricians and Gynecologists (ACOG), of whom 565 participate in the Collaborative Ambulatory Research Network (CARN) and 600 were randomly selected. Results: Of the questionnaires, 64% were returned. Statistical analyses were limited to the 632 respondents whose primary medical specialty was gynecology (Gyn Only) or obstetrics and gynecology (ObGyn). CARN membership was not a significant factor on any nondemographic measure. Almost one-half of physicians do not ask nonpregnant patients their family history of CF or provide them with information about CF screening. The majority of ObGyns (88.7%) ask obstetric patients their family history of CF, and offer CF carrier screening. Almost two-thirds (65.8%) offer screening to all prenatal patients. Among those ObGyns who selectively offer CF screening to pregnant patients, only 27.4% utilized all of the selection criteria in the guidelines. Liability for not offering screening, familiarity with CF, and the ability to interpret a positive screening test were important physician concerns. Conclusion: The results indicate a need for minimizing the complexity of clinical guidelines for population-based genetic screening, prospective assessment of implementation and focused continuing education for providers.

Coleman VH. Power ML. Zinberg S. Schulkin J. Contemporary clinical issues in outpatient obstetrics and gynecology: findings of the Collaborative Ambulatory Research Network, 2001-2004: part II. Obstetrical & Gynecological Survey. 59(11):787-94, 2004 Nov.

Obstetrician/gynecologists are taking on more primary care responsibilities and thus are expected to have a wider base of medical knowledge on a variety of women's health issues. The Collaborative Ambulatory Research Network (CARN) was created in 1990 to investigate 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 2001 to 2004, covering topics of abnormal pregnancy outcomes, complications of pregnancy, and psychologic disorders. Each study provides a glimpse into the current practice patterns, attitudes, and knowledge of the practicing obstetrician/gynecologist. Although aggregate results suggest that clinicians are consistent and knowledgeable in traditional areas of practice, there appears to be a need for comprehensive educational programs to increase clinicians' comfort level with and knowledge of many primary care issues.


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