2005 Publications

Chamany S., Schulkin J., Rose C.E.Jr., Riley L.E., Besser R.E.  Knowledge, attitudes, and reported practices among obstetrician-gynecologists in the USA regarding antibiotic prescribing for upper respiratory tract infections. Infectious Diseases in Obstetrics & Gynecology. 13(1):17-24, 2005 Mar.

Background: Knowledge, attitudes, and practices regarding antibiotic prescribing for upper respiratory tract infections (URIs) have not been well described among obstetrician-gynecologists (OB/GYNs). This information is useful for determining whether an OB/GYN-specific program promoting appropriate antibiotic use would significantly contribute to the efforts to decrease inappropriate antibiotic use among primary care providers. Methods: An anonymous questionnaire asking about the treatment of URIs was sent to 1031 obstetrician-gynecologists. Results: The overall response rate was 46%. The majority of respondents (92%) were aware of the relationship between antibiotic use and antibiotic resistance, and respondents estimated that 5% of their patients had URI symptoms at their office visits. Overall, 56% of respondents reported that they would prescribe an antibiotic for uncomplicated bronchitis and 43% for the common cold. OB/GYNs with the fewest years of experience were less likely than those with the most years of experience to report prescribing for uncomplicated bronchitis (Odds ratio (OR) 0.46, 95% confidence interval (CI) 0.23 to 0.91) or the common cold (OR 0.44, CI 0.22 to 0.89). The majority of respondents (60%) believed that most patients wanted an antibiotic for URI symptoms, with male OB/GYNs being more likely than female OB/GYNs (OR 2.1, CI 1.2 to 3.8) to hold this belief. Both male OB/GYNs (OR 1.9, CI 1.1 to 3.4) and rural practitioners (OR 2.1, CI 1.1 to 4.0) were more likely to believe that it was hard to withhold antibiotics for URI symptoms because other physicians prescribe antibiotics for these symptoms. OB/GYNs who believed that postgraduate training prepared them well for primary care management were more likely than those who did not (OR 2.1, CI 1.1 to 4.2) to believe that they could reduce antibiotic prescribing without reducing patient satisfaction. Conclusion: Multiple demographic factors affect attitudes and reported practices regarding antibiotic prescribing. However, in view of the low proportion of office visits for URIs, an OB/GYN-specific program is not warranted.

Ogunmodede F., Jones J.L., Scheftel J., Kirkland E., Schulkin J., Lynfield R. Listeriosis prevention knowledge among pregnant women in the USA. Infectious Diseases in Obstetrics & Gynecology. 13(1):11-5, 2005 Mar.

Background: Listeriosis is a food-borne disease often associated with ready-to-eat foods. It usually causes mild febrile gastrointestinal illness in immunocompetent persons. In pregnant women, it may cause more severe infection and often crosses the placenta to infect the fetus, resulting in miscarriage, fetal death or neonatal morbidity. Simple precautions during pregnancy can prevent listeriosis. However, many women are unaware of these precautions and listeriosis education is often omitted from prenatal care. Methods: Volunteer pregnant women were recruited to complete a questionnaire to assess their knowledge of listeriosis and its prevention, in two separate studies. One study was a national survey of 403 women from throughout the USA, and the other survey was limited to 286 Minnesota residents. Results: In the multi-state survey, 74 of 403 respondents (18%) had some knowledge of listeriosis, compared with 43 of 286 (15%) respondents to the Minnesota survey. The majority of respondents reported hearing about listeriosis from a medical professional. In the multi-state survey, 33% of respondents knew listeriosis could be prevented by not eating delicatessen meats, compared with 17% in the Minnesota survey (p=0.01). Similarly, 31% of respondents to the multi-state survey compared with 19% of Minnesota survey respondents knew listeriosis could be prevented by avoiding unpasteurized dairy products (p=0.05). As for preventive behaviors, 18% of US and 23% of Minnesota respondents reported avoiding delicatessen meats and ready-to-eat foods during pregnancy, whereas 86% and 88%, respectively, avoided unpasteurized dairy products. Conclusions: Most pregnant women have limited knowledge of listeriosis prevention. Even though most respondents avoided eating unpasteurized dairy products, they were unaware of the risk associated with ready-to-eat foods. Improved education of pregnant women regarding the risk and sources of listeriosis in pregnancy is needed.

Glass N.E., Schulkin J., Chamany S., Riley L.E., Schuchat A., Schrag S. Opportunities to reduce overuse of antibiotics for perinatal group B streptococcal disease prevention and management of preterm premature rupture of membranes. Infectious Diseases in Obstetrics & Gynecology. 13(1):5-10, 2005 Mar.

Objective: To identify opportunities to reduce overuse of antibiotics for prevention of perinatal group B streptococcal (GBS) disease and management of preterm premature rupture of membranes (pPROM). Method: An anonymous written questionnaire was sent to each of 1031 Fellows of the American College of Obstetricians and Gynecologists, and the responses were subjected to statistical analysis. Results: Among those of the 404 respondents who saw obstetric patients in 2001, most (84%) screened for GBS colonization, and 22% of these prescribed prenatal antibiotics to try to eradicate GBS colonization. Of the 382 respondents (95%) who prescribed antibiotics for pPROM, 36% continued antibiotics for more than 7 days despite negative results from GBS cultures collected before initiation of treatment. Having more years of clinical experience (adjusted odds ratio (OR) 3.0, 95% confidence interval (CI) 1.5 to 6.2), working in a non-academic setting (adjusted OR 2.7, 95% CI 1.0 to 6.9), and prescribing antibiotics prenatally for GBS colonization (adjusted OR 2.0, 95% CI 1.1 to 3.4) were associated with prescribing prolonged antibiotics for pPROM. Conclusion: Prenatal antibiotic treatment for GBS colonization and prolonged antibiotic treatment for pPROM contribute to overuse of antibiotics in obstetrics.

Hill, L.D., Gray, J.J., Carter, M.M., Schulkin, J. Obstetrician-gynecologists' decision making about the diagnosis of major depressive disorder and premenstrual dysphoric disorder. Journal of Psychosomatic Obstetrics & Gynecology. Vol 26(1), 41-51, 2005 Mar.

Major depressive disorder (MDD) is underdiagnosed and undertreated in ambulatory care settings [1-4] including gynecologic practices [5]. Far less is known about the diagnosis of Premenstrual Dysphoric Disorder (PMDD). Three hundred and thirty-five gynecologists responded to mailed questionnaires that used descriptive scenarios as analogues to clinical cases. Questionnaire recipients were randomly selected to receive either a MDD or PMDD version of the questionnaire. Respondents were less accurate when diagnosing MDD cases (48% accuracy; p=0.526), than PMDD cases (80% accuracy; p<0.001), but were significantly more confident about their probability ratings of MDD cases, t=2.57, p<0.02. Qualitative analysis suggested that less accurate MDD respondents did not prioritize case data according to DSM-IV criteria, whereas almost all PMDD respondents made use of valid reasoning strategies. Respondents did not take base rates into account when deciding about the probability of either affective disorder. Results imply that gynecologists employ cognitive strategies that result in accurate diagnostic judgments about PMDD, but overconfidence, lack of attention to DSM-IV criteria and base rate neglect could hinder clinical decisions about MDD, and may contribute to underdiagnosis of depression.

Coleman V.H., Erickson K., Schulkin J., Zinberg S., Sachs B.P. Vaginal birth after cesarean delivery: practice patterns of obstetrician-gynecologists. Journal of Reproductive Medicine. 50(4):261-6, 2005 Apr.

Objective: To assess obstetrician-gynecologists' current practice patterns and opinions regarding vaginal birth after cesarean delivery (VBAC). Study Design: Questionnaires were mailed to a random sample of 1,200 American College of Obstetricians and Gynecologists (ACOG) fellows in July 2003. Information was gathered on percentage of cesarean and VBAC deliveries performed, factors influencing changes in these rates in the past 5 years, hospital protocol regarding VBAC and factors influencing the recommendation of VBAC. Results: Fifty-three percent of questionnaires were returned to ACOG after 3 mailings. Approximately 49% of respondents reported that they were performing more cesarean deliveries than they were 5 years earlier. The primary reasons for this increase were the risk of liability and patient preference for delivery method. More than 25% of physicians reported that they practiced in hospitals that do not follow the ACOG guidelines with respect to resources and immediate availability. Almost all (98.2%) respondents agreed that they knew the risks and benefits of VBAC. However, only 61% reported feeling competent in determining which patients will have a successful VBAC. Conclusion: Obstetrician-gynecologists seem to be aware of the risks and benefits of VBAC; however, there is some doubt as to who should be offered a trial of labor and what predicts a successful VBAC.

Morgan M.A., Driscoll D.A., Zinberg S., Schulkin J., Mennuti M.T. Impact of self-reported familiarity with guidelines for cystic fibrosis carrier screening. Obstetrics & Gynecology. 105(6):1355-61, 2005 Jun.

Objective: To assess the impact of self-reported familiarity with published guidelines on knowledge, implementation, and opinions of obstetrician-gynecologists regarding carrier screening for cystic fibrosis. Methods: A questionnaire pertaining to cystic fibrosis screening guidelines was mailed to 1,165 members of the American College of Obstetricians and Gynecologists. Results: Sixty-four percent of questionnaires were returned. Statistical analyses were limited to the 632 respondents whose primary medical specialty was gynecology (GynOnly) or obstetrics and gynecology (ObGyns). More ObGyns had thoroughly read or skimmed the guidelines (67.1%) than had GynOnlys (41.6%). Correctly responding to basic questions regarding cystic fibrosis was associated with having read the guidelines, although responding to a more complex question was not. Familiarity with the guidelines was associated with correctly identifying the recommendations for offering screening, with practice implementation of cystic fibrosis screening, and with self-ratings of qualifications and training to offer screening and to provide counseling. In contrast, familiarity with the guidelines was not associated with ObGyn's opinion that burden of disease is likely to be influential in patient acceptance of screening. Physicians who had thoroughly read the guidelines were more likely to disagree that the cystic fibrosis screening test is too inaccurate to risk influencing reproductive decision making (thoroughly read = 79% disagree, skimmed = 69%, not read = 58%, not heard of it = 50%). Conclusion: There was a strong association between self-reported familiarity with the American College of Obstetricians and Gynecologists/American College of Medical Genetics guidelines and physicians' knowledge, implementation, and ratings of training for offering cystic fibrosis carrier screening.

Jones J.L., Schulkin J., Maguire J.H. Therapy for common parasitic diseases in pregnancy in the United States: a review and a survey of obstetrician/gynecologists' level of knowledge about these diseases. Obstetrical & Gynecological Survey. 60(6):386-93, 2005 Jun.

A number of food- and waterborne parasitic diseases that are common in the United States can adversely impact women during pregnancy. Therapeutic considerations during pregnancy for these diseases are reviewed. Also, the level of knowledge of obstetrician-gynecologists about diagnosis and treatment of these diseases (toxoplasmosis, cryptosporidiosis, giardiasis, amebiasis, cyclosporiasis, trichinellosis, ascariasis, and taeniasis) was estimated by means of a questionnaire developed by the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG). Of the 1200 obstetrician-gynecologists surveyed, 521 (43%) responded. In general, respondents gave correct answers to questions about toxoplasmosis, but for other illnesses responses, it varied. For example, most (61.4%) respondents gave incorrect answers about treatment of cryptosporidiosis in pregnancy, and many (41.2%) respondents incorrectly identified metronidazole as the safest treatment for giardiasis in the first trimester of pregnancy. Although knowledge among obstetrician-gynecologists about toxoplasmosis is good, there is a wide variation in knowledge about other common food- and waterborne parasitic diseases that are likely to be encountered in the United States. Therapeutic considerations for these diseases during pregnancy are discussed. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to list the various common protozoal diseases, to outline the clinical manifestations as well as route of spread for each of the protozoal diseases, and to outline potential therapies for each of the protozoal diseases.

Morgan M.A., Hankins G.D., Zinberg S., Schulkin J. Neonatal encephalopathy and cerebral palsy revisited: the current state of knowledge and the impact of american college of obstetricians and gynecologists task force report. Journal of Perinatology. 25(8):519-25, 2005 Aug.

Objectives: To re-assess obstetrician-gynecologists' knowledge of neonatal encephalopathy and cerebral palsy after publication of the ACOG/AAP Task Force report. Study Design: A questionnaire investigating knowledge of neonatal encephalopathy and cerebral palsy was mailed to 1060 members of ACOG, 337 of whom participated in a similar study in 2001. Results: There was a strong association between familiarity with ACOG documentation and knowledge of neonatal encephalopathy (NE) and cerebral palsy (CP) (p<0.001). As with obstetricians surveyed in 2001, knowledge gaps remain. Performance was better on practices questions than knowledge questions. About one-third (34.2%) of the physicians said their knowledge of neonatal encephalopathy was poor or deficient; the majority (76%) rated their residency training as inadequate to marginal. Conclusion: The results indicate better knowledge of neonatal encephalopathy and cerebral palsy among physicians more familiar with the Task Force report. There is a clear need for emphasis on these topics during training and continuing medical education.

Coleman V.H., Power M.L., Williams S., Carpentieri A., Schulkin J. Continuing professional development: racial and gender differences in obstetrics and gynecology residents' perceptions of mentoring. Journal of Continuing Education in the Health Professions. 25(4):268-77, 2005 Dec.

Introduction: Having a mentor during residency is often linked to greater success in professional development. The present study compares changes in the percentage of residents with mentors in 1999 and in 2004, while considering current residents' perceptions of their mentors, with particular attention focused on what role race and gender might play in resident-mentor interactions. Method: A survey was administered to 4, 721 residents who took the 2004 Council on Resident Education in Obstetrics and Gynecology in-training examination. Data are reported for respondents from four racial categories: white, African American, Hispanic, and Asian/Pacific Islander. Results were compared to those of a similar survey administered in 1999. Responses were analyzed by chi-square analysis and univariate analyses of variance. Results: The response rate was 97%. Most residents (64.9%) reported having a mentor. White female residents were least likely to have a mentor. Compared to results from 1999, the percentage of residents with a mentor, and the percentage of residents with female mentors, has increased. For all residents, personal rapport, knowledge of the field, and similarity in professional interests were the three most important factors in choosing a mentor. The proportion of residents reporting explicit discussions about career options has declined since 1999. Discussion: Ethnic minorities are more likely than white residents to have a mentor, and to report that their mentors provide helpful advice. Although the proportion of residents with a mentor has increased since 1999, the quality of the mentoring relationship is meeting resident expectations but not exceeding them.