Practice trends in outpatient obstetrics and gynecology: findings of the Collaborative Ambulatory Research Network, 1995--2000.

UNLABELLED: Historically, obstetrics and gynecology has been a medical/surgical specialty focusing on women's health and reproductive concerns during the childbearing years. Newer responsibilities-for example, in primary care, gerontology, and genetics-require Ob-Gyns to draw upon a base of medical knowledge that traditionally was not considered germane to their practices. Ob-Gyns are increasingly providing more primary care services to their patients; consequently, the field has expanded considerably. The Collaborative Ambulatory Research Network (CARN) was created in 1990 as a vehicle for investigating issues pertinent to women's health and to the practice of obstetrics and gynecology in the outpatient setting. This article summarizes the findings of CARN studies from 1995 to 2000, covering a range of topics related to women's health across the life cycle, including, but not limited to perinatal care. Topics include nutrition, infectious disease, hormone replacement therapy, psychosocial issues, and genetic testing in obstetric and gynecologic practice. Each study produced a picture of current practice patterns and knowledge of the physicians surveyed. Findings on knowledge, attitudes, and practices varied widely. Overall, Ob-Gyns were knowledgeable and consistent in more traditional areas of practice. Conversely, inconsistencies were observed in newer areas. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader will be able to define what the Collaborative Ambulatory Research Network (CARN) involves, describe how CARN obtains its data, and summarize some of the findings of CARN from the years 1995 to 2000.

Effects of perceptions and mentorship on pursuing a career in academic medicine in obstetrics and gynecology.

PURPOSE: To understand the perceptions of residents and Fellows in obstetrics and gynecology about the impacts of race or ethnicity, gender, and mentorship experiences on pursuing careers in academic medicine. METHOD: Two surveys were administered: one to a sample of 2,000 Fellows of the American College of Obstetricians and Gynecologists, and one to the 4,814 obstetrics and gynecology residents taking the 1998 in-training examination. The questionnaires asked about demographics, perceptions about careers in academic medicine, and residents' experiences with mentorship. RESULTS: Response rates were 96.8% for residents and 40.6% for FELLOWS: Of the residents, 26.1% indicated they would not consider a career in academic medicine. First-year women residents were more inclined to pursue careers in academic medicine than were first-year men (p =.042), but their interest declined during residency. Women residents (43%)-especially minorities-felt that men were mentored and recruited more for faculty positions, while men (38%) felt that women were mentored and recruited more. Fellows' reports of recruitment did not differ by gender. Most white residents did not perceive racial or ethnic bias in mentoring or recruiting, while most non-white residents did. Almost one third of non-white women residents felt that supervisors were more likely to condescend to women and minority individuals. CONCLUSIONS: It is likely that neither men nor women residents in obstetrics and gynecology receive adequate mentorship for careers in academic medicine. Perceptions of bias are a serious barrier to developing racial, ethnic, and gender diversity in leadership positions.

Long hours and little sleep: work schedules of residents in obstetrics and gynecology.

OBJECTIVE: To investigate residents' work schedules and their attitudes toward limiting their hours. METHODS: An anonymous survey regarding resident work hours and call schedules was administered to the 4674 obstetric-gynecologic residents who took the year 2000 Council on Resident Education in Obstetrics and Gynecology in-training examination. RESULTS: A total of 4510 surveys were analyzed (96.5%). Three of four (75.5%) respondents reported working between 61 and 100 hours each week. Most (71.3%) reported sleeping less than 3 hours while on night call. Eight of ten reported having postcall clinical responsibilities. The reported number of hours on call declined and the reported number of hours of sleep increased with year of residency. Three of four residents wanted limits on their work hours. Residents who reported longer on-call hours or less sleep during night shift were significantly more likely to want a restriction on work hours. Fatigue was the most commonly selected reason (77.6%) followed by "need more personal time" (76.3%), and "fear of compromising quality of care" (59.8%). Women were more concerned about fatigue than were men. Among residents who did not want work hour restrictions, "additional surgical experience" was the most commonly selected reason (69.0%). CONCLUSION: Residents in obstetrics and gynecology report working long hours, and experiencing periods of little sleep. Most want their work hours to be limited. Fatigue is a major concern among residents that want their hours limited. A sizable minority worries that such limits might also limit their experience.

A survey on the management of nausea and vomiting in pregnancy by obstetrician/gynecologists.

Our objective was to survey obstetrician/gynecologists concerning their management of nausea and vomiting in pregnancy. We mailed a survey on nutrition during pregnancy to the 230 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a control sample of 800 non-Network Fellows. Results presented here are for the questions concerning prevalence and management of pregnancy-induced nausea. A total of 488 surveys (47.4% response rate) were analyzed. Respondents reported that on average, 51.4% of patients complain of nausea during pregnancy, and 9.2% complain of severe or prolonged nausea with vomiting. Respondents reported that on average, 2.4% of patients require hospitalization because of hyperemesis gravidarum. Treatments recommended by a majority of respondents for moderate nausea were eating frequent small meals (95.5%), snacking on soda crackers (88.5%), avoiding strong odors (75.6%), taking a prescribed antiemetic (71.3%), taking ginger (51.8%), and eliminating iron supplements (50%). Women physicians were more likely to recommend ginger and less likely to prescribe an antiemetic. For severe and sustained nausea with vomiting, with additional symptoms such as dehydration or weight loss, intravenous hydration (88.7%) and antiemetics (74.0%) were the most common treatment options. Almost half (48.8%) of respondents would hospitalize such patients. We conclude that obstetrician/gynecologists appear to be knowledgeable concerning current opinion on managing nausea and vomiting of pregnancy. Improvements in the management of nausea during pregnancy are more likely to come from further research, not education of physicians.

Obstetrician-gynecologists' views on the health risks of obesity.

OBJECTIVE: To assess the knowledge and opinions of obstetrician-gynecologists concerning the health risks of obesity and the importance of weight management of patients to clinical practice. STUDY DESIGN: A questionnaire survey covering physician and patient demography, disease risk related to obesity, relevance of weight management to patient's health, and self-assessments of medical education and training was sent to the 418 American College of Obstetricians and Gynecologists (ACOG) fellows who constitute the Collaborative Ambulatory Research Network and to 700 ACOG fellows selected at random. RESULTS: Five hundred twenty-five surveys were returned (47.0% response rate). Membership in the network was not a significant factor regarding responses; therefore, the data were pooled. Respondents estimated that 20.6 +/- 0.5% of their patients were obese and that a further 35.9 +/- 0.8% were overweight. The respondents were knowledgeable concerning health risks associated with obesity, and a majority considered obesity to be a major health concern that should be treated. Weight management was considered an important or very important part of practice by 81.5% of respondents. Almost half the respondents (45.5%) thought that the importance of weight management would increase. More than one of three responding physicians (36.4%) had prescribed weight loss medications in the previous year. Most responding physicians did not consider medical school or residency to be sources of information on these issues. CONCLUSION: Obstetrician-gynecologists think that managing the weight of their patients is part of their clinical responsibilities but do not consider their training in medical school and residency on these topics to be adequate.

Obstetrician-gynecologists' attitudes towards premenstrual dysphoric disorder and major depressive disorder.

Nine hundred ninety-seven fellows of the American College of Obstetricians and Gynecologists were surveyed by mailed questionnaire regarding their attitudes toward the conceptualization, diagnosis and treatment of premenstrual dysphoric disorder (PMDD) and major depressive disorder (MDD). Hypothesized differences in attitudes based on age, gender and professional identity as a primary care provider versus non-primary care provider were examined. Comparisons between attitudes toward PMDD and MDD were also investigated. Approximately 36% of the questionnaires were completed and returned. Overall attitudes toward PMDD versus MDD were found to be significantly different. Roughly one in three respondents disagreed with statements indicating responsibility for and confidence in their ability to treat MDD, but not PMDD. When significant differences were found for age, gender and professional identity, younger physicians, women physicians and those who self-identified as primary care providers reported attitudes that may be more likely to be associated with diagnosis and treatment of MDD and PMDD in gynecologic practice. For example, about 41% of self-identified non-primary care providers and 14.8% of primary care providers disagreed with the statement 'treating depression is my responsibility as a gynecologist'. Differences in gynecologists' attitudes toward MDD versus PMDD may be associated with under-treatment of MDD in gynecologic practice.

Obstetrician-gynecologists' opinions and attitudes on the role of genetics in women's health.

Our objective was to describe gynecologists' current practice patterns and opinions on genetic screening and their perceived importance of genetic screening within individual practices. A questionnaire survey was sent to 1248 American College of Obstetrics and Gynecology (ACOG) Fellows, of whom 564 (45%) responded. Results from the 428 respondents providing genetic screening for heritable diseases or disorders are reported. Forty-four percent of respondents believe advances in the treatment of genetic diseases are likely in the next 10 years. Currently, however, genetics in gynecological practice receives infrequent attention. Twenty-four percent of respondents do not routinely review family histories at gynecological visits, 39% rate genetic issues as last among priorities in the office, and only 14% obtain consent for the DNA tests that they initiate. Although 21.3% identified themselves as sole providers of genetic information and counseling to their patients, most (65.4%) note they are not confident of their knowledge of genetics, particularly concerning breast and ovarian cancer. For obstetrician-gynecologists to keep pace with the rapid changes in genetics, further education and assimilation of genetics into the routine office practice will need to occur. Not currently viewed as a priority among practitioners, issues of genetic knowledge, ethics, and test interpretation will soon need attention. National organizations, continuing medical education, and existing genetic centers will need to meet these recognized demands.

Knowledge and clinical practice regarding folic acid among obstetrician-gynecologists.

OBJECTIVE: To assess obstetrician-gynecologists' knowledge of and clinical practice concerning folate. METHODS: We mailed surveys on nutrition during pregnancy to the 230 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a random sample of 800 Fellows who are not members of the Network. Our results focus on questions concerning folate. RESULTS: We analyzed 488 surveys (a 47.4% response rate). Approximately two thirds of respondents screen their pregnant patients for folate intake. Fewer (53%) screen their nonpregnant patients of childbearing age. Those who screened their patients for folate intake were more likely to counsel pregnant patients about diet. They also were more likely to believe that nutritional counseling would improve pregnancy outcomes (70.0% versus 56.5%) and overall patient health (77.5% versus 66.5%). Most Fellows were aware that macrocytic anemia was a manifestation of folate deficiency (90.4%) and that folic acid supplementation during preconception and the early prenatal period helps protect against neural tube defects (96.5%). They were aware that alcoholics (91.4%), smokers (61.3%), and lactating women (53.5%) are at increased risk of folate deficiency. They were less aware of other consequences of low folate intake, such as increased serum homocysteine (20.3%). Respondents who screen their pregnant patients for folate intake correctly answered more of the knowledge questions about folate than physicians who do not screen. CONCLUSION: Obstetrician-gynecologists are generally aware of the link between folate intake and neural tube defects, but are less aware of other aspects of folate metabolism.

Gynecologists' training, knowledge, and experiences in genetics: a survey.

OBJECTIVE: To explore gynecologists' knowledge, training, and practice experience with genetic screening and DNA-based testing. METHODS: A questionnaire survey was sent to 1,248 ACOG Fellows, of whom 564 (45%) responded. One hundred thirty-four respondents (24%) reported that they do not order DNA-based tests or take family histories to screen for heritable diseases or disorders. Results from the 428 respondents who provide genetic screening services are reported. RESULTS: Most physicians (90%) knew that genetic tests are most informative when used in conjunction with family histories. Gynecologists gave more correct responses regarding genetic testing for breast and ovarian cancers than for colon cancer and other adult-onset diseases. Sixty-five percent of the respondents had not received formal training in DNA-based testing in gynecologic practice. Older physicians were less likely to have had training. Younger physicians generally gave more correct responses on the knowledge portion of the survey (r = -.165, P < .01). Physicians who had formal training in genetics gave more correct answers. Physicians who order DNA-based tests scored higher than those who do not and had no formal training, but not higher than those who had formal training and do not order DNA-based tests. CONCLUSION: Gynecologists were more knowledgeable about genetic issues pertaining to breast and ovarian cancer than to other cancers or certain adult-onset disorders. Training appeared to increase knowledge. Increased training and affiliation with genetic specialists and others could improve gynecologists' ability to use genetic screening in clinical practice.

Knowledge and clinical practice regarding calcium nutrition among obstetrician-gynecologists.

OBJECTIVE: To survey the knowledge of and attitude toward nutrition among practicing obstetrician-gynecologists, using calcium as a specific example. METHODS: Our survey on calcium nutrition consisted of 29 questions divided into four categories: demographic information, professional interest and clinical practice, knowledge and opinions, and education. We mailed this survey to the 244 ACOG Fellows who are members of the Collaborative Ambulatory Research Network and to a random sample of 756 Fellows who are not members of the Collaborative Ambulatory Research Network. RESULTS: Most (75.4%) respondents considered making dietary recommendations an important part of their practice. Interest in nutrition was correlated significantly with its perceived importance in clinical practice and was associated with a greater self-reported likelihood of making dietary recommendations to patients and referring patients to nutritional counseling. Nutrition was of greater importance to women and to older respondents. Women were more likely to make dietary recommendations to patients. Men were more likely to recommend nonfoods and higher fat foods as sources of dietary calcium. The daily calcium intake that obstetrician-gynecologists recommended for different types of patients varied widely but did not differ between male and female respondents. The responses to the knowledge questions concerning calcium metabolism were predominantly "don't know." CONCLUSIONS: Although specific knowledge of calcium metabolism and regulation was incomplete, obstetrician-gynecologists generally recognized the importance of nutrition in their clinical practice. Being older and female independently increased the perceived importance of nutrition.

Genetics in obstetricians' offices: a survey study.

OBJECTIVE: To investigate obstetricians' genetic knowledge base and practice trends. METHODS: A questionnaire survey was sent to 1003 ACOG Fellows, 554 (55%) of whom responded. Results from the 446 respondents practicing obstetrics are reported. RESULTS: The majority of obstetricians surveyed (85.6%) reported completing standardized genetic-history forms for prenatal patients, and about half (48%) performed their own invasive diagnostic procedures. Most (87%) had access to genetic counselors. For aneuploidy risks associated with advanced maternal age, up to 69% of respondents provided at least some patient counseling in their offices. Physician knowledge of risk assessment and diagnostic testing in the areas of aneuploidy and neural tube defects was very good; however, for single-gene disorders such as cystic fibrosis, Tay-Sachs disease, and sickle cell disease, correct risk assessment or appropriate test selection presented difficulties for at least half of the respondents. Respondents cited the rapidity of changes in genetic testing as the greatest obstacle to providing genetic information to patients. CONCLUSION: Obstetricians' knowledge of inheritance and test selection pertaining to single-gene disorders was more limited than that for aneuploidy and neural tube defects. Comparable deficits were noted in patient-education efforts for single-gene disorders.

Continuing medical education for life: eight principles.

Continuing medical education (CME) is being pressured to change in response to increasing and changing educational needs of practicing physicians, fostered by technical innovations, evolution of practice styles, and the reorganization of health care delivery. Leadership in the reform of CME falls primarily to the medical specialty societies in light of their traditional responsibilities for accrediting CME and maintaining professional standards. To address the need for reform, the American College of Obstetricians and Gynecologists in 1997 organized a conference to assemble CME program administrators from several medical specialties and academicians with expertise in postgraduate learning. At the conference, issues facing CME were examined. The authors, who were conference participants, state and explain eight principles that emerged from conference discussions. (For example: "Educational activities should be supportive of and coordinated with the transition to evidence-based medicine.") The principles reflect the interspecialty and interdisciplinary consensus achieved by the conference participants and can serve as useful guideposts for educators as they work to improve CME in their institutions. The authors conclude by noting the need for a more systematic and rigorously analytic approach, where CME content is determined according to assessed needs and CME is evaluated by measuring outcomes; for this to happen, CME educators and faculty must be brought up to date through training, including the use of problem-based learning. CME must also instill collegiality, interaction, and collaboration into the learning environment instead of being a solitary learning activity. Finally, CME must not only emphasize the acquisition of knowledge but also instruct physicians in the process of decision making to help them better use their knowledge as they make clinical judgments.

Attitudes of obstetricians and gynecologists toward hormone replacement therapy.

OBJECTIVE: To determine the attitudes of obstetricians and gynecologists toward hormone replacement therapy (HRT), and the beliefs and intuitions that affected those attitudes. DESIGN: A questionnaire was sent to 1,000 gynecologists in the United States; 328 replies were received. The questionnaire asked about effects of HRT, practices concerning HRT, and decisions in hypothetical scenarios. RESULTS: The respondents strongly favored HRT, and they were well informed about its effects on osteoporosis, cardiovascular disease, and breast cancer. They were aware of conflicting findings concerning breast cancer. The strength of their recommendation of HRT was sensitive to patient differences in risk factors. The respondents also showed four biases hypothesized to cause resistance to HRT: omission bias (more concern about harmful acts than harmful omissions); proportionality bias (attention to relative risk rather than risk differences); naturalness bias (preference for the natural); and ambiguity (avoiding options with missing information). Proportion bias, naturalness bias, and (weakly) omission bias were related to less favorable attitudes toward HRT. CONCLUSION: Although specialists are highly favorable toward HRT in general, some negativity toward HRT may result from decision biases.

Treatment of depression by obstetrician-gynecologists: a survey study.

OBJECTIVE: We performed an exploratory survey of depression diagnosis, treatment, and patient referral patterns by Fellows of ACOG. We also examined obstetrician-gynecologists' professional training in the management of clinical depression. METHODS: We sent a questionnaire to a total of 1370 ACOG Fellows. Sixty percent of the surveys were returned. RESULTS: As a group, obstetrician-gynecologists reported diagnosing an average of four new cases of depression per month. Within the overall sample, the number of new diagnoses of depression made each month was significantly greater for those defining themselves as primary care physicians than for those defining themselves as specialists. When treating depression pharmacologically, obstetrician-gynecologists reported that they overwhelmingly (74% of the time) chose selective serotonin reuptake inhibitor antidepressants. Ninety-five percent of obstetrician-gynecologists reported that they referred severely depressed patients to a mental health professional. A majority of respondents neither received residency training (80%) nor completed a continuing medical education course (60%) on the treatment of clinical depression in women. CONCLUSION: Obstetrician-gynecologists who describe themselves as primary care physicians make significantly more diagnoses of depression than those considering themselves specialists. Studies further to assess obstetrician-gynecologists' management of depression and better to define needs for professional education are warranted.

Answers to applicant selection from a directory of residency programs in obstetrics and gynecology.

OBJECTIVE: To answer six questions applicants commonly ask of programs, using the data base of a directory of residency programs in obstetrics and gynecology. METHODS: We analyzed data from a directory of 258 civilian residency programs in the United States compiled from a 1994-1995 survey. We expanded the analysis to compare small and large residency programs on the six questions. RESULTS: The average-size program of four residents per year received 50 applications for each position, offered interviews to less than a third of its applicants, and interviewed 15 applicants for each position. An interview gives an applicant a 7% chance of matching with a program. Small programs (fewer than four residents per year) interviewed more of their applicants than did large programs. Programs reported that their residents' scores on part I ranged from the 25th to the 90th percentile, and on part II from the 38th to the 92nd percentile. In general, residents in large programs scored better on these tests than did residents in small programs. Most programs (74%) considered electives beneficial in obtaining a residency position and reported a higher percentage of elective takers than programs without this policy. One in four residents in a program either took a senior elective there, graduated from the same institution, or both. Residents from programs offering fellowship training were twice as likely to pursue fellowship training than residents from programs with no fellowships. Large programs were four times more likely to sponsor fellowships than were small programs. CONCLUSION: Getting an interview in a residency program is a major accomplishment, whereas becoming known in a program may improve the applicant's odds of matching there. Applicants should review a program's policy on electives and selection record. Those considering fellowships should probably apply to programs that offer them. The directory offers a valuable data source for comparing residency programs in obstetrics and gynecology.

Hormonal replacement therapy: analysis of clinical strategies used by residents.

The authors investigated strategies employed by resident physicians to decide whether to prescribe hormonal replacement therapy (HRT) for menopausal women, a matter of continuing clinical controversy. Verbal protocols were obtained from 21 residents in three specialties as they responded to 12 brief case descriptions. The cases incorporated three levels of cancer risk and two levels of osteoporosis risk in a 3 x 2 factorial design with two replications in each cell. Substantial variation in willingness to prescribe HRT was observed. By clustering subjects with relatively similar approaches to the problem, three treatment strategies were formulated that accounted for the decisions of 20 subjects. Each strategy is a simplified representation of the conflicting considerations in this clinical dilemma that facilitates rapid decision making. The differences between these representations and formal decision-analytic models help to explain why observed clinical decisions were inconsistent with expected utility maximization.

Considering obstetrics and gynecology as a specialty: current attractors and detractors.

We surveyed senior students at 11 medical schools to identify the criteria they used in considering obstetrics and gynecology (OBG) as a career. Nearly half (49.6%) of the students responded. Their demographic characteristics compared well with national figures. Regression analyses identified 15 significant predictors of specialty choice among the 445 students who ranked OBG as one of their top four choices. More women than men chose OBG. Students attracted to the specialty liked contact with (mostly healthy) patients. They expressed strong beliefs on reproductive issues and perceived a need for more obstetrician-gynecologists. They associated their interests in operative procedures with certain risks and responsibilities. Physicians in OBG modestly affected their decision. Students who chose a different specialty wanted more variety in disease and patient mix. They wanted a more controllable life-style, particularly in residency training. They felt that the insurance costs and the risk of lawsuit detracted from OBG. These findings offer a stimulus for discussion between students and their advisors. Students need sufficient exposure to the specialty to help them assess the value they place on these specialty characteristics.

The application of a computer data base system to the generation of hospital discharge summaries.

The task of maintaining accurate and timely records of resident experiences, as well as section and departmental statistical data, may be readily accomplished with many commercially available computer data base packages. The application of this type of technology to the generation of "narrative" discharge summaries represents an extension of these applications and an incentive for house officer compliance. A system of data gathering and reporting, combined with the generation of discharge summaries, letters to referring physicians, and billing work sheets, has been in use in the Department of Obstetrics and Gynecology at The Medical College of Georgia for 2 years. A group of 103 patients discharged during the month of October 1985 served as controls for a comparable prospective group of 104 patients discharged beginning October 1, 1987. Analysis shows an average (+/- SEM) of 3.8 +/- 0.6 days from discharge to printed discharge summary from the computer system. Before implementation of the system (1985), the average was 20.9 +/- 4.5 days. This difference was statistically significant at P = .001. Although it may be difficult to quantitate improvement in quality of the data obtained for residency and departmental purposes, this reduction in delinquent charts alone may be sufficient to recommend the application of computer technology to this problem.

Student performance on the NBME Part II subtest and subject examination in obstetrics-gynecology.

Clerkship directors in obstetrics-gynecology often use the National Board of Medical Examiners (NBME) norms to evaluate third-year medical students' performance on the NBME obstetrics-gynecology subject examination. A comparison of the scores of 342 students at the Medical College of Georgia School of Medicine showed that the students performed significantly better on the NBME subject examination than on the Part II subtest in obstetrics-gynecology. These results concur with the findings of the NBME, which advises directors wishing to adjust the criterion group norms to determine the average difference observed in a school's performance on the two examinations and to use that difference or some portion of it in their interpretation of percentile scores on the subject examination. Additional analyses revealed that a single, linear weight may inappropriately adjust these scores, that student performance on the Part II subtest depends on specialty choice (obstetrics-gynecology versus all others), and that time and sequence of the clerkship were unrelated to the students' performance on the two examinations.