2006 Publications

Cleary-Goldman J., Bettes B., Robinson J.N., Norwitz E., D'Alton M.E., Schulkin J. Postterm pregnancy: practice patterns of contemporary obstetricians and gynecologists. American Journal of Perinatology. 23(1):15-20, 2006 Jan.

The purpose of this study was to determine the management of postterm pregnancy by contemporary practicing obstetricians. A questionnaire investigating practice patterns pertaining to postterm pregnancy was mailed to 1000 randomly selected American College of Obstetricians and Gynecologists (ACOG) Fellows and Junior Fellows in March 2004. The response rate was 52.2% (522/1000). Statistical analysis included the answers from the 420 practicing obstetricians. Males comprised 55.7% (234/420) of the responding obstetricians. The majority of responding obstetricians (95.4%) rated their residency training regarding management of postterm pregnancy as adequate or comprehensive. Forty-eight percent define postterm pregnancy as 42 weeks gestation or greater, whereas 43.1% consider 41 weeks gestation or greater to be postterm. Seventy-three percent routinely induce low-risk patients with singletons at 41 weeks gestation. If patients decline induction at 41 weeks or if the practitioner does not induce patients until after 41 weeks gestation, the majority of respondents (64.8% and 65.0%, respectively) start postterm pregnancy fetal testing in singletons at 41 weeks and obtain testing twice weekly. Most (64.6%) use cervical ripening agents when inducing both nulliparous and multiparous patients with unfavorable cervices. The majority of practitioners (97.3%) do not use prostaglandins when inducing postterm patients with one previous cesarean delivery. Although most respondents manage postterm pregnancy according to recent ACOG educational materials with regard to antenatal fetal surveillance and methods of induction, the majority induce patients with singleton postterm pregnancies at 41 weeks gestation rather than at 42 weeks gestation.

Coleman V.H., Morgan M.A., Zinberg S., Schulkin J. Clinical approach to mental health issues among obstetrician-gynecologists: a review. Obstetrical & Gynecological Survey. 61(1):51-8, 2006 Jan.

In recent years, obstetrician-gynecologists have taken on a greater role in the provision of primary care. Mental health has been a topic worthy of further exploration as a result of the high prevalence rates of women presenting in gynecologic settings with depressive, anxiety, or eating-disordered symptoms. The detrimental effects of psychopathology have been well documented in the literature, especially if present during pregnancy. This article provides a review of the literature in the area of clinical practice related to mental health among obstetrician-gynecologists based on searches of the Psyc Info and MEDLINE databases. Lack of recognition and underdiagnosis are common problems that need to be addressed by focused educational initiatives. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall the importance of screening for various types of mental disease during an ob/gyn visit; describe the detrimental effects of psychopathology, especially during pregnancy; and explain the importance of educational initiatives in detecting and treating mental disorders.

Cleary-Goldman J., Morgan M.A., Malone F.D., Robinson J.N., D'Alton M.E., Schulkin J. Screening for Down syndrome: practice patterns and knowledge of obstetricians and gynecologists.  Obstetrics & Gynecology. 107(1):11-7, 2006 Jan.

Objective: To assess obstetricians' practice patterns and knowledge regarding screening for Down syndrome. Methods: A questionnaire was mailed to 1,105 American College of Obstetricians and Gynecologists Fellows and Junior Fellows in 2004. Results: Sixty percent of questionnaires were returned. Statistical analyses were limited to the 532 practicing obstetricians. Greater than 80% felt their training and experience qualified them to counsel patients about genetic issues in pregnancy. However, 45% rated their residency training regarding prenatal diagnosis as barely adequate or nonexistent. American College of Obstetricians and Gynecologists publications were rated by 86% as an important source of information on genetic counseling. Seventy-eight percent of practitioners counsel all obstetric patients about risks for fetal aneuploidy, and 67% provide counseling for heritable genetic abnormalities. Although the majority (99%) offer second-trimester Down syndrome screening, only 55% also offer first-trimester screening for Down syndrome. Almost one half (49%) use the quad screen, and 6% offer integrated first- and second-trimester screening. The majority (88%) routinely offer amniocentesis to patients who are at elevated risk for genetic abnormalities, whereas 44% also offer chorionic villus sampling. Few (2%) perform chorionic villus sampling. Conclusion: Most obstetricians manage patients at risk for fetal genetic abnormalities according to American College of Obstetricians and Gynecologists educational materials. This survey identified deficiencies related to Down syndrome screening, including a limited number of practitioners performing chorionic villus sampling and physicians' own perception that training regarding genetic counseling should be improved. Educational strategies are needed to address these deficiencies before first-trimester screening programs are widely implemented. LEVEL OF EVIDENCE: III.

Morgan, M.A., Dana, J.,   Loewenstein, G., Zinberg, S., Schulkin, J. Interactions of doctors with the pharmaceutical industry. Journal of Medical Ethics, 32:559-563, 2006. 

Objective: To assess the opinions and practice patterns of obstetrician-gynaecologists on acceptance and use of free drug samples and other incentive items from pharmaceutical representatives.  Methods: A questionnaire was mailed in March 2003 to 397 members of the American College of Obstetricians and Gynecologists who participate in the Collaborative Ambulatory Research Network. Results: The response rate was 55%. Most respondents thought it proper to accept drug samples (92%), an informational lunch (77%), an anatomical model (75%) or a well-paid consultantship (53%) from pharmaceutical representatives. A third (33%) of the respondents thought that their own decision to prescribe a drug would probably be influenced by accepting drug samples. Respondents were more likely to think the average doctor’s prescribing would be influenced by acceptance of the items than theirs would be (p<0.002). Respondents who distributed drug samples to patients indicated doing so because of patients’ financial need (94%) and for their convenience (76%) and less so as a result of knowledge of the efficacy of the sample product (63%). A third (34%) of respondents agreed that interactions with industry should be more strictly regulated. Conclusion: Obstetrician-gynaecologists largely indicated that they would act in accordance with what they think is proper regarding accepting incentive items from pharmaceutical representatives. Although accepting free drug samples was considered to be appropriate more often than any other item, samples were most commonly judged to be influential on prescribing practices. The widely accepted practice of receiving and distributing free drug samples needs to be examined more carefully.

Gray A.D., Power, M.L., Zinberg, S., Schulkin, J.Assessment and Management of Obesity.  Obstetrical and Gynecological Survey.  Obstetrical & Gynecological Survey 61(11): 742-748,  2006.

Obesity is a serious medical condition that significantly impacts the health of pregnant and nonpregnant women.  Although obstetrician-gynecologists have reported that they are knowledgeable of the health risks associated with obesity, they have also reported that their knowledge of weight assessment and management is inadequate.  The purpose of this article is to review the proper procedures for assessing and managing obesity.  By properly assessing obesity and constructing individualized weight management plans for those affected, obstetrician-gynecologists can help reduce the prevalence of obesity in women of childbearing ages.  Target Audience: Obstetricians & Gynecologists, Family Physicians.  Learning Objectives: After completion of this article, the reader should be able to explain the impact of obesity on the health of nonpregnant and pregnant women, summarize the methods of distinguishing overweight from obesity, and recall the proper weight management programs for and assessments of obesity in women.

Power M.L., Cogswell M.E., Schulkin, J. Obesity Prevention and Treatment Practices of U.S. Obstetrician–Gynecologists.  Obstetrics & Gynecology, 108:961-968, 2006.

Objective: To describe obesity prevention and treatment practices of U.S. obstetrician–gynecologists. Methods: A cross-sectional survey was mailed to 1,806 practicing members of the American College of Obstetricians and Gynecologists (ACOG) in February-April 2005.   Results: Of the 900 respondents who returned questionnaires, 82% reported using body mass index (BMI) to assess obesity; 80% reported counseling patients about weight control and 84% about physical activity "most of the time" or "often." Most reported counseling patients about diet; the most frequently recommended dietary strategies were changing eating patterns, limiting intake of specific foods, and controlling portion size. About 27% reported referring their patients for behavioral therapy "most of the time" or "often," and 35% reported ever prescribing weight loss medications to obese patients. More than 85% counseled patients about pregnancy weight gain, and 64% used the patients’ prepregnancy BMI to modify their recommendations "most of the time" or "often." Respondents who completed their residency after 1996 were more likely to use patients’ BMI to screen for obesity than those who finished earlier. Respondents who believed that they could help their patients lose weight (44%) were more likely to counsel their patients to do so (P<.001). Conclusion: A majority of obstetrician–gynecologists appear to use BMI to screen for obesity and to counsel their patients about weight control, diet, and physical activity. Many, however, do not prescribe weight loss medications or refer patients to behavioral weight loss therapy. Obstetrician–gynecologists who believe they can help patients lose weight are more likely to follow recommendations for the treatment of obesity.   Level of Evidence: III

Morgan, M.A. & Schulkin, J. Obstetrician-gynecologists and self-identified depression: Personal and clinical. Depression and Anxiety. Vol 23(2), 83-89, 2006.

A survey was designed to explore the effect of obstetrician-gynecologists' subjective awareness of depression in themselves and close family/friends on screening patients for depression and on assessing and treating depression in three scenarios describing hypothetical patients during the adolescence, postpartum, and perimenopausal periods. Questionnaires were mailed to 397 members of the American College of Obstetricians and Gynecologists (ACOG) who participate in the Collaborative Ambulatory Research Network (CARN). Fifty-five percent of the questionnaires were returned. One third of physicians reported having suffered from depression occasionally (28.1%), often (3.8%), or all the time (2.4%) during the past year. Having personally suffered from depression was associated with elevated assessment of depression in the scenarios but not with elevated rates of screening for depression in actual practice, nor with aggressiveness of treatment choices in the scenarios. Awareness that a close friend suffered from depression was not associated with lowered mood as measured, but was associated with increased rates of screening for depression in adolescent, postpartum, and perimenopausal patients, and with elevated assessment of depression and more aggressive treatment practices for depression in hypothetical patients at these three life stages. As such, physicians' practices regarding depression may be influenced by something other than reactivity to their own emotional state.

Power M.L., Zinberg S., Schulkin J. A survey of obstetrician-gynecologists concerning practice patterns and attitudes toward hormone therapy. Menopause. 13(3):434-41, 2006 May-Jun.

Objective: To examine the knowledge and prescribing practices of obstetrician-gynecologists regarding hormone therapy in light of the published evidence from the Women's Health Initiative study on combined estrogen + progestin. Design: A survey questionnaire was sent to 2,500 randomly selected Fellows of the American College of Obstetricians and Gynecologists in November of 2003; 705 surveys were returned. Of those, 644 reported their specialty as obstetrics and/or gynecology and those responses are reported. Results: A majority of physicians that completed their residency before 1995, both men and women, were not convinced by the WHI research results and disagreed with the decision to end the trial. Physicians that rated themselves very confident about their ability to interpret the scientific literature were more likely to be unconvinced by the results and to disagree with the decision to end the trial. In general, physicians that completed their residency more recently rated the benefits of hormone therapy lower and the risks higher. A majority of respondents (53.3%) reported that their prescribing practices were unlikely to change; however, 29.6% reported that they would be somewhat less likely and 9.5% dramatically less likely to prescribe hormone therapy. Physicians reported that their patients were less likely to request hormone therapy (91.8%) and were more likely to discontinue use (93.0%). Conclusion: Physicians that have been in practice longer were more positive about the risks and benefits of HT, and were more skeptical about the recent research. The published data seem to have affected patient preferences and to have had some effect on physician prescribing practices.

Emmons S.L., Nichols M., Schulkin J., James K.E., Cain J.M. The influence of physician gender on practice satisfaction among obstetrician gynecologists. American Journal of Obstetrics & Gynecology. 194(6):1728-38; discussion 1739, 2006 Jun.

Objective: A survey was conducted to investigate the hypothesis that female gender would positively affect job satisfaction among obstetrician gynecologists. Study Design: A survey was sent to 500 randomized, age matched American College of Obstetrics and Gynecology members, 50% each men and women: 49.8% responded. Data were analyzed with the chi2 contingency test, Cochran's test for linear trends, Student t tests, and multiple regression. Results: Women considered their gender an asset in deciding on a career in obstetrics and gynecology, in obtaining jobs, and in maintaining their practices. Men considered that their gender limited their practice options and were more likely to report that they would not choose a career in obstetrics and gynecology if they could choose again. The only significant difference between men and women in measures of obtaining and maintaining a practice was that men were more likely to practice in small urban or rural settings. Men reported higher incomes. Both genders were equally satisfied with their jobs. Conclusion: Although both genders considered female gender to be an asset in obstetrics and gynecology, this survey showed no difference in their ratings of overall career satisfaction.

Power M.L. &  Schulkin J. Obstetrician-gynecologists' patients' knowledge of and attitudes toward hormone therapy: a survey. Journal of Reproductive Medicine. 51(7):525-32, 2006 Jul.

Objective: To investigate the opinions of obstetrician-gynecologists' patients toward hormone therapy (HT). Study Design: Survey questionnaires for patients were mailed to obstetrician-gynecologists who belong to the Collaborative Ambulatory Research Network. Results: Surveys were returned by 1,659 patients from 39 states and the District of Columbia. Women over 50 years old and postmenopausal women of all ages were more likely to report being well informed. Perimenopausal and postmenopausal women were significantly more likely than premenopausal women to have extensively considered the risks and benefits of HT (p<0.001). More highly educated women were more likely to be aware of the results of the recent clinical trials of HT and to have formed an opinion about the risks and benefits of HT. Women who had formed an opinion were essentially divided over whether HT use after menopause would be helpful or harmful. Less than half the women thought that physicians know enough about HT to give appropriate advice. Conclusion: There was little consensus regarding the risks and benefits of HT. Postmenopausal and more educated women considered themselves more informed and were more likely to have reached a decision regarding HT but were as evenly divided regarding the risks and benefits.

Shaer C.M., Chescheir N., Erickson K., Schulkin J. Obstetrician-gynecologists' practice and knowledge regarding spina bifida. American Journal of Perinatology. 23(6):355-62, 2006 Aug.

The purpose was to assess practicing obstetrician-gynecologists' knowledge about the prenatal diagnosis and postnatal prognosis of spina bifida. Written questionnaires designed to assess practicing obstetrician-gynecologists' knowledge of spina bifida were mailed to 1000 randomly selected American College of Obstetricians and Gynecologists Fellows. More than 50% did not identify many of the sonographic features indicative of an open neural tube defect in the fetus and more than one third overestimated the risks of stillbirth, whereas more than two thirds overestimated the risk for premature delivery in a pregnancy complicated by fetal spina bifida. Just more than 50% correctly estimated the 1-year survival rate and just less than 50% correctly estimated survival at 6 years. Sixty-six percent overestimated the incidence of mental retardation associated with spina bifida. Maternal-fetal medicine specialists returning the survey exhibited a much better understanding of the prenatal issues and prognostic and outcome factors related to spina bifida. There are gaps in obstetrician-gynecologists' knowledge about the diagnostic features of and prognosis for fetal spina bifida. It is important for them to take advantage of continuing medical education opportunities to learn more about the management of pregnancies complicated by fetal spina bifida and about the prognosis for affected individuals.

Morgan M.A., Hawks D., Zinberg S., Schulkin J. What obstetrician-gynecologists think of preconception care. Maternal & Child Health Journal. 10 Suppl 7:59-65, 2006 Sep.

Objectives: To describe obstetrician-gynecolog-ists' opinions of preconception care (PCC) and ascertain patient uptake for this service. Methods: A questionnaire was mailed to 1105 ACOG members in August 2004. Results: There was a 60% response rate. Most physicians think PCC is important (87%) and almost always recommend it to women planning a pregnancy (94%); 54% do so with women who are sexually active. Around a third (34%) thought their patients usually do not plan their pregnancies and 49% said very few pregnant patients came in for PCC. Of those who obtain PCC, they were believed to do so more likely to assure a healthy pregnancy (83%) than because of an elevated risk for birth defects (20%). Of 11 issues presented, cigarette smoking and folic acid supplementation were rated the most important for PCC counseling; exercise and environmental concerns were the least important. Conclusions: Physicians are willing to provide PCC but few patients are accessing such services.

Curtis M., Abelman S., Schulkin J., Williams J.L., Fassett E.M. Do we practice what we preach? A review of actual clinical practice with regards to preconception care guidelines. Maternal & Child Health Journal. 10 Suppl 7:53-8, 2006 Sep.

Objectives: To review what past studies have found with regard to existing clinical practices and approaches to providing preconception care. Methods: A literature review between 1966 and September 2005 was performed using Medline. Key words included preconception care, preconception counseling, preconception surveys, practice patterns, pregnancy outcomes, prepregnancy planning, and prepregnancy surveys. Results: There are no current national recommendations that fully address preconception care; as a result, there is wide variability in what is provided clinically under the rubric of preconception care. Conclusions: In 2005, the Centers for Disease Control and Prevention sponsored a national summit regarding preconception care and efforts are underway to develop a uniform set of national recommendations and guidelines for preconception care. Understanding how preconception care is presently incorporated and manifested in current medical practices should help in the development of these national guidelines. Knowing where, how, and why some specific preconception recommendations have been successfully adopted and translated into clinical practice, as well as barriers to implementation of other recommendations or guidelines, is vitally important in developing an overarching set of national guidelines. Ultimately, the success of these recommendations rests on their ability to influence and shape women's health policy.

Contact:

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