2011 Publications

Link-Gelles R, Chamberlain AT, Schulkin J, Ault K, Whitney E, Seib K, Omer SB. (2011).Missed opportunities: a national survey of obstetricians about attitudes on maternal and infant immunization. Matern Child Health J, 16, 1743-1747.

The recent reoccurrence of several vaccine-preventable diseases demonstrates the need for new techniques to promote childhood vaccination. Many mothers make decisions regarding vaccination of their children during pregnancy. As a result, obstetricians have a unique opportunity to influence maternal decisions on this crucial component of child health. Our objective was to understand OB/GYNs' attitudes, beliefs, and current practices toward providing vaccinations to pregnant patients and providing information about routine childhood immunizations during standard prenatal care. We surveyed OB/GYNs in the United States about their vaccination practices and perceptions during the 2009 H1N1 outbreak. Most (84%) respondents indicated their practice would be administering H1N1 vaccines to pregnant patients. While a majority (98%) of responding providers felt childhood vaccination is important, relatively few (47%) felt that they could influence mothers' vaccination choices for their children. Discussion of routine childhood immunization between obstetricians and their patients is an area for future improvements in childhood vaccination.

Matteson KA, Anderson BL, Pinto SB, Lopes V, Schulkin J, Clark MA. (2011). Surveying ourselves: Examining the use of a web-based approach.  Evaluation and Health Professions, 34(4), 448-63.

A survey was distributed, using a sequential mixed-mode approach, to a national sample of obstetrician-gynecologists. Differences between responses to the web-based mode and the on-paper mode were compared to determine if there were systematic differences between respondents. Only two differences in respondents between the two modes were identified. University-based physicians were more likely to complete the web-based mode than private practice physicians. Mail respondents reported a greater volume of endometrial ablations compared to online respondents. The web-based mode had better data quality than the paper-based mailed mode in terms of less missing and inappropriate responses. Together, these findings suggest that, although a few differences were identified, the web-based survey mode attained adequate representativeness and improved data quality. Given the metrics examined for this study, exclusive use of web-based data collection may be appropriate for physician surveys with a minimal reduction in sample coverage and without a reduction in data quality.

Leddy M, Haaga D, Gray J, Schulkin J. (2011).  Postpartum mental health screening and diagnosis by obstetrician-gynecologists. J Psychosom Obstet Gynaecol, 32(1), 27-34.

Postpartum depression (PPD) and postpartum psychosis (PPP) can impact mother, infant, and family. Obstetrician-gynecologists (ob-gyns) are often the most frequent medical contact for postpartum women, and so are in a position to identify women needing psychological care. This study assessed ob-gyns' knowledge, attitudes, and practices regarding diagnosing PPD/PPP. A survey was sent to 400 members of the American College of Obstetricians and Gynecologists who have volunteered to participate in research. Response rate was 56%. Routine screening for PPD and PPP is conducted by 72% and 30% of respondents, respectively. Personal experience (through friend, family, or self) was associated with increased screening. Perceived PPP screening barriers are similar to those found in the PPD literature: time constraints, lack of training, and lack of knowledge of diagnostic criteria. In responding to standardised vignettes, physicians were more likely to over-diagnose, than under diagnose PPD/PPP. This study is the first to provide exploratory data of ob-gyns' knowledge, attitudes, and practice regarding PPD and PPP. Ob-gyns are screening for PPD/PPP, though not universally so. Future research should identify ways to mitigate screening barriers.

Kissin DM, Power ML, Kahn EB, Williams JL, Jamieson DJ, MacFarlane K, Schulkin J, Zhang Y, Callaghan WM. (2011). Attitudes and practices of obstetrician-gynecologists regarding influenza vaccination in pregnancy. Obstet Gynecol, 118(5), 1074-80.

Objective: To assess knowledge, attitudes, and practices of obstetrician-gynecologists (ob-gyns) regarding vaccination of pregnant women during the 2009 H1N1 pandemic. Methods: From February to July 2010, a self-administered mail survey was conducted among a random sample of American College of Obstetricians and Gynecologists (the College) members involved in obstetric care. To assess predictors of routinely offering influenza vaccination, adjusted prevalence ratios and 95% confidence intervals (CIs) were calculated from survey data. Results: Among 3,096 survey recipients, 1,310 (42.3%) responded to the survey, of whom 873 were eligible for participation. The majority of ob-gyns reported routinely offering both seasonal and 2009 H1N1 influenza vaccination to their pregnant patients (77.6% and 85.6%, respectively) during the 2009-2010 season; 21.1% and 13.3% referred patients to other specialists. Reported reasons for not offering vaccination included inadequate reimbursement, storage limitations, or belief that vaccine should be administered by another provider. Seasonal and 2009 H1N1 influenza vaccination during the first trimester was not recommended by 10.6% and 9.6% of ob-gyns, respectively. Predictors of routinely offering 2009 H1N1 influenza vaccine included: considering primary care and preventive medicine a very important part of practice (adjusted prevalence ratio 1.2, CI 1.01-1.4); observing serious conditions attributed to influenza-like illness (adjusted prevalence ratio 1.1, CI 1.02-1.1); personally receiving 2009 H1N1 influenza vaccination (adjusted prevalence ratio 1.2, CI 1.1-1.4); and practicing in multispecialty group (adjusted prevalence ratio 1.1, CI 1.1-1.2). Physicians in solo practice were less likely to routinely offer influenza vaccine (adjusted prevalence ratio 0.8, CI 0.7-0.9). Conclusions: Although most ob-gyns routinely offered influenza vaccination to pregnant patients, vaccination coverage rates may be improved by addressing logistic and financial challenges of vaccine providers.

Anderson BL & Schulkin J. (2011). Physicians’ Perceptions of Patients’ Knowledge and Opinions Regarding Breast Cancer: Associations with Patient Education and Physician Numeracy. Breast Care, 6(4), 285-8.

Background: The aim of this study was to assess physicians’ perception of their patients’ knowledge and opinions regarding regular screening, and the association of their perceptions with physician numeracy and patient education level. Methods: We carried out a survey study of 240 obstetrician-gynecologists. Results: Overall, 99.6% physicians perceive that their patients know that breast cancer is hereditary, 86.5% predicted that there is a gene mutation related to breast cancer, and 79.4% predicted that most breast cancer cases occur in women aged 50 years or greater. Physicians with less educated patients thought that their patients would not know about genetic screening, and physicians with more educated patients thought that their patients would know that mammography does not reduce the risk of getting breast cancer. A total of 66.0% of obstetrician-gynecologists answered all 3 numeracy questions correctly. Less numerate physicians were more likely to indicate that their typical patient would agree with the statement about regular mammography screens than the more numerate physicians. Conclusions: Obstetrician-gynecologists expect that their patients know some things about breast cancer and not others. Some of the physicians’ perceptions about patients differ based on numeracy.

Anderson BL, Strunk AL, Schulkin J. (2011). Study on defensive medicine practices among obstetricians and gynecologists who provide breast care. Journal for Healthcare Quality33(3), 37-43.

Abstract: The purpose of this study was to assess malpracticeconcerns, career satisfaction, defensive medicine, experiencewith liability lawsuits, and changes in breast care practicesamong obstetricians and gynecologists (ob-gyns) who providebreast care. Four hundred ACOG Fellows were randomly selectedand invited to participate, 247 (62%) responded. A majority ofresponders had increased the number of referrals for thediagnosis of breast abnormalities (58.9%) and treatment ofbreast disease (53.6%) due to fears and concerns regarding malpractice.On average, there was a high level of career satisfaction(M58.5 [SD52.5] on a scale from 0 to 10); however, those whohad been sued were significantly less satisfied than those whohad not. Physicians who had decreased breast surgicalprocedures and increased referrals for diagnosis and treatmentof breast disease reported practicing defensive medicine morefrequently. In a regression analysis, having been sued was asignificant predictor of practicing defensive medicine more often.Physicians from states with malpractice crisis reported practicingdefensive medicine more frequently and more lawsuits thanphysicians from stable states. Malpractice fears and defensivemedicine continue to affect the practices of ob-gyns, most specifically,as this study shows, ob-gyns who provide breast care.

Anderson BL, Obrecht NA, Chapman G, Driscoll DA, Schulkin J. (2011). Physicians' Communication of Down Syndrome Screening Test Results: The Influence of Physician Numeracy. Genetics in Medicine, 13(8), 744-9.

Purpose: We investigated three questions: (1) How do obstetrician-gynecologists communicate positive and negative test results? (2) When reporting screening test results, do obstetrician-gynecologists use quantitative or qualitative information? and (3) Is physician numeracy (i.e., the ability to use and understand numbers) associated with use of quantitative or qualitative information?  Method: Obstetrician-gynecologists (N = 203; 55.6% response rate) who were members of the American College of Obstetricians and Gynecologists completed a survey about their communication of Down syndrome screening test results, an Objective Numeracy Scale, and the Subjective Numeracy Scale.  Results: Higher scores on the Subjective Numeracy Scale and younger age predicted obstetrician-gynecologists' use of numbers to explain testing results. The Objective Numeracy Scale did not predict use of numbers. Gender was correlated with scores on the Subjective Numeracy Scale (r = 0.2) and the Subjective Numeracy Scale-Ability Subscale (r = 0.3), with men scoring higher than women when controlling for age. Open-ended questions revealed that communication strategies vary, with approximately one in three obstetrician-gynecologists providing numerical information, and frequency format being the commonly used numerical format.  Conclusion:  Although physicians are often overlooked in the problem of low health literacy, it is important that we continue to investigate the impact of physician numeracy on patient care.

Matteson K, Anderson BL, Pinto SB, Lopes V, Schulkin J, Clark MA. (2011). Practice patterns and attitudes about treating abnormal uterine bleeding: A national survey of obstetricians and gynecologists.  Am J Obstet Gynecol, 205(4), 32.e1-8.

Objective:  We sought to examine the practice patterns and attitudes of obstetricians and gynecologists surrounding treatment of abnormal uterine bleeding (AUB).  Study Design:  We conducted a cross-sectional study of members of the American College of Obstetricians and Gynecologists. Surveys, which were distributed using a sequential mixed method (both web- and mail-based) approach, included questions about practice characteristics, practice patterns, and knowledge about treatment options for AUB.  Results:  Of 802 questionnaires, 417 were returned (52%). The most commonly selected first-line choice for AUB treatment was combined oral contraceptives (97% anovulatory, 98% ovulatory). The levonorgestrel intrauterine system was the next most frequently selected option (63% anovulatory, 53% ovulatory). Respondents did not score high on questions about the effectiveness of treatments for AUB. Only 25% (n = 86) answered at least 2 of the 3 questions correctly.  Conclusion:  Continued education is necessary to increase the utilization of the most effective treatment options for AUB.

Farrow VA, Leddy MA, Lawrence H, Schulkin J. (2011). Ethical concerns and career satisfaction in obstetrics and gynecology: a review of recent findings from the Collaborative Ambulatory Research Network. Obstet Gynecol Surv, 66(9):572-9.

Obstetricians-gynecologists (ob-gyns) are frequently confronted with situations that have ethical implications (e.g., whether to accept gifts or samples from drug companies or disclosing medical errors to patients). Additionally, various factors, including specific job-related tasks, costs, and benefits, may impact ob-gyns' career satisfaction. Ethical concerns and career satisfaction can play a role in the quality of women's health care. This article summarizes the studies published between 2005 and 2009 by the Research Department of the American College of Obstetricians and Gynecologists, which encompass ethical concerns regarding interactions with pharmaceutical representatives and patient safety/medical error reporting, as well as ob-gyn career satisfaction. Additionally, a brief discussion regarding ethical concerns in the ob-gyn field, in general, highlights key topics for the last 30 years. Ethical dilemmas continue to be of concern for ob-gyns. Familiarity with guidelines on appropriate interactions with industry is associated with lower percentages of potentially problematic relationships with pharmaceutical industries. Physicians report that the expense of patient safety initiatives is one of the top barriers for improving patient safety, followed by fear of liability. Overall, respondents reported being satisfied with their careers. However, half of the respondents reported that they were extremely concerned about the impact of professional liability costs on the duration of their careers. Increased familiarity with guidelines may lead to a decreased ob-gyn reliance on pharmaceutical representatives and free samples, whereas specific and practical tools may help them implement patient safety techniques. The easing of malpractice insurance and threat of litigation may enhance career satisfaction among ob-gyns. This article will discuss related findings in recent years.

Dalton VK, Harris LH, Bell JD, Schulkin J, Steinauer J, Zochowski M, Fendrick AM. (2011).Treatment of early pregnancy failure: does induced abortion training affect later practices? Am J Obstet Gynecol, 204(6), 493.e1-6.

Objective: The objective of the study was to examine the relationship between induced abortion training and views toward, and use of, office uterine evacuation and misoprostol in early pregnancy failure (EPF) care. Study Design: We surveyed 308 obstetrician-gynecologists on their knowledge and attitudes toward treatment options for EPF and previous training in office-based uterine evacuation. Results: Sixty-seven percent of respondents reported training in office uterine evacuation, and 20.3% reported induced abortion training. Induced abortion training was associated with strongly positive views toward both office-based uterine evacuation and misoprostol as treatment for EPF compared with those with office uterine evacuation training in other settings (odds ratio [OR], 2.64; P < .004 and OR, 3.22; P < .003, respectively). Furthermore, induced abortion training was associated with the use of office uterine evacuation for EPF treatment compared with those with office evacuation training in other settings (OR, 2.90; P = .004). Conclusion: Training experiences, especially induced abortion training, are associated with the use of office uterine evacuation for EPF.

Burwick RM, Schulkin J, Cooley SW, Janakiraman V, Norwitz ER, Robinson JN. (2011).Recent Trends in Continuing Medical Education Among Obstetrician–Gynecologists.Obstetrics & Gynecology, 117(5), 1060-4.

Objective: To estimate current trends in continuing medical education among obstetrician–gynecologists in relation to the Maintenance of Certification program.  Methods: A validated questionnaire was mailed to 1,030 randomly selected physicians of the American College of Obstetricians and Gynecologists in the United States, Puerto Rico, and Canada. Participants were asked about current practices and opinions regarding continuing medical education activities. Responses were compared between members mandated for Maintenance of Certification (board certification 1986 or later; time-limited certificate) or not (board certification before 1986; nontime-limited certificate).  Results: Five hundred twenty (50.4%) surveys were completed. Respondents were more often male (57.1%), generalists (87.3%), in community-based (73.8%) group practices (77.2%) with mean (±standard deviation) age 52.4±9.9 years. College physicians mandated to participate in the Maintenance of Certification program were more likely to rely on Annual Board Certification articles as a major source of continuing medical education credits compared with those not requiring Maintenance of Certification (79.9% compared with 44.6%, P<.001). This finding remained significant after multivariable adjustment for age, gender, years in practice, and practice type (odds ratio [OR] 9.09, 95% confidence interval [CI] 4.03–20.5). Conversely, Maintenance of Certification requirement led to decreased use of the national or international meetings (OR 0.31, 95% CI 0.14–0.67) and self-selected continuing medical education materials (OR 0.29, 95% CI 0.14–0.60) as sources of continuing medical education credits. Despite these differences, physicians in both groups equally valued the relevance of Annual Board Certification articles (92.6% compared with 96.4%,P=.23), the importance of content at academic meetings (98.3% compared with 99.3%,P=.33), the usefulness of simulation drills (97.8% compared with 94.3%, P=.35), and the general ability of continuing medical education activities to improve skills as a physician (90.9% compared with 86.4%, P=.20).  Conclusion: Requirement of the Maintenance of Certification program has led to significant changes in continuing medical education choices by obstetrician–gynecologists. The changes in continuing medical education appear related to mandated obligations rather than personal preference. 

Jones JL, Anderson B, Schulkin J, Parise ME, & Eberhard ML. (2011). Sushi in Pregnancy, Parasitic Diseases–Obstetrician Survey. Zoonoses and public health, 58(2), 119-125.

Parasites from raw fish can lead to a wide range of clinical manifestations and can be challenging to treat in pregnancy as result of medication exposure of the foetus. We surveyed obstetrician-gynecologists (ob-gyns) in the U.S. to determine their knowledge about the consumption of raw fish during pregnancy. In March 2007, a questionnaire was mailed to members of the American College of Obstetricians and Gynecologists (ACOG) randomly selected to represent all members. Non-responding physicians were sent two additional mailings. Of the 606 ACOG members surveyed, 305 (50%) responded. Most (82%) respondents indicated that eating raw fish is not safe during pregnancy. However, few (19%) knew that thorough freezing kills parasites in fish. Nearly all (94%) respondents thought that parasitic infections can be more challenging to treat in pregnancy. U.S. ob-gyns believe that eating raw fish during pregnancy is not safe; most would benefit from information about how to prevent infection and about treatment.

Leddy MA, Lawrence H, Schulkin J (2011). Obstetrician-gynecologists and women’s mental health: Findings of the collaborative ambulatory research network 2005-2009. Obstetrical and Gynecological Survey, 66(5), 316-323.

Background: Many mental illnesses are more prevalent in women than men (e.g., depression). Obstetrician-gynecologists (ob-gyns) are frequent medical contacts for women, and so can play an important role in screening for mental illness. Methods: This review summarizes studies published between 2005 and 2009 by the Research Department of the American College of Obstetricians and Gynecologists that encompass depression, anxiety, and eating disorders (EDs).Results: Ob-gyns were more accurate in identifying depression than anxiety. Treatment with antidepressants was reported as a course of action twice as often as referral to a mental health professional. Physicians were moderately confident that they could recognize anxiety, but were less confident regarding treatment. One-fifth routinely screen pregnant patients for anxiety; level of interest in anxiety was the only significant predictor of screening rates. The main barriers to anxiety screening in pregnancy were time constraints and perceived inadequate training. Almost all believed EDs can harm pregnancy outcome, although few ask about ED histories. Only half view assessment of ED as within routine ob-gyn practice. Those who self-identify as primary care providers, and those who more strongly believe EDs can harm pregnancy outcomes, agreed more strongly that ED assessment is within their role. Ob-gyns perceived training regarding EDs to be poor. Knowledge of risks associated with EDs was low. Conclusions: Ob-gyns view mental health issues as important topics; however, they are not confident in their abilities to diagnose these conditions and are also concerned about the adequacy of their training. Additional training could prepare ob-gyns to incorporate mental health screening into their practices.


Michael Power, PhD

Carrie Snead, MA


American College of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188
Mailing Address: PO Box 96920, Washington, DC 20024-9998