2012 Publications

Anderson BL, Gigerenzer G, Parker S, Schulkin J. (2012). Statistical literacy in obstetricians and gynecologists. J Healthc Qual, doi: 10.1111/j.1945-1474.2011.00194.x [Epub ahead of print]

The Obstetrician-Gynecologist Statistical Literacy Questionnaire (OGSLQ) was designed to examine physicians’ understanding of various number tasks that are relevant to obstetrician-gynecologists (ob-gyns) practice. Forty-seven percent of the nationally representative, practicing ob-gyns responded. Physicians did poorly on the questions about numerical facts (e.g., number of women living with HIV/AIDS), better on questions about statistical concepts (e.g., incidence, prevalence), and best on questions about numerical relationships (e.g., convert frequency to percentage) with 0%, 7%, 36%, answering all correctly, respectively. Only 19% correctly estimated the number of U.S. women with cancer. Sixty-six percent were able to use sensitivity and specificity to choose a test option. Around 90% could translate between frequency and probability formats. Forty-nine percent of respondents were able to calculate the positive predictive value of a mammography screening test. Physicians lack some understanding of statistical literacy. It is important that we monitor physicians’ statistical literacy and provide training to students and physicians.

Pearlman M, Anderson BL, Bell AV, Griffin JL, Schulkin J, De Vries R. (2012). A survey of ob/gyn physicians' training and current practice patterns in breast care. The Breast Journal, doi: 10.1111/tbj.12028  (This is a letter to the editor and has no abstract.)

Byams VR, Anderson BL, Grant AM, Atrash H, Schulkin J. (2012). Evaluation of bleeding disorders in women with menorrhagia: a survey of obstetrician-gynecologists. Am J Obstet Gynecol, 207(4), 269.e1-5.

Objective: To better understand the current evaluation of unexplained menorrhagia by obstetrician-gynecologists and the extent to which a bleeding disorder diagnosis is being considered in this population. Study Design: A total of 1200 Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists were invited to participate in a survey on blood disorders. Respondents completed a questionnaire regarding their patient population and their evaluation of patients with unexplained menorrhagia. Results: The overall response rate was 42.4%. Eighty-two percent of respondents reported having seen patients with menorrhagia caused by a bleeding disorder. Seventy-seven percent of physicians reported they would be likely or very likely to consider a bleeding disorder as causing menorrhagia in adolescent patients; however, only 38.8% would consider bleeding disorders in reproductive age women. Conclusion: The current data demonstrate that obstetrician-gynecologists seem to have a relatively high awareness of bleeding disorders as a potential underlying cause of menorrhagia.

Rasmussen SA, Power ML, Jamieson DJ, Williams J, Schulkin J, Kahn EB, Zhang Y, Macfarlane K, Kissin DM. (2012). Practices of obstetrician-gynecologists regarding nonvaccine-related public health recommendations during the 2009 H1N1 influenza pandemic. Am J Obstet Gynecol, 207(4), 294.e1-7.

Objective: We examined practices of obstetrician-gynecologists regarding nonvaccine-related public health recommendations during the 2009 H1N1 influenza pandemic. Study Design: From February-May 2010, a survey was sent to a random sample of members of the American College of Obstetricians and Gynecologists involved in obstetric care. Results: Obstetrician-gynecologists varied in their adherence to 2009 H1N1 influenza public health recommendations. Nearly all reported prescribing antiviral medications to pregnant women with suspected influenza. Most obstetrician-gynecologists reported using preventive practices in the outpatient setting to reduce exposure of well patients to ill ones. A wide range of responses was provided regarding postpartum infection control practices, suggesting lack of awareness of, disagreement with, or difficulty adhering to these recommendations. Conclusion: Obstetrician-gynecologists reported that they adhered to some recommendations related to 2009 H1N1 influenza, but not to others. These data provide insight into strategies for development and dissemination of recommendations in a future pandemic.

Power ML & Schulkin J. (2012). Maternal obesity, metabolic disease, and allostatic load. Physiol Behav, 106(1), 22-8.

Maternal obesity is a risk factor for many metabolicdiseases for the mother, both during gestation and post partum, and for the child in later life. Obesity and pregnancy both result in altered physiological states, significantly different from the state of the non-obese, non-reproductive adult female. The concept of allostasis may be more appropriate for understanding the physiology of both pregnancy and obesity. In pregnancy these altered physiological states are adaptive, in both the evolutionary and physiological senses of the word. Obesity, however, represents a state outside of the adaptive evolutionary experience of our species. In both cases the altered physiological state derives at least in part from signals from an active endocrine organ. In obesity this is adipose tissue, and in pregnancy it is the placenta. The signaling molecules from adipose tissue and placenta all have multiple functions and can affect multiple organ systems. Placenta acts as a central regulator of metabolism for both the maternal and fetal compartments, in essence acting as a “third brain” during pregnancy. Both adipose tissue and placenta express many proinflammatory cytokines; obesity and pregnancy are states of low-grade inflammation. Both obesity and pregnancy are also states of insulin resistance, and maternalobesity is associated with fetal insulin resistance. We argue that obesity during pregnancy leads to sustained and inappropriate activation of normally adaptive regulatory circuits due in part to competing and conflicting signaling from adipose tissue and placenta. This results in allostaticload, leading to the eventual break down of regulatory mechanisms. The result is impaired metabolic function of the mother, and altered development of metabolic systems and potentially altered neural appetite circuits for the offspring.

Leddy MA, Farrow VA, Joseph GF Jr, Schulkin J. (2012). Obstetrician/gynecologists and postpartum mental health: differences between CME course takers and nontakers. J Contin Educ Health Prof, 32(1), 39-47.

Introduction: Continuing medical education (CME) courses are an essential component of professional development. Research indicates a continued need for understanding how and why physicians select certain CME courses, as well as the differences between CME course takers and nontakers.  Purpose: Obstetrician-gynecologists (OB-GYNs) are health care providers for women, and part of their purview includes mental health, such as postpartum depression (PPD) and psychosis (PPP). This study evaluated OB-GYNs' knowledge, attitudes, and behavior (KAB) regarding PPD/PPP, and compared characteristics of CME course takers and nontakers.  Method: A survey was sent to 400 OB-GYNs.  Results:  Response rate was 56%. One-third had taken a CME course on PPD/PPP. Those who consider themselves a "specialist" were less likely to have taken a CME course on postpartum mental health than those who consider themselves "both primary care provider and specialist." Non-CME course takers rely on clinical judgment more. They also are less likely to track patients' psychiatric histories and they utilize validated assessments less frequently. However, CME course takers and nontakers did not differ on knowledge or belief items.  Conclusions: CME courses on PPD/PPP were associated with increased screening and utilization of validated assessments. There was no association between having taken a course and several knowledge questions. It is unclear if CME courses are effective in disseminating information and altering KAB.

Queenan J, Power ML, Farrow V, Schulkin J. (2012). U.S. obstetrician-gynecologists' estimates of their patients' breastfeeding rates. Obstet Gynecol, 119(4), 838-44.

Objectives:  To estimate obstetrician-gynecologists' promotion and support of breastfeeding and their perception of patient breastfeeding practices to examine whether variation in physician practice contributes to low breastfeeding rates.  Methods: We conducted a survey study of 290 members of the Collaborative Ambulatory Research Network, a sample of college fellows (response rate 48.3%). We compared the results with the Centers for Disease Control and Prevention state-by-state Breastfeeding Report Card data: 75% or more initiating breastfeeding termed high, 65-74% termed medium, and 64% or lower termed low. The survey consisted of questions regarding physician and patient demographics, physician satisfaction regarding breastfeeding practices, opinions and knowledge of breastfeeding, opinions of breastfeeding duration, and physicians' effort toward encouraging breastfeeding. An "effort" score was created from these questions.  Results: Physicians' perceptions of breastfeeding initiation rates were consistent with Centers for Disease Control and Prevention data for high (77.3%±1.5%), medium (70.9%±2.7%), and low states (59.4%±3.4%). Physicians with a high proportion of African American or Medicaid-eligible patients reported lower rates of initiating breastfeeding; a high proportion of Medicaid-eligible patients was associated with lower breastfeeding at 3, 6, and 12 months. More physicians were satisfied in high breastfeeding states (72.7%) than in medium (60%) or low states (34.3%). We found no association between the effort score and physician age or patient demographics; however, women (10.2±0.2) scored higher than men (8.6±0.3, P=.001). Effort score did not differ among high, medium, or low breastfeeding states. Conclusion:  Physician satisfaction reflected perceived patient behavior. Physician effort scores were similar across patient breastfeeding behavior. Patient demographics rather than physician practice predicted low breastfeeding rates.

Anderson BL, Lawrence H, Schulkin J. (2012). Academic Workforce Trends in Community Hospitals. Journal of Community Hospital Internal Medicine Perspectives, 2(1), 17361.

Introduction: Obstetrician-gynecologist faculty workforce studies have been limited to faculty at university training programs. Not much is known about the obstetrician-gynecologist faculty workforce at community programs. Method: This study assessed the obstetrician-gynecologist faculty workforce in community training programs via administering surveys to the department chairs. The questionnaire assessed number of current faculty by degree, work status (part-time/full-time), rank, and sub-specialty. Out of 125 programs, 65 responded (52% response rate). Results: The mean number of full-time faculty per department in community hospitals was 17 faculty. Two-thirds of community department chairs anticipated an increase in full-time faculty and 43% anticipated an increase in part-time faculty. Like university programs, sub-specialists and Professors (compared to generalists and assistant professors) were more likely to be male. Conclusion: There are similarities between the community and university faculty workforce, many of the community program faculty are involved in research. Given the evolving clinical, educational, and research demands on community faculty, it is important to continue to monitor and study community program faculty.

Obrecht NA, Chapman G, Anderson BL, Schulkin J. (2012). Retrospective frequency formats promote consistent experience-based Bayesian judgmentsApplied Cognitive Psychology, 26(3), 436-40.

On the basis of their experiences with pregnant patients in their practice, obstetrician/gynecologists estimated the posterior probability of Down syndrome given a positive screening result. They also estimated the base rate of Down syndrome in their practice, along with the hit and false alarm rates for the screening test; for each subject, these numbers were combined to calculate a posterior probability to which the initial estimated posterior probability could be compared. Physicians gave highly consistent estimates when asked to think about their past experiences in terms of event frequencies. However, those told to respond using single event probabilities or to use past experiences to predict prospective frequencies gave inconsistent Bayesian estimates. Thus, when making Bayesian judgments based on real life experience, natural frequency formats only lead to better judgments, compared with single event probability formats, if people think retrospectively, not when using past experiences to make prospective predictions.

Anderson BL, Carlson R, Anderson J, Hawks D, Schulkin J. (2012).  What factors influence obstetrician-gynecologists to follow recommended HIV screening and testing guidelines? J Womens Health (Larchmt), 21(7), 762-8.

Background: The purpose of this study was to determine what factors may influence obstetrician-gynecologists' HIV testing practices and to learn more about obstetrician-gynecologists' current HIV screening and testing practicesMethods: Survey questionnaires were sent to 1200 American College of Obstetricians and Gynecologists (the College) Fellows and Junior Fellows in practice between October 2009 and January 2010. Four hundred of the recipients were members of the Collaborative Ambulatory Research Network (CARN), and 800 recipients were randomly selected from the ACOG Fellows and Junior Fellows in practice.  Results: The survey response rate was 62.0% (248 of 400) for CARN and 31.1% (249 of 800) for non-CARN. Nearly 100% (99.7%) of the study sample report recommending HIV testing to all pregnant women at least once during each pregnancy, while reported rates for repeat testing in the third trimester remain low (20.1% for all patients and 42.6% for high-risk patients). Two thirds (66.0%) of respondents recommend labor and delivery testing to women with unknown or undocumented HIV status. Fewer than 22.0% of respondents report routinely recommending HIV screening to all non-pregnant women, citing a low-risk population as the most common reason. State laws and regulations have only moderate influence on obstetrician-gynecologists' HIV testing practice, as do practice type, location, and setting. Conclusions: The results of this study suggest that the provider's perception about the patients' risk for being infected as well as practice type and location are important factors influencing an obstetrician-gynecologist's decision to screen a nonpregnant woman for HIV.

Morgan MA, Anderson BL, Lawrence H, Schulkin J. (2012). Well-Woman Care among Obstetrician-Gynecologists: Opportunity for Preconception Care. J Matern Fetal Neonatal Med, 25(6), 595-9.

Objective: To describe the practices of obstetrician-gynecologists who provide routine gynecological care and assess the relative importance of well-woman care to their training and practices. Methods: A questionnaire was mailed to 1000 members of the American College of Obstetricians and Gynecologists, of whom 600 participated in the Collaborative Ambulatory Research Network. Results: The response rate was 57%. Of these, 403 respondents providing routine obstetric and gynecologic care (OB&Gyn) are included. Obstetricians-gynecologists spend the majority of their time on labor/delivery (22%) followed by well-woman care (14%). It was found that 26% of the respondents rarely or never discuss sexual abuse or domestic violence with non-pregnant patients and only 19% always discuss folic acid with non-pregnant patients during well-woman care. Most (71%) say that 50% or more of their pregnant patients initially contact them once they are pregnant. Respondents rated their training in well-woman care least strong of several areas listed. Conclusion: Obstetrician-gynecologists devote a substantial proportion of work time to providing well-woman care, though some important topics are not addressed and training in this area was rated least strong.

Green DR, Anderson BL, Burke MF, Griffith J, Schulkin J. (2012). Obstetric Providers’ Knowledge, Awareness, and Use HIV Testing Recommendations and One Test. Two Lives.™  Martern Child Health J, 16(5), 1113-9.

This study examined the impact of the Centers for Disease Control and Prevention's (CDC's) One Test. Two Lives.™ (OTTL) campaign on key outcomes related to CDC's revised HIV testing recommendations and the use of the campaign materials. Data from three cross-sectional surveys were used to assess the effect of OTTL on Obstetricians/Gynecologists' (OB/GYN) HIV knowledge and practice. A 2-year combined sample of 500 OB/GYNs completed DocStyles, a Web-based survey for physicians, and 575 American College of Obstetricians and Gynecologists (ACOG) Fellows completed an ACOG survey. The surveys were similar in focus but did not contain the same items. Data were analyzed using cross-tabulations, χ(2) analyses, and logistic regression. There was a 20% recall of exposure to OTTL with DocStyles and 25% with ACOG. DocStyles respondents reporting having seen OTTL materials were significantly more likely to report awareness of CDC's recommendations [χ(2)(1) = 25.43, P < .001] and include HIV testing as a regular screening test for all patients [χ(2)(1) = 4.98, P < .05]. ACOG respondents not using the materials indicated high levels of willingness to use the materials-63.0 to 71.5%, depending on the material. Of the ACOG sample, 68.1% correctly answered the knowledge items regarding the recommendations. However, a significant relationship between correct knowledge and campaign exposure was not found. Overall, results suggest that OTTL is instrumental in raising awareness and implementation of the testing recommendations and plays an important role in facilitating HIV testing practices with obstetric providers and their patients.

Wenstrom K, Erickson K, Schulkin J. (2012). Are Obstetrician-Gynecologists Satisfied with Their Maternal-Fetal Medicine Consultants? A Survey.  Amer J Perinatol, 29(08), 599-608.

Study Design:A survey was sent three times to 1030 randomly selected American Congress of Obstetricians and Gynecologists members across the country, and results were tabulated. Results: A total of 516 surveys (50%) were returned; 68% of respondents were satisfied (S) with available MFM services and 31% were not satisfied (Not S). S and Not S respondents were similar with respect to age, gender, years in practice, type of practice, hours worked per week, proximity to MFM specialists, number of deliveries per year, and level of nursery in their hospital. Reasons for dissatisfaction included: MFM specialist not readily available (49%), during the day (26%), at night (35%), or on weekends (36%); MFM specialist unwilling to take care of hospitalized patients (26%); or MFM specialist does only ultrasound, chorionic villus sampling, and amniocentesis (32%). Although some generalists do not consult MFM specialists frequently, the majority of both S and Not S respondents would request an MFM consult or comanagement for 26 of 38 specific maternal, fetal, and obstetric diagnoses/complications.  Conclusion: The majority of obstetrician-gynecologists are satisfied with their MFM support. The dissatisfaction expressed by 31% of generalists might be ameliorated if individual MFM specialists increased their availability and/or broadened their scope of practice.