2010 Publications

Jones JL, Krueger A, Schulkin J, Schantz PM. Toxoplasmosis Prevention and Testing in Pregnancy, Survey of Obstetrician-Gynaecologists. Zoonoses Public Health. 2010 57, Number 1, February 2010 , pp. 27-33(7).

Toxoplasmosis in pregnant women can lead to congenital disease with severe neurological and ocular complications in the foetus. In 2006, we surveyed US obstetrician-gynaecologists to determine their knowledge and practices about toxoplasmosis prevention and testing. Questionnaires were mailed (four mailings) to a random sample of 1200 of the 33 354 members of the American College of Obstetricians and Gynecologists (ACOG). Of the 1200 surveyed, 502 (42%) responded. The respondents were similar to all ACOG members by gender, region of the country and practice type (P > 0.5), and age (respondents were slightly younger, mean 46 years versus 47 years). To prevent toxoplasmosis, most respondents indicated that they counsel pregnant women about cat litter (99.6%), but fewer counselled about eating undercooked meat (77.6%), handling raw meat (67.4%), gardening (65.4%) or washing fruits and vegetables (34.2%). Many (73.2%) respondents were not aware that some Toxoplasma IgM tests have had a high false positive rate, and most (91.2%) had not heard of the avidity test, which can help determine the timing of Toxoplasma gondii infection in relation to pregnancy. There is a need for more education about T. gondii serological testing, particularly the Toxoplasma avidity test. US obstetrician-gynaecologists are providing beneficial counselling to their patients, but could provide more information about undercooked meat and soil risks.

Rayburn WF, Anderson BL, Johnson JV, McReynolds MA, Schulkin J. (2010) Trends in the Academic Workforce of Obstetrics and Gynecology.  Obstetrics & Gynecology, 115:141-146.

Objective: The objective was to report results from the seventh survey that monitored trends in numbers of full-time department faculty and from a first survey on the current and anticipated numbers of part-time faculty.  Methods: A faculty workforce survey, drafted in the same format as the prior published questionnaire, was sent electronically to chairs of obstetrics and gynecology at all 125 U.S. medical schools. Each chair was asked to provide the number of current full-time and part-time (0.5–0.9 full-time equivalent) faculty in each specialty and the projected department size in 5 years. When accuracy of data were questioned, we reviewed the department’s Web site and directly communicated with the chair.  Results: The mean number of full-time faculty per department increased from 25 in 1994 to 29 in 2008 (95% confidence interval 25–33). Most departments (84.0%) had part-time faculty, which constituted 21.2% of the total faculty. Growth was only substantial in the number of medical faculty. In 2008, half (50.1%) of all faculty were women. Private schools and research-oriented departments had the largest faculty sizes. Two-thirds of all chairs anticipated that the number of faculty will increase, especially for part-time faculty and entry-level assistant professors as generalists or maternal–fetal medicine specialists.  Conclusion: Continued growth in department sizes was accompanied by considerably more women and more part-time faculty. The numbers of full-time and part-time faculty are anticipated to increase.

Menzin AW, Anderson BL, Williams S, Schulkin J. Education and experience with breast health maintenance and breast cancer care: a survey of obstetricians and gynecologists. J Cancer Educ. 2010 DOI: 10.1007/s13187-009-0019-8.

Breast cancer is one of the most common malignancies in the United States. A survey regarding the practice, training, and knowledge of breast health maintenance and cancer screening was conducted with a response rate of 59%. Most respondents reported adequate knowledge and that continuing educational efforts were at least adequate. Most recognize the importance of family history and incorporate patient inquiry and referral to genetics practitioners into their practice. A considerable portion does not inquire about hereditary risk factors and feel “not qualified” to manage genetic counseling and screening. Continued training is needed regarding understanding and interpreting hereditary predisposition to breast disease.

Anderson BL, Parra Dang E, Floyd, RL, Sokol R, Mahoney J, & Schulkin J. (2010).  Knowledge, opinions, and practice patterns of obstetrician-gynecologists regarding their patients’ use of alcohol.  Journal of Addiction Medicine, 4, 114-121.

Objective: To evaluate the evolution of fetal alcohol spectrum disorder prevention practices including awareness and use of recently published tools.  Methods: Fellows of the American College of Obstetricians and Gynecologists were asked about their knowledge, opinions, and practice regarding alcohol-related care. Eight hundred obstetrician-gynecologists (ob-gyns) were selected; 48.1% returned the survey.  Results: The majority (66.0%) indicated that occasional alcohol consumption is not safe during any period of pregnancy. There was no consensus when asked if alcohol's effect on fetal development is clear (46.9% thought it was clear and 45.9% did not). Most (82.2%) ask all pregnant patients about alcohol use only during patients' initial visit, whereas 10.6% ask during initial and subsequent visits. Most (78.5%) advise abstinence when pregnant women report alcohol use. When asked which validated alcohol risk screening tool they most commonly use with pregnant patients, 57.8% said they use no tool. Although 71.9% felt prepared to screen for risky or hazardous drinking, older ob-gyns indicated feeling significantly more unprepared than younger ob-gyns. “Patient denial or resistance to treatment” was the top issue affecting alcohol screening and “referral resources for patients with alcohol problems” was the resource needed most. Most ob-gyns were not aware of the National Institute on Alcohol Abuse and Alcoholism “Clinician's Guide” or the American College of Obstetricians and Gynecologists “Fetal Alcohol Spectrum Disorder Prevention Tool Kit.”  Conclusions: There are few changes in the alcohol-related screening and treatment patterns of ob-gyns since 1999; although perceived barriers and needs have changed. Interventions, including referral resources and continuing medical education training, are warranted.

Einarsson J.I, Matteson, KA., Schulkin J., Chavan, NR, & Sangi-Haghpeykar, H. (2010) Minimally invasive hysterectomies-a survey on attitudes and barriers among practicing gynecologists. The Journal of Minimally Invasive Gynecology, 17, 167-175.

Study Objective: To explore attitudes and hysterectomy practices among gynecologists in the United States and to identify potential barriers to offering minimally invasive hysterectomies.  Design: Mixed-mode (online and on-paper) survey of a random sample of 1500 practicing obstetrician-gynecologists.  Setting: Nationwide survey in the United States.  Participants: Nonretired obstetrician-gynecologists identified through a physician list from the American Medical Association.  Interventions: Postal and online survey.  Main Results: We received a response from 376 physicians (25.8% response rate). The average age of respondents was 47.9 years, and 87% were generalists. Participants performed on average 4 surgical cases per week and 32 hysterectomies per year, most of which were abdominal hysterectomies. When asked for preferred mode of access for themselves or their spouse, 55.5% chose vaginal hysterectomy (VH), 40.6% chose laparoscopic hysterectomy (LH), and 8% chose abdominal hysterectomy (AH). Younger physicians (<40) and high surgical volume physicians were significantly more likely to chose a laparoscopic approach and identified significantly fewer barriers for performing LH. The main barriers to performing VH were technical difficulty, potential for complications, and caseload of VH. The main barriers for performing LH were training during residency, technical difficulty, personal surgical experience and operating time. The majority of gynecologists wanted to decrease their AH rates and increase their LH rates. The most significant identified contraindications to VH were prior laparotomy, a uterus larger than 12 weeks, narrow introitus, adnexal mass, and minimal uterine descent.  Conclusions: While a large majority of gynecologists would prefer a VH or LH for themselves or their spouse, AH remains the most common hysterectomy method in the United States. A generation gap appears to be brewing with younger gynecologist more in favor of the laparoscopic approach. More emphasis should be placed on training gynecologists in performing minimally invasive hysterectomies, given their desire to change their surgical mode of access.

Silverman, G.K., Loewenstein, G., Anderson, BL., Zinberg, S., & Schulkin, J. (2010). Failure to discount for conflict of interest when evaluating medical literature: a randomized trial of physicians.  Journal of Medical Ethics, 36, 265-270.

Context: Physicians are regularly confronted with research that is funded or presented by industry. Objective: To assess whether physicians discount for conflicts of interest when weighing evidence for prescribing a new drug.  Design and Setting: Participants were presented with an abstract from a single clinical trial finding positive results for a fictitious new drug. Physicians were randomly assigned one version of a hypothetical scenario, which varied on conflict of interest: 'presenter conflict', 'researcher conflict' and 'no conflict'. Participants: 515 randomly selected Fellows in the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network; 253 surveys (49%) were returned. Main Object Measures: The self-reported likelihood that physicians would prescribe the new drug as a first-line therapy. Results: Physicians do not significantly discount for conflicts of interest in their self-reported likelihood of prescribing the new drug after reading the single abstract and scenario. However, when asked explicitly to compare conflict and no conflict, 69% report that they would discount for researcher conflict and 57% report that they would discount for presenter conflict. When asked to guess how favourable the results of this study were towards the new drug, compared with the other trials published so far, their perceptions were not significantly influenced by conflict of interest information.  Conclusion: While physicians believe that they should discount the value of information from conflicted sources, they did not do so in the absence of a direct comparison between two studies. This brings into question the effectiveness of merely disclosing the funding sources of published studies.

Coleman-Cowger, V.H., Erickson, K., Spong, C.Y., Portnoy, B., Croswel, J., & Schulkin (2010) Current practice of cesarean delivery on maternal request following 2006 state of the science conference. The Journal of Reproductive Medicine, 55, 25-30.

Objective: To determine obstetrician-gynecologists' practice patterns of cesarean delivery on maternal request (CDMR) following the 2006 National Institutes of Health (NIH) State-of-the-Science conference on this topic, and compare them with those in their practice prior to the conference.  Study Design: Questionnaires were mailed to 612 American College of Obstetricians and Gynecologists fellows who participated in a 2006 preconference survey, with 59% responding. The survey assessed demographic characteristics, practice, attitudes, knowledge regarding potential risks and benefits, counseling practices, and department policies with regards to CDMR.  Results: The majority of obstetrician-gynecologists in our sample continues to believe that a woman has the right to CDMR, but fewer than in 2006 would agree to perform this procedure. In general, obstetrician-gynecologists associate more risks and fewer benefits with CDMR than in 2006.  Conclusion: Some physicians have shifted their perception of CDMR risks and benefits since the NIH State-of-the-Science conference; however, practice patterns have not changed significantly.

Dalton, V.K., Harris, LJ, Gold, KJ, Low-Kane, L.,Schulkin, J. Guire, K.,& Fendrick, M. (2010). Provider knowledge, attitudes and treatment preferences for early pregnancy failure.  American Journal of Obstetrics and Gynecology, 202, 531-537.

Objective: We sought to describe health care provider knowledge, attitudes, and treatment preferences for early pregnancy failure (EPF).  Study Design: We surveyed 976 obstetrician/gynecologists, midwives, and family medicine practitioners on their knowledge and attitudes toward treatment options for EPF, and barriers to adopting misoprostol and office uterine evacuations. We used descriptive statistics to compare practices by provider specialty and logistic regression to identify associations between provider factors and treatment practices.  Results: Seventy percent of providers have not used misoprostol and 91% have not used an office uterine evacuation to treat EPF in the past 6 months. Beliefs about safety and patient preferences, and prior induced abortion training were significantly associated with use of both of these treatments.  Conclusion: Increasing education and training on the use of misoprostol and office uterine evacuation, and clarifying patient treatment preferences may increase the willingness of providers to adopt new practices for EPF treatment.

Cogswell, ME, Power, ML, Sharma, AJ, & Schulkin, J. (2010) Prevention and management of obesity in nonpregnant women and adolescents: beliefs and practices of US obstetricians and gynecologists. Journal of Women’s Health, 19, 1625-1634.

Objective: To describe associations between dissemination of educational materials and U.S. obstetrician/gynecologists' prevention and management of obesity in nonpregnant patients.  Methods: Cross-sectional surveys mailed to 806 and 787 members of the American College of Obstetrician and Gynecologists (ACOG) Collaborative Ambulatory Research Network in February-April 2005 and March-May 2007, respectively, before and after dissemination of ACOG Committee Opinions.  Results: Compared with participants in 2005 (n = 437), the proportion of participants in 2007 (n = 433) who reported they would screen nonpregnant adult patients using body mass index (BMI), counsel patients most of the time about physical activity, and ever prescribed weight loss medications increased from 84% to 91%, 48% to 55%, and 40% to 48%, respectively (p < 0.05 for all comparisons). In contrast, reported frequencies of counseling or referring nonpregnant patients for weight control were not significantly different (p > 0.05). In 2007, 33% reported counseling most of the time, and 70% reported referral at least sometimes. A lower proportion of 2007 participants indicated it was likely or very likely that patients would follow advice about physical activity or diet or they can help patients lose weight (p < 0.01 for all comparisons). For adolescent patients, 43% and 24% of participants reported counseling most of the time about physical activity and sedentary activity, respectively. Reported frequency of counseling patients about activity, counseling adult patients about weight control, and prescribing medications was higher among obstetrician/gynecologists who reported reading the Committee Opinions.  Conclusions: Despite decreased optimism about the likelihood of patients following advice, modest improvements occurred in some obstetrician/gynecologists' obesity prevention practices between 2005 and 2007.

Funk, C., Weinstein, L., Anderson, BL., & Schulkin, J. (2010) Survey of obstetric and gynecologic hospitalists and laborists.  American Journal of Obstetrics and Gynecology, 203, 2, 177.e1-4.

Objective: The objective of the study was to obtain descriptive information about obstetricians/gynecologists who currently are practicing as hospitalists or laborists.  Study Design: A survey was emailed to all actively practicing member Fellows of the American College of Obstetricians and Gynecologists in April 2009. A second emailing of the survey was sent in May 2009.  Results: Obstetrician/gynecologist hospitalists and laborists are significantly younger than the rest of the obstetrician/gynecologist sample by age and years in residency and have a high rate of career satisfaction. There was a great deal of variation in work schedules and compensation of the respondents.  Conclusion: We analyzed the rapidly growing hospitalist/laborist model of care within the obstetrician/gynecologist specialty. The laborists and hospitalists model provides an alternative type of practice for obstetricians/gynecologists, and it is associated with high career satisfaction. It is important that we continue to monitor the needs of this burgeoning field of clinical practice.

Morgan, M.A. Lawrence, H., & Schulkin, J. (2010). Obstetrician-gynecologists approach to well-woman care. Obstetrics and Gynecology, 116, 3, 715-722.

Objective: To estimate obstetrician-gynecologists' attitudes and management practices regarding well-woman care.  Methods: A questionnaire was mailed to 1,000 members of the American Congress of Obstetricians and Gynecologists, 600 of whom participate in the Collaborative Ambulatory Research Network.  Results: The response rate was 57%. Of these, 513 (91%) respondents provide routine gynecologic care and are the focus of the study. Most obstetrician-gynecologists include an examination of the abdomen (97%) and thyroid and neck (92%) during a well-woman examination, although fewer conduct skin (73%) or mouth (19%) surveys. Asked how they would most likely treat several conditions in nonpregnant patients, respondents would prescribe medications for menopausal issues (69%), hormone therapy (73%), and for generalized anxiety disorder (39%), and they would refer patients to a primary care physician for high blood pressure (73%) and high cholesterol (65%). Female and younger respondents were more likely than male and older respondents to refer patients for several nonreproductive health conditions and were less likely to personally treat them. A majority (61%) of obstetrician-gynecologists define well-woman care within the context of gynecologic practices as care related to overall health and primary care rather than care limited to reproductive health (39%); this majority was less likely to agree that obstetrician-gynecologists should limit their care to reproductive health (15% compared with 62%) and more likely to personally treat most nonreproductive health issues than were those who see care as limited to reproductive health.  Conclusion: The majority of obstetrician-gynecologists define well-woman care as overall health and primary care, and their opinions and practices reflect this.

Verani JR, Montgomery S, Schulkin J, Anderson BL, Jones JL. (2010). Survey of obstetrician-gynecologists in the United States about Chagas disease. American Journal of Tropical Medicine and Hygiene, 83(4), 891-895.

Chagas disease affects an estimated 300,000 people in the United States, and as many as 300 congenital infections are estimated to occur annually. The level of knowledge about Chagas disease among obstetricians-gynecologists in the United States has not been assessed. The American College of Obstetricians and Gynecologists surveyed a representative sample of 1,000 members about Chagas disease. Among 421 respondents, 68.2% (95% confidence interval [CI] = 63.5-72.6) described their knowledge level about Chagas disease as "very limited." Only 8.8% (95% CI = 6.2-12.0) knew the risk of congenital infection, and 7.4% (95% CI = 5.1-10.4) were aware that both acute and chronic maternal infections can lead to congenital transmission. The majority of respondents (77.9%; 95% CI = 73.5-81.9) reported "never" considering a diagnosis of Chagas disease among their patients from endemic countries. Most of those who did consider the diagnosis did so "rarely." Knowledge of Chagas disease among obstetricians-gynecologists in the United States is limited. Greater awareness may help to detect treatable congenital Chagas cases.

Morgan MA, Cragan JD, Goldenberg RL, Rasmussen SA, & Schulkin J. (2010). Obstetrician-gynaecologist knowledge of and access to information about the risks of medication use during pregnancy. Journal of Maternal-Fetal and Neonatal Medicine, 23(10), 1143-1150.

Objective: To assess opinions, knowledge, and informational resources of obstetrician-gynaecologists regarding the safety of medication use during pregnancy. Methods:  A questionnaire was mailed to 770 members of the American College of Obstetricians and Gynecologists who participate in the Collaborative Ambulatory Research Network. Results: The response rate was 58%. Of these, 305 respondents provide both routine gynecologic and obstetric care and are the focus of the study. There was wide variation in obstetrician-gynaecologists' assessments of the safety for the foetus of medications ranging from aspirin to valproic acid. The Physicians' Desk Reference was most frequently (75%) cited as a source of information about medication safety. Forty-two percent of obstetrician-gynaecologists selected lack of sufficient information on medications as the greatest barrier to counselling pregnant women about their use, while only 4% selected lack of access to information as the greatest barrier. Most (79%) obstetrician-gynaecologists indicated they would be willing to participate in pregnancy exposure registries, but far fewer (24%) reported having done so. Conclusion: These results emphasise the need for safety information about the effects of medication use during pregnancy and suggest that pregnancy exposure registries are underutilised.


Morgan MA, Cragan JD, Goldenberg RL, Rasmussen SA, & Schulkin J. (2010). Management of prescription and nonprescription drug use during pregnancy. Journal of Maternal-Fetal and Neonatal Medicine, 23(8), 813-819.

Objective: To assess screening and treatment patterns of obstetrician-gynecologists regarding medication use during pregnancy. Methods:A questionnaire was mailed to 770 members of the American College of Obstetricians and Gynecologists who participate in the Collaborative Ambulatory Research Network. Results: The response rate was 58%. Most respondents reported always asking pregnant patients about use of over-the-counter (OTC) (86%) and prescription (98%) drugs; 24% reported not always asking about alternative medications. Far fewer reported always asking nonpregnant patients about use of alcohol (67%), illegal drugs (51%) and OTC medications (52%) than pregnant patients. Two-fifths (41%) reported prescribing a medication during pregnancy for which they had insufficient information about potential effects on the fetus; nearly half (47%) reported that there are medical conditions for which they would like to prescribe medications but do not due to insufficient safety information. Physician responses indicate that they are less likely to refer pregnant than nonpregnant patients to a specialist for treatment of certain conditions. Conclusions: These results indicate that obstetrician-gynecologists sometimes prescribe medications for pregnant patients under less than optimal conditions and emphasize the importance of generating up-to-date information on effects of medications during pregnancy and having it readily available to health care providers.


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