Research Department Publications 2014

Anderson, B.L., & Schulkin, J (eds.). (2014). Numerical reasoning in judgments and decision making about health. Cambridge: Cambridge University Press.

Every day thousands of individuals need to make critical decisions about their health based on numerical information, yet recent surveys have found that over half the population of the United States is unable to complete basic math problems. How does this lack of numerical ability (also referred to as low numeracy, quantitative illiteracy or statistical illiteracy) impact healthcare? What can be done to help people with low numeracy skills? Numerical Reasoning in Judgments and Decision Making about Health addresses these questions by examining and explaining the impact of quantitative illiteracy on healthcare and in specific healthcare contexts, and discussing what can be done to reduce these healthcare disparities. This book will be a useful resource for professionals in many health fields including academics, policy makers, physicians and other healthcare providers.

Anderson, B.L, Urban, R.R, Pearlman, M., Schulkin, J. (2014). Obstetrician-gynecologists’ knowledge and opinions about the United States Preventive Services Task Force (USPSTF) committee, the Women’s Health Amendment, and the Affordable Care Act: national study after the release of the USPSTF 2009 Breast Cancer Screening Recommendation Statement. Preventive Medicine, 59, 79-82.

Objective: Investigate the knowledge and opinions of obstetrician and gynecologists (ob-gyns) regarding the USPSTF committee and statement, and to assess their reactions to healthcare legislation.

Methods: A national cross-sectional survey study of ob-gyns was conducted six months after a controversial USPSTF recommendation statement was released in November 2009. Ob-gyns' opinions about the Women's Health Amendment (WHA) and the Affordable Care Act (ACA) were also assessed.

Results: A total of 54% of ob-gyns knew that the USPSTF recommendations do not represent the position of the U.S. government and 40% knew that the USPSTF is not comprised of federal employees. A majority (60%) thought that the USPSTF was influenced by potential costs more than guidelines should be. When examining ob-gyns opinions about new national health policies, 88% support the mammography coverage provided by the WHA but support for the ACA varied.

Conclusion: This study provides a snapshot of ob-gyns' knowledge and opinions about the USPSTF and breast cancer screening guidelines at a controversial point in time. Our findings are a unique contribution to larger efforts to understand health and political policy as the culture of medicine continues to evolve.

Anderson, B.L, Gigerenzer, G., Parker, S., Schulkin, J. (2014). Statistical literacy in obstetrics and gynecology. Journal for Healthcare Quality, 36(1), 5-17.

Physicians’ numeracy, the ability to use and understand numbers, has been overlooked. We assessed physician numeracy skills on tasks that are relevant to their practice. 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). Almost all could translate between frequency and probability formats. About half were able to calculate the positive predictive value of a mammography screening test.

Azonobi, I., Anderson, B., Byams, V., Grant, A., Schulkin, J. (2014). Obstetrician-gynecologists’ knowledge of sickle cell disease screening and management. BMC Pregnancy and Child Birth, 14, 1-5.

Background: Although obstetrician/gynecologists (OB/GYNs) play an important role in sickle cell disease (SCD) screening and patient care, there is little information on knowledge of SCD or sickle cell trait (SCT) or related practices in this provider group. Our objective was to assess SCD screening and prenatal management practices among OB/GYNs.

Methods: Twelve hundred Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists (the College)a were invited to complete a mailed survey, of which half (n = 600) belonged to the Collaborative Ambulatory Research Network.b Participants answered questions regarding appropriate target patient groups for prenatal SCD screening, folic acid requirements, practice behaviors and adequacy of their medical school and residency training.

Results: A total of 338 CARN members (56.3%) and 165 non-CARN members (27.5%) returned a survey. Of the 503 responders, 382 provided obstetric services and were included in the analyses. Forty percent of these respondents (n = 153) reported seeing at least 1 patient with SCD in the last year. Of these, 97.4% reported regularly screening people of African descent for SCD or SCT, whereas 52.9% reported regularly screening people of Mediterranean descent and 30.1% reported regularly screening people of Asian descent. Only 56.2% knew the correct recommended daily dose of folic acid for pregnant women with SCD. The proportion of respondents that rated training on SCD screening, assessment and treatment as barely adequate or inadequate ranged from 19.7% to 39.3%

Conclusions: The practice of many OB/GYNs who care for patients with SCD are not consistent with the College Practice Guidelines on the screening of certain target groups and on folic acid supplementation. There may be an opportunity to improve this knowledge gap through enhanced medical education.

Benn, P., Chapman, A.R., Erickson, K., DeFrancesco, M.S., Wilkins-Haug, L., Egan, J.F.X., & Schulkin, J. (2014). Obstetricians and gynecologists’ practice and opinions of expanded carrier testing prenatal testing. Prenatal Diagnosis, 34(2), 145-152.

Objective: The objective of this study is to assess the opinions of Fellows of the American College of Obstetricians and Gynecologists on expanded carrier testing (molecular detection of >100 genetic diseases of variable severity) and noninvasive prenatal testing (NIPT).

Methods: A survey conducted between March and August 2012, assessed current use of testing, provision of genetic counseling, types of disorders that should be identified, preferences for future use, ethical aspects, and views on regulatory oversight.

Results: Expanded carrier testing was offered to all patients by 15% of the responders and 52.1% upon patient request. Most (67.3%) favored testing only for mutations of known significance. In this study, 79.1% supported the use of NIPT as a screen for Down syndrome for all women with 47.9% viewing NIPT as a complete substitution for invasive testing. Most supported expansion to other aneuploidies (97.5%) and severe early-onset Mendelian disorders (90.4%) but not for adult-onset disorders (29.8%) or nonmedical sex identification (15.7%). A majority (73.2%) believed that NIPT would increase pregnancy terminations for mild disease states. Respondents favored a role for professional societies in providing regulatory oversight.

Conclusion: Rapid incorporation of new genetic technologies may be limited by the availability of genetic counseling, concerns regarding inclusion of clinically mild disorders, results of unknown significance, and costs.

Coleman-Cowger V, Anderson BL, Mahoney J, Schulkin J (2014). Smoking cessation during pregnancy and postpartum: Practice patterns among obstetrician-gynecologists.Journal of Addiction Medicine, 8(1), 14-24.

Objectives: To assess current obstetrician-gynecologist (ob-gyn) practice patterns related to the management of and barriers to smoking cessation during pregnancy and postpartum.

Conclusions: Compared with findings from a similar study conducted in 1998, physicians are less likely to adhere to the 5 A’s smoking cessation guideline at present. As we know that brief intervention is effective, it is imperative that we work toward addressing practice gaps and providing additional resources to address the important public health issue of smoking during pregnancy and postpartum.

Domjahn, B., Hlavasa, M., Anderson, B., Schulkin, J., Leon, J., Jones, J. (2014). A survey of U.S. obstetrician-gynecologists' clinical and epidemiological knowledge of cryptosporidiosis in pregnancy. Zoonoses Public Health, 61, 356-363.

Although cryptosporidiosis is frequently diagnosed in the U.S., there has been very little assessment of obstetrician-gynaecologist knowledge about this disease. In 2010, we surveyed U.S. obstetricians about the diagnosis, treatment and epidemiology of cryptosporidiosis. Data were examined through univariable analysis and multivariable regression models. Of 1000 obstetrician-gynaecologists surveyed, 431 (43.1%) responded. Only 44.4% of respondents correctly identified that prolonged, intermittent diarrhoea would lead them to consider cryptosporidiosis in a differential diagnosis. Routine ova and parasites (O&P) testing was incorrectly chosen to identify Cryptosporidium in stool by 30.4% of respondents. Questions about nitazoxanide, the only drug approved by the U.S. Food & Drug Administration (FDA) for treatment of cryptosporidiosis, were the most frequently missed questions. Only 9.0% of respondents correctly classified nitazoxanide as an FDA pregnancy Category B drug, and only 5.6% of respondents correctly indicated that FDA approved nitazoxanide for immunocompetent patients aged ≥1 years. Regarding prevention- and control-related knowledge, only 14.1% of respondents correctly indicated that alcohol-based hand sanitizers were not effective at inactivating Cryptosporidium spp., and <10% correctly indicated that cryptosporidiosis is a reportable disease in their state of practice. Multivariable analysis found that ≥19 years in practice was positively associated with O&P diagnostic testing knowledge, while rural and urban non-inner city practice location, compared with suburban practice location, was positively associated with nitazoxanide knowledge. The low level of knowledge among obstetrician-gynaecologists about cryptosporidiosis indicates a need to develop resources for physicians about all aspects of cryptosporidiosis, particularly on diagnosis, treatment and prevention strategies.

Donnelly, J.C., Raglan, G.B., Bonanno, C., Schulkin, J., & D’Alton, M.E. (2014). Practice patterns and preferences of obstetricians and gynecologists regarding thromboprophylaxis at the time of cesarean section. The Journal of Maternal-Fetal & Neonatal Medicine, 27, 1870–1873.

Objective: Our survey aimed to identify knowledge and application of guidelines in the United States by assessing practicing obstetricians and gynecologists (OBGYN) use of thromboprophylaxis, preferred methods, and whether their type of practice influenced their choices.

Conclusion: Awareness of the risk of thromboembolism around delivery by cesarean section is high amongst OBGYN practitioners. Broadening guidelines to encompass all deliveries, not only caesareans, with a focus on identifying the patient at risk, would likely be successful.

England, J., Anderson, A., Tong, V., Mahoney, J., Coleman-Cowger, V., Melstrom, P., Schulkin, J. (2014). Screening practices and attitudes of obstetricians-gynecologists toward new and emerging tobacco products. American Journal of Obstetrics and Gynecology, 211, 695e1-7.

Objective: We examined screening practices and attitudes of obstetricians-gynecologists toward the use of noncombustible tobacco products (chewing tobacco, snuff/snus, electronic cigarettes, and dissolvables) during pregnancy.

Study Design:The authors mailed a survey in 2012 to 1024 members of the American College of Obstetricians and Gynecologists, including Collaborative Ambulatory Research Network (CARN) and non-CARN members. Stratified random selection was used to generate CARN and non-CARN samples.

Results: Response rates were 52% and 31% for CARN and non-CARN members, respectively. Of 252 total eligible respondents (those currently providing obstetrics care) 53% reported screening pregnant women at intake for noncombustible tobacco product use all or some of the time, and 40% reported none of the time. Respondents who reported that noncombustible products have adverse health effects during pregnancy, but are safer than cigarettes, ranged from 20.2% (dissolvables) to 29% (electronic cigarettes) and that the health effects are the same as those of cigarettes from 13.5% (electronic cigarettes) to 53.6% (chewing tobacco). Approximately 14% reported that electronic cigarettes have no adverse health effects; <1% reported no health effects for the remaining products. Two-thirds of the respondents wanted to know more about the potential health effects of noncombustible tobacco products; only 5% believed themselves to be fully informed.

Conclusion: A large proportion of obstetrician-gynecologists reported never or inconsistently screening their pregnant patients for the use of noncombustible tobacco products. Responses regarding the harms of these products relative to cigarettes were mixed and most respondents wanted more information. Development and dissemination of guidance for providers is needed to improve decision-making regarding noncombustible tobacco products.

Farrow, V.A., Lawrence, H., & Schulkin, J. (2014). Women’s healthcare providers’ range of services and collaborative care. Journal of Healthcare Quality, 36(2), 39-49.

Physician shortages and healthcare reform are important topics in the healthcare field today. The utilization of the skills and professional competencies of nonphysician healthcare providers, as well as collaboration between physicians and nonphysician healthcare providers may in part provide a solution to some current healthcare concerns. The purposes of this study were to describe the range of services provided by nonphysician women's healthcare providers (WHCPs), and to begin to explore the collaborative relationship between obstetrician-gynecologists (ob-gyns) and WHCPs. Questionnaires were sent to ob-gyns, certified nurse-midwives, certified midwives, nurse practitioners (NPs), and physician's assistants (PAs) with questions regarding the types of services WHCPs provide, as well as collaboration between ob-gyns and WHCPs. Overall, 62.1% of ob-gyns employ WHCPs. NPs are the most common type of WHCP employed in our sample. WHCPs are more likely to be younger than ob-gyns, and an overwhelming majority of WHCPs in our sample are female. Most reported that they are anticipating an expansion in the roles and services they provide over the next 5 years. In an era of healthcare reform, WHCPs may in part provide a solution to the growing physician shortage. Collaboration between ob-gyns and WHCPs is a key aspect of the changing healthcare environment.

Gaissmaier W, Anderson BL, Schulkin J. (2014). How do physicians provide statistical information about antidepressants to hypothetical patients? Medical Decision Making, 34(2), 206-15.

Background: Little is known about how physicians provide statistical information to patients, which is important for informed consent.

Conclusions: Most physicians did not provide complete and transparent information. Clinicians who presented consistent information to different patients tended to present complete information, whereas those who varied what information they chose to present appeared more prone to nudging.

Jones, K., Schmidt, L.A., Schulkin, J. (2014) Shyness. PSYCHOLOGY 5:244-254.

Decades of research on the study of introversion and extraversion have allowed researchers to distinguish among individual differences on each of these dimensions. Research indicates that shyness, a rather common personality trait, is a construct that is related, but not identical, to introversion. Once regarded as a unitary construct, modern day personality theorists propose that shyness is based on a number of orthogonal dimensions. Empirical evidence suggests that distinct subtypes of shyness develop as a result of differences in social approach and social avoidance behaviors. Temperamental shyness is a risk factor for behavioral and affective problems, as well as more severe psychological problems. This article focuses on the phenomenon of shyness by reviewing its subtypes, psychosocial correlates, and efficacious treatment interventions.

Leddy, M., Farrow, V., Schulkin, J. (2014) Obstetrician-gynecologists’ knowledge, attitudes, and practice regarding elder abuse screening. Women’s Health Issues 24: e455-e464.

Background: Elder abuse is a prevalent and growing social problem with significant consequences on victims’ mental and physical health. Unfortunately, many cases of elder abuse go unreported. Elderly women are at increased risk for abuse and, as such, obstetrician-gynecologists (OB/GYNs) are in a unique position to screen for and report abuse. This study intended to determine OB/GYNs’ knowledge, attitudes, and practice regarding elder abuse.

Methods: Two hundred Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists (ACOG) received a survey. Analysis was completed with SPSS 20.0. In addition to descriptive statistics, c2 analyses were used to determine differences between groups.

Findings: In total, 122 fellows responded (61%). Abuse screening rates differed by abuse type. Few "always" screen for abuse, with half assessing only when it is suspected. Most (81%) had never reported a case of abuse. Younger males reported different clinical practice patterns than other groups. Generally, OB/GYNs were knowledgeable about risk factors and facts about elder abuse, but several knowledge gaps were identified. Most reported that elder abuse screening is within their professional purview. Half of the respondents cited time constraints as a barrier to screening.

Conclusions: Greater education about elder abuse screening is needed. Specifically, training regarding available valid and brief screening tools, local abuse reporting laws, and available community resources. This study identified the potential need to target younger male OB/GYNs for additional training.

Luchowski A, Anderson BL, Power M, Raglan GB, Espey E, Schulkin J. (2014). Obstetrician–Gynecologists and Contraception: Practice and Opinions about the use of IUDs in Nulliparous Women, Adolescents, and Other Patient Populations. Contraception, 89(6), 572-577.

Objectives: This study examined obstetrician-gynecologists’ practices and opinions about the use of IUDs in adolescents, nulliparous women, and other patient groups, as well as for emergency contraception.

Conclusions: Although most obstetrician-gynecologists offer IUDs, many exclude appropriate candidates for IUD use, both for emergency contraception and for longterm use despite evidence-based recommendations. Implications: This study shows that obstetrician-gynecologists still do not offer IUDs to appropriate candidates, such as nulliparous women and adolescents, and rarely provide the copper IUD as emergency contraception.

Luchowski A, Anderson BL, Power M, Raglan GB, Espey E, Schulkin J. (2014). Obstetrician–Gynecologists and Contraception: Long-Acting Reversible Contraception Practices and Education. Contraception, 89(6), 578-583.

Objectives: This study examined obstetrician-gynecologists’ knowledge, training, practice, and beliefs regarding LARC methods.

Conclusions: Barriers to LARC provision could be reduced if more obstetrician–gynecologists received implant training and provided same-day IUD insertion. Continuing education will likely increase implant provision.

Implications: This study shows that obstetrician–gynecologists generally offer IUDs but fewer offer the single-rod contraceptive implant. Recent continuing education strongly predicted whether obstetrician–gynecologists inserted implants and was also associated with other practices that encourage LARC use.

Raglan, G.B., Lawrence III, H., & Schulkin, J. (2014). Obstetrician/Gynecologists care considerations: Practice changes in disease management with an aging patient population. Women’s Health, 10(2), 155-160.

Demographic changes across the country are leading to an increased proportion of older Americans. This shift will likely lead to changes in the patient population seen by obstetrician/gynecologists (ob/gyns), and practices may need to adapt to the needs of older women. This paper looks at mental health, sexual health, bone loss, cardiovascular disease, and cancer as areas in which ob/gyns may experience changes with the increasing age of patients. While this is by no means a comprehensive list of changing areas of practice, it offers a guide for reflecting on the future of ob/gyn training, and the importance of considering the needs of older patients in practice.

Raglan, G.B., Margolis, B., Paulus, R.A., & Schulkin, J. (2014). Electronic health record adoption among obstetrician/gynecologists in the United States: Physician practices and satisfaction. Journal for Healthcare Quality, epub ahead of print.

Background: This study aimed to explore the experiences of obstetrician/gynecologists (ob/gyns) with regard to the use of electronic medical record (EMR) systems in practice.

Results: The majority of ob/gyns who used an EMR reported being satisfied with that system (59.5%). The most commonly reported impediments to EMR use were time needed, ineffective templates, note quality, interference with patient interactions, and expense. The most commonly cited positive were e-scribing, efficiency, and ease of access to notes including legibility.

Conclusions: In spite of increased adoption of EMR systems, more work is needed to improve ob/gyn satisfaction with EMR systems.

Raglan, G., Cain, J., & Schulkin, J. (2014). Brief report on Obstetricians’/Gynecologists’ Distribution of Scarce Resources. Journal for Healthcare Quality, epub ahead of print.

On a day-to-day basis, doctors must decide which treatments are most beneficial for their patients, and which make the most sense in terms of costs. In medical decision making, factors such as efficiency and cost-effectiveness can be particularly challenging to navigate because many of the most expensive procedures encountered in medical practice are also high-stake treatments for patients. One-hundred-six obstetricians-gynecologists (Obs/Gyns) completed a survey asking them to allocate the following resources in scenarios in which they are scarce: human papilloma virus (HPV) vaccinations, mammograms, and in vitro fertilization (IVF) treatments. Additional questions focused on how fairness and cost-effectiveness factored into the allocation decisions of each group. Results indicated that Obs/Gyns were more efficient in their distribution of HPV vaccinations and mammograms than in their distribution of IVF treatments. More efficient responding was associated with placing less emphasis on fairness in decision making. This study demonstrates the differences that exist in the emphasis that physicians place on medical evidence, cost, outcomes, and perceptions of fair (equal) allocation when faced with different costs and health impacts.

Raglan, G., Babush, M., Farrow, V., Kruglanski, A., Schulkin, J. (2014). Need to know: the need for cognitive closure impacts the clinical practice of obstetrician/gynecologists. BMC Med Inform Decis Mak, 14,122-126.

Background:Need for cognitive closure (NFCC) has been shown to be a consistent and measurable trait. It has effects on decision making and has been associated with more rapid decision making, higher reliance on heuristics or biases for decision making, reduced tolerance for ambiguity, and reduced interest in searching for alternatives. In medical practice, these tendencies may lead to lower quality of decision making.

Methods: This study measured NFCC in 312 obstetrician/gynecologists using a survey-style approach. Physicians were administered a short NFCC scale and asked questions about their clinical practice.

Results: Obstetrician/gynecologists with high NFCC were found to be less likely to address a number of clinical questions during well-woman exams, and were more likely to consult a greater number of sources when prescribing new medications.

Conclusions: NFCC of physicians may have an important impact on practice. It is possible that increased training during residency or medical school could counteract the detrimental effects of NFCC, and steps can be taken through increased use of electronic reminder systems could orient physicians to the appropriate questions to ask patients.


Michael Power, PhD

Carrie Snead, MA


American College of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188 | Mailing Address: PO Box 70620, Washington, DC 20024-9998