Medscape Ob/Gyn & Women's Health 8(1), 2003. © 2003 Medscape

This collection of recent MEDLINE abstracts is one of a series that considers the Ob/Gyn as a study subject. In this easy-to-navigate collection, we feature studies that highlight continuing education needs of the practicing Ob/Gyn.

General Continuing Education Issues

Cultural and Ethical Issues

Fetal Anomalies: Ethical and Legal Considerations in Screening, Detection, and Management

Strong C
Clin Perinatol. 2003;30:113-126

A number of ethical considerations arise with regard to screening for, detecting, and managing fetal anomalies. Some of these considerations involve the need to give attention to emotional distress the pregnant woman might be experiencing. The ethical principle of beneficence gives rise to a duty of the obstetrician to provide emotional support when needed in relation to screening, confirmatory testing, giving bad news, making abortion decisions, making management decisions after viability, and dealing with the grieving process. Other issues involve ethical decision-making, such as deciding what recommendations to make concerning management of fetal anomalies after viability. The ethical principle of autonomy creates a duty of the obstetrician to help the pregnant woman make informed management decisions based on her values and goals. A recommendation for a particular approach to management is sometimes ethically justifiable on the basis of an analysis of the risks and benefits to the mother and fetus. Legal considerations are relevant because they create requirements or prohibitions that must be taken into account in ethical decision-making. The discussion in this article does not exhaust the range of issues that arise. For example, sometimes a delivery procedure is considered that is traumatic to the fetus, such as cephalocentesis for vaginal delivery of a fetus with hydrocephaly. The reader is referred to other sources for a discussion of the ethics of delivery procedures that might injure or kill the fetus. Other issues involve deciding when there is a duty to offer new prenatal genetic tests, routinely or for high-risk couples, and whether to carry out maternal requests for prenatal tests for late-onset diseases and susceptibilities to diseases. These issues have been discussed elsewhere.

Ultrasound Screening in Pregnancy: Advancing Technology, Soft Markers for Fetal Chromosomal Aberrations, and Unacknowledged Ethical Dilemmas

Getz L, Kirkengen AL
Soc Sci Med. 2003;56:2045-2057

Fetal ultrasound screening has become routine practice in many western countries. During the last decade, such screening has led to frequent situations characterised by clinical uncertainty due to the disclosure of soft markers in the unborn child. Soft markers are minor anatomical variations indicating a somewhat increased likelihood that the fetus has a chromosomal aberration, most frequently trisomy 21 (Down syndrome). This paper presents the results of a comprehensive literature search of the National Library of Medicine with emphasis on the chronological development of scientific knowledge in relation to soft markers and the link between advancing imaging technology and clinical counselling dilemmas. An analysis of the literature makes evident that many ultrasound examiners have counselled individual pregnant women on the basis of insufficient data. Moral dilemmas have thus emerged as a direct result of advancing medical technology, and healthy fetal lives prove to have been lost due to invasive diagnostic testing aimed at resolving clinical uncertainty. Ultrasound examiners have warned against a policy of disclosing all findings of soft markers to expectant parents, but no exploration of experiential aspects linked to the disclosure of fetal soft markers has yet been published in the medical literature. The emotional reactions of mothers are important to consider given their potential impact on the biological development of the fetus. In conclusion, this paper stresses the need for paying close attention to the crucial distinction between technology development and technology implementation in relation to prenatal testing. Furthermore, it provides strong arguments for scrutinising the interface between prenatal testing and human experience.

Issues for South Asian Indian Patients Surrounding Sexuality, Fertility, and Childbirth in the US Health Care System

Fisher JA, Bowman M, Thomas T
J Am Board Fam Pract. 2003;16:151-155

Background: In 1998 ethnic minorities comprised 28% of the US population, and India is the third most common country of origin for immigrants. Many recently immigrated South Asian Indian patients are seen in health care settings in the United States. To deliver health care effectively to these patients, it is helpful for physicians to understand common cultural beliefs and practices of South Asian Indian patients.
Methods: Two illustrative cases are reported. One author's observations of the care of pregnant and parturient women in India and similar experiences in our own office spurred a literature search of the cultural behaviors surrounding sexuality, fertility, and childbirth. A literature search was conducted in Index Medicus, Grateful Med, and the catalogue of the University of Pennsylvania Arts and Sciences library, using the terms "Indian," "South Asian," "male and female gender roles," "gynecology in third world," "sexuality," "sexual health," "women's health," "women's health education," "obstetrical practices/India," and "female roles/India."
Results: Issues surrounding sexuality and childbirth that arise during the US physician-South Asian Indian patient encounter might not correspond to the commonly held knowledge, beliefs, and behaviors of the US health care system. Common cultural beliefs and behaviors of South Asian Indian patients around sexuality and childbirth experience include the role of the individual patient's duty to society, the patient's sense of place in society, lack of formal sexual education, prearranged marriages, importance of the birth of the first child, little premarital contraceptive education, dominance of the husband in contraceptive decisions, and predominant role of women and lack of role for men (including the husband) in the childbirth process.
Conclusion: Lack of understanding of the Indian cultural mores surrounding sexual education, sexual behavior, and the childbirth experiences can form barriers to Indian immigrants in need of health care. These misunderstandings can also lead to patient dissatisfaction with the health provider and health system, underutilization of health services, and poorer health outcomes for Indian immigrants and their families. For this reason, it is important to teach cultural issues during undergraduate, graduate, and continuing medical education.

The Genomic Revolution and the Obstetrician/Gynaecologist: From Societal Trends to Patient Sessions

Evans WJ, Britt DW
Best Pract Res Clin Obstet Gynaecol. 2002;16:729-744

A major aspect of reaping the benefits of the genome revolution in women's health relates to questions of how we are going to handle this scientific manna of information and potential treatment options while minimizing social exclusion along the lines of race, class and gender. Four society-level scenarios or patterns of diffusion of genomic access are discussed, each with its own set of assumptions and outcomes in terms of equity. Like it or not, the front-line obstetrician/gynaecologist will play a critical role in whether such new information helps either to reduce or to exacerbate discrepancies in health-care status along the lines of race and socio-economic status. Patients must not be denied access to knowledge and information within the genetic counselling session, or to the opportunity to make an informed autonomous decision because of the use of unfamiliar language and conventions of conversation that support power differentials and discourage rapport and empathy. Aspects of communication that are critical to the outcome of the genetic counselling session, such as the level of directness of counselling, physician interruptions of the patient and the power implications of the rhetorical question, are explored. In addition, the special challenges to counsellor neutrality and patient autonomy offered by the longitudinal primary obstetrician/gynaecologist relationship are discussed. Strategies encouraging more effective collaboration and communication between generalist and patient in the counselling session are offered.

Ethical Decision-Making in Prenatal Diagnosis and Termination Of Pregnancy: A Qualitative Survey Among Physicians and Midwives

Garel M, Gosme-Seguret S, Kaminski M, Cuttini M
Prenat Diagn. 2002;22:811-817

Objectives: This study was aimed at exploring the conflicts and ethical problems experienced by professionals involved in prenatal diagnosis and termination of pregnancy (TOP) in order to improve the understanding of decision-making processes and medical practices in the field of prenatal diagnosis.
Methods: Qualitative study with in-depth tape-recorded interviews conducted in three tertiary care maternity units in France, between May 1999 and March 2000. All full-time obstetricians and half of the full-time midwives were contacted. Seventeen obstetricians and 30 midwives participated (three refusals, five missing). Interviews were transcribed and analysed successively by two different researchers.
Results: All respondents stated that prenatal diagnosis and TOP raised important ethical dilemmas, the most frequent being request for abortion in case of minor anomalies. They pointed out the inability of our society to appropriately care for disabled children and the risk of eugenic pressures. The decisions and practices in prenatal diagnosis should be debated throughout society. All respondents reported that their unit did not have protocols for deciding when a TOP was justifiable. The transmission of information to the women appeared to be a problematic area. Moral conflicts and emotional distress were frequently expressed, especially by midwives who mentioned the need for more discussions and support groups in their department.
Conclusion: Health diagnosis face complex ethical dilemmas which raise important personal conflicts. A need for more resources for counselling women and for open debate about the consequences of the current practices clearly emerged. Copyright 2002 John Wiley & Sons, Ltd.

Clinical Practice Guidelines

Clinical Practice Guidelines as Educational Tools for Obstetrician-Gynecologists

Farquhar CM, Kofa E, Power ML, Zinberg S, Schulkin J
J Reprod Med. 2002;47:897-902

Objective: To examine the awareness of and attitudes toward clinical practice guidelines (CPGs) produced by the American College of Obstetricians and Gynecologists (ACOG) among its fellows and to identify factors that would enhance the perceived value of the CPGs.
Study Design: A questionnaire survey on clinical practice guidelines sent to 1,000 practicing fellows of ACOG.
Results: Four hundred sixty-two fellows (46.2%) responded. Virtually all (98%) were aware of ACOG CPGs; 61% stated that an ACOG CPG had changed their practice. Far fewer (6-56%) were aware of CPGs from other organizations; 71.9% were aware of all eight ACOG CPGs that were added in 2000 (range, 83.3-90%). Important factors that would enhance the value of CPGs to the respondents were CPGs that were up to date, had demonstrated improved outcomes, were evidence based and were produced by ACOG. Barriers to use were CPGs without summaries, CPGs not specific to the fellows' settings, CPGs not taking patient cost into account and patient requests for different procedures.
Conclusion: The widespread awareness by ACOG fellows of CPGs produced by ACOG demonstrates the potential importance of specialty societies in disseminating CPGs. The data suggest that important characteristics of CPGs are being up to date, being evidence based, containing a summary and providing patient education materials.

The Impact of National Clinical Guidelines on Obstetricians in Scotland

Foy R, Penney G, Greer I
Health Bull (Edinb). 2001;59:364-372

Objective: To audit reported clinical practice in relation to four national obstetric guidelines on The Preparation of the Foetus for Preterm Delivery, The Management of Mild, Non-proteinuric Hypertension in Pregnancy, The Management of Pregnancy in Women with Epilepsy and The Management of Postpartum Haemorrhage.
Design: Questionnaire surveys before and after dissemination of the guidelines.
Subjects: One hundred and sixty one consultants and senior specialist registrars in Scotland.
Results: The response rates to the baseline and follow-up surveys were 85% and 74% respectively. Over 90% of the obstetricians kept the guidelines for reference and 85% had been prompted to change or reconsider their practice. Reported compliance improved significantly for six out of twenty nine recommendations covering: the use of tocolysis in women at risk of pre-term labour; the use of prophylactic antibiotics or entry to a clinical trial for pre-term, pre-labour rupture of the membranes; the initiation of steroid therapy in women with insulin-dependent diabetes mellitus; and the prescribing of periconceptual folic acid and vitamin K to women with epilepsy. There were no significant improvements in relation to mild, non-proteinuric hypertension or post-partum haemorrhage.
Conclusions: There were significant improvements in the reported management of women at risk of preterm labour and those with epilepsy. However, reported practice in relation to mild, non-proteinuric hypertension and post-partum haemorrhage has improved little. This is possibly because the guidelines for these topics were relatively complicated to understand and apply, and established patterns of practice more resistant to change.

Issues in Gynecology

Seeking Help for Sexual Function Complaints: What Gynecologists Need to Know About the Female Patient's Experience

Berman L, Berman J, Felder S, et al.
Fertil Steril. 2003;79:572-576

Objective: To further explore the patient experience of seeking help for a sexual function complaint.
Design: Survey administered on a Web-based instrument.
Setting: Healthy volunteers visiting an online Website.
Patient(s): The majority of participants were married (73%), Caucasian (88%), and premenopausal (67%). Most commonly reported sexual complaints included low desire (77%), low arousal (62%), and difficulty achieving orgasm (56%).
Intervention(s): None.
Main outcome measure(s): Patient experience survey on a women's sexual health website.
Result(s): Although 40% of the women reported that they did not seek help from a physician for sexual function complaints, 54% reported that they would like to. Although only a minority of the women internalized their experience with extremely negative emotions like shame, devaluation, or disgust, the experience was not a particularly emotionally positive one along the lines of relief, optimism, or confidence, and a great deal of frustration and anxiety about treatment was reported.
Conclusion(s): The extent to which health professionals currently receive exposure to training in human sexuality as well as the way in which female sexual complaints are handled in the medical setting remain ambiguous. The inflow of patients with sexual function complaints only will increase, and it is time for physicians to start to acknowledge women's sexuality with the same importance their patients do.

The Vaginitis Monologues: Women's Experiences of Vaginal Complaints in a Primary Care Setting

Karasz A, Anderson M
Soc Sci Med. 2003;56:1013-1021

Vaginal complaints are a common presenting problem in primary care settings. A disease model has dominated current research and treatment paradigms, with little attention to the illness or experiential dimensions of vaginal complaints. In this paper, we report data from a qualitative study of the experiences of women diagnosed with vaginitis. In semi-structured interviews with 44 women in New York City, United States, we investigated women's interpretations and explanations of their illness, their accounts of its impact on their lives, their experiences with treatment, and the role of vaginal symptoms in communicating distress and anger. We found that women's explanations of vaginal complaints differed strikingly from the current medical model described in the literature on vaginitis. Vaginal symptoms often occasioned extreme anxiety; their impact on social and sexual functioning could be severe. Finally, vaginal symptoms often functioned to express distress and gender conflict. These findings have important implications for the management of the disorder.

Obstetrician-Gynecologists and the Intrauterine Device: A Survey of Attitudes and Practice

Stanwood NL, Garrett JM, Konrad TR
Obstet Gynecol. 2002;99:275-280

Objective: To assess obstetrician-gynecologists' clinical use of the intrauterine device (IUD), their attitudes toward the IUD and how they select IUD candidates, and to test the hypotheses that limited residency training in IUDs, fear of litigation, and a belief that IUDs cause pelvic inflammatory disease decrease IUD use.
Methods: We performed a national mailed survey of 811 practicing obstetrician-gynecologists obtained from systematic sampling of ACOG membership listings to assess use of and attitudes toward the IUD.
Results: The survey response rate was 50%. Most respondents agreed that the copper IUD is safe (95%) and effective (98%). However, 20% of respondents had not inserted an IUD in the past year, and of those who had, most (79%) reported inserting 10 or fewer. Fear of litigation and a belief that IUDs cause pelvic inflammatory disease were associated with lower IUD use; the number of IUDs inserted during residency was not. In selecting IUD candidates, respondents were most restrictive about patient monogamy. Having less conservative criteria for selecting IUD candidates was associated with greater IUD use. Respondents with liberal criteria inserted a mean of nine IUDs in the past year, whereas those with conservative criteria inserted four.
Conclusions: Because most obstetrician-gynecologists are inserting few IUDs, educational programs should target these physicians to expand their IUD use. Such programs should highlight modern IUD safety and the rarity of litigation. The number of IUDs inserted in residency may be less important than the development of less restrictive, more evidence-based criteria for selecting IUD candidates.

A Survey of Gynecologists Concerning Menorrhagia: Perceptions of Bleeding Disorders as a Possible Cause

Dilley A, Drews C, Lally C, Austin H, Barnhart E, Evatt B
J Womens Health Gend Based Med. 2002;11:39-44

We sought to determine perceptions and practices of American gynecologists when treating with a woman complaining of menorrhagia, specifically with regard to an underlying bleeding disorder as a potential cause. A mail survey of Georgia members of the American College of Obstetricians and Gynecologists was conducted. The survey response was 52%, and the analysis includes 376 physicians who reported seeing at least one gynecological patient per week. On average, respondents were in practice 20 years and reported that 8% of their patient population complain of menorrhagia. Virtually all physicians reported employing a menstrual history as a starting point for the workup for menorrhagia, and 95% order a hemoglobin/hematocrit determination. About 50% of physicians considered saturating three tampons/pads per 4 hours as excessive, although the criterion varied widely (range 0-24 per 4 hours, SD = 3). The diagnoses considered most likely among reproductive age women were anovulatory bleeding or benign lesions or that the heavy bleeding was within normal limits. Only 4% of physicians would consider von Willebrand disease (VWD) for this age group (women of reproductive age). Among girls near menarche, physicians overwhelmingly consider anovulatory bleeding or bleeding within normal limits the likely diagnoses, and 16% would consider VWD in this age group. Only rarely (3%) do surveyed physicians refer menorrhagia patients to other specialists. Most respondents believe that most menorrhagia is caused by anovulation or is within normal limits. Bleeding disorders are believed to be a rare cause of menorrhagia.

Sexually Transmitted Disease Screening by United States Obstetricians and Gynecologists

Hogben M, St Lawrence JS, Kasprzyk D, et al.
Obstet Gynecol. 2002;100:801-807

Objective: To assess compliance with practice guidelines and to determine the extent of missed opportunities for sexually transmitted disease (STD) prevention by describing screening practices of a national sample of obstetricians and gynecologists and comparing them to the practices of other specialists.
Methods: Physicians (n = 7300) in five specialties that diagnose 85% of STDs in the United States were surveyed. Obstetrics and gynecology (n = 647) was one of the five specialties. Besides providing demographic and practice characteristics, respondents answered questions about who they screen (nonpregnant females, pregnant females) and for which bacterial STDs (syphilis, gonorrhea, chlamydia).
Results: Responding obstetricians and gynecologists were most likely to be non-Hispanic white (75%), male (66%), and in their 40s (mode 43 years old). They saw an average of 90 patients per week during 47 hours of direct patient care. Approximately 95% practiced in private settings. Almost all (96%) screened some patients for at least one STD. Obstetricians and gynecologists screened women more frequently than other specialties, but no specialty screened all women or all pregnant women.
Conclusion: Obstetricians and gynecologists screen women for STDs at a higher rate than other specialties represented in this study. Consistent with published guidelines, most obstetricians and gynecologists in our survey screened pregnant women for chlamydia, gonorrhea, and syphilis. Nonetheless, only about half of obstetricians and gynecologists screened nonpregnant women for gonorrhea or chlamydia, and fewer screen nonpregnant women for syphilis.

Barriers to Screening Sexually Active Adolescent Women for Chlamydia: a Survey of Primary Care Physicians

Cook RL, Wiesenfeld HC, Ashton MR, Krohn MA, Zamborsky T, Scholle SH
J Adolesc Health. 2001;28:204-210

Purpose: To determine the proportion of primary care physicians who screen sexually active teenage women for chlamydia and to determine demographic factors, practice characteristics, and attitudes associated with chlamydia screening.
Methods: We obtained a random sample of 1600 Pennsylvania physicians from the American Medical Association masterfile, stratified to include at least 40% women and equal numbers of family physicians, internists, obstetricians/gynecologists, and pediatricians. In January 1998, physicians received mailed questionnaires; nonrespondents received two follow-up mailings. Physician characteristics associated with chlamydia screening were determined using bivariate and logistic regression analyses.
Results: Only one-third of physicians responded that they would screen asymptomatic, sexually active teenage women for chlamydia during a routine gynecologic examination. In multivariate analysis, physicians were significantly (p <.05) more likely to screen if they were female (43% vs. 24%), worked in a clinic versus solo practice (60% vs. 18%), worked in a metropolitan location (46% vs. 26%), or had a patient population > or = 20% African-American (54% vs. 25%). Attitudes associated with screening included the belief that most 18-year-old women in their practice were sexually active (36% vs. 12%), feeling responsible for providing information about the prevention of sexually transmitted diseases to their patients (42% vs. 21%), or knowing that screening for chlamydia prevents pelvic inflammatory disease (37% vs. 13%). Physicians were less likely to screen if they believed that the prevalence of chlamydia was low (10% vs. 41%).
Conclusions: A majority of physicians do not adhere to recommended chlamydia screening practices for teenage women. Interventions to improve chlamydia screening might target physicians who are male, in private practice, or who practice in rural areas, and should focus on increasing awareness of the prevalence of chlamydia and benefits of screening.

Issues in Obstetrics

Neonatal Encephalopathy and Cerebral Palsy: A Knowledge Survey of Fellows of the American College of Obstetricians and Gynecologists

Hankins GD, Erickson K, Zinberg S, Schulkin J
Obstet Gynecol. 2003;101:11-17

Objective: To assess practicing obstetricians' knowledge of the etiology and pathophysiology of neonatal encephalopathy and its relationship to cerebral palsy.
Methods: A questionnaire designed to test both knowledge and practice patterns was mailed to 413 members of the Collaborative Ambulatory Research Network of The American College of Obstetricians and Gynecologists (ACOG), as well as 600 randomly selected non-Network ACOG Fellows. The questionnaire was composed of 15 knowledge questions and three clinical scenarios containing seven knowledge questions. Six of the questions directly assessed knowledge of cerebral palsy.
Results: Of those who returned the questionnaire, 351 practiced obstetrics and were included in the statistical analyses. For the majority of questions, "Don't know" was the most frequent response. The next most frequent response for 8/13 questions was the correct answer. Performance was strongest as regarded actual clinical practice and relatively weak regarding the antecedents of neonatal encephalopathy and cerebral palsy. The physicians' actual knowledge scores showed a significant correlation with their self-assessments of knowledge (r =.41, P <.001). The majority of physicians rated their training on this topic in medical school, residency, and through continuing medical education as marginal or inadequate.
Conclusion: The results of this survey identified large knowledge gaps in this area, suggesting a need to develop educational projects to address these deficits by both professional organizations and individual teachers.

Thromboembolism Prophylaxis and Cesarean Section: a Survey of General Obstetricians

Connolly T
South Med J. 2003;96:146-148

Background: Venous thromboembolism (VTE) has historically remained a risk factor for obstetric patients, particularly those requiring cesarean section. The objective of this survey was to assess the response of general obstetricians to risk factor considerations for VTE prophylaxis and cesarean section.
Methods: A survey regarding VTE prophylaxis and cesarean section was sent to 113 obstetricians practicing in suburban Chicago and northern Wisconsin.
Results: There were 51 responses (45%) to the survey. Most respondents do not routinely use VTE prophylaxis for cesarean section in patients who may have one or more risk factors.
Conclusion: There appears to be lack of consensus or appreciation for VTE and prophylaxis for cesarean section. Further studies and education are warranted.

The Effort to Increase Breast-Feeding. Do Obstetricians, in the Forefront, Need Help?

Power ML, Locke E, Chapin J, Klein L, Schulkin J
J Reprod Med. 2003;48:72-78

Objective: To assess the knowledge, training and attitudes of obstetricians concerning management of breast-feeding. STUDY
Design: A survey was sent to 1,200 fellows of the American College of Obstetricians and Gynecologists; 397 practicing obstetricians responded.
Results: Obstetricians who were satisfied with their patients' behavior (69.5%) estimated that on average > 70% of their patients planned to breast-feed, while those who were unsatisfied (21.4%) estimated that < 60% of their patients planned to breast-feed. African American race and eligibility for Medicaid both appear to predict low rates of breast-feeding among patients. Most physicians considered that they were very well qualified to treat mastitis, prescribe maternal medications and advise their patients regarding contraception. They were less certain of their qualifications regarding educating their patients about breast-feeding and aiding them in solving breast-feeding problems. Personal breast-feeding experience was a significant predictor of female physician confidence. Four of 10 physicians regarded their residency training as inadequate in terms of breast-feeding management.
Conclusion: The perceptions of obstetricians regarding breast-feeding practices of their patients appear consistent with national surveys. Obstetricians consider counseling their patients and managing breast-feeding care to be important parts of their clinical responsibilities, but further training and educational materials are warranted.

Survey of Physician Attitudes Toward HIV Testing in Pregnant Women in Ohio

Duggan J, Khuder S, Sinha N, Chakraborty J
AIDS Patient Care STDS. 2003;17:121-127

HIV infection among women of childbearing age is still increasing in the United States. In most states, HIV testing of women or neonates during pregnancy is not mandatory. The current study assessed HIV prenatal testing practices among obstetrician-gynecologists and primary care physicians listed in a regional physician referral data base in a predominantly rural region. Between December 2000 and March 2001 a 20-question survey was sent by mail to regional physicians in obstetrics/gynecology and primary care regarding physician practice demographics and prenatal HIV testing practices. Of 1116 surveys sent, 431 were returned (38.6% response). Only 42% of physicians offered universal HIV prenatal testing. Factors associated with universal testing (p < 0.5) included obstetrics/gynecology as the practice specialty (90%) physicians' age younger than 50 years, and a practice with predominantly Medicaid or African American patients. Further educational and public health initiatives may be needed to increase nonselective, universal HIV testing in pregnant women.

Physician Beliefs and Practices Regarding SIDS and SIDS Risk Reduction

Moon RY, Gingras JL, Erwin R
Clin Pediatr (Phila). 2002;41:391-395

The AAP has alerted pediatricians to the importance of safe sleep environment for infants. The elements of a safe sleep environment include supine sleep position, safe crib, and avoidance of smoke exposure, soft bedding, and overheating. With the Back to Sleep campaign, prone sleeping among all U.S. infants has decreased to less than 20%, and the incidence of SIDS has decreased 40%. However, the decline in SIDS and prone sleeping has leveled off in recent years. Further declines may be possible with decreasing other modifiable risk factors, such as prenatal and postnatal exposure to cigarette smoking. Prior studies have demonstrated that health care professional advice is influential in determining infant care practices. It is important that physicians caring for infants be aware of the importance of a safe sleep environment and understand other modifiable risk factors for SIDS. We surveyed a random sample of 3,717 physicians in North Carolina and the metropolitan Washington, DC, area to determine knowledge, beliefs, and practices regarding SIDS and SIDS risk reduction among physicians caring for pregnant women and infants. Twenty-three percent (835) responded. Most physicians are aware of prone sleeping and cigarette smoke exposure as risk factors for SIDS. Almost all physicians agree that there are measures that can be taken to reduce the risk of SIDS, and they consider it important to discuss SIDS and SIDS risk reduction strategies with parents of young infants. In spite of this belief, only 56% of family/general practitioners, 18% of obstetrician-gynecologists, and 79% of pediatricians discuss SIDS routinely. Only 35% of pediatricians, 15% of family/general practitioners, and 16% of obstetrician-gynecologists provide written information. In addition, only 38% of physicians recommend supine, while 50% recommend side or back, 6% side, and 7% prone. Only two thirds of pediatricians and one third of family/general practitioners are aware that the AAP recommends supine as the preferred sleep position for infants. Pediatricians are more likely to be aware of the AAP recommendation (p<0.0001) and to discuss SIDS risk reduction strategies with parents (p=0.03). We conclude that many physicians who care for infants are unaware of the AAP's most current recommendation for sleep position and are incorrectly recommending the side position. Physicians may also be unaware of other sleep environment hazards. Further educational efforts must continue for physicians who provide care to pregnant women and children to ensure a continued decline in the incidence of SIDS.

Obstetrician-Gynecologists' Knowledge and Training About Antenatal Corticosteroids

Erickson K, Schmidt L, Santesso DL, Schulkin J, Gregory K, Hobel C
Obstet Gynecol. 2001;97:140-146

Objective: To characterize the clinical decisions, knowledge, opinions, and education of obstetricians and gynecologists about antenatal corticosteroids.
Methods: Questionnaires mailed to 1020 ACOG Fellows included items on demographics, knowledge, clinical practice patterns, and educational background regarding antenatal corticosteroids.
Results: The survey response rate was 47.8%. Almost all respondents (94%) reported administering antenatal corticosteroids, with reduction of respiratory distress syndrome (82%) as the primary reason for antenatal corticosteroid administration. Most (59.2%) were unaware of newly recognized associations between multiple administrations of corticosteroids and fetal growth restriction. In hypothetical clinical situations, responses by physicians who completed their residency training before 1970 indicated less likelihood to administer corticosteroids when administration is relatively indicated per National Institutes of Health (NIH) and ACOG guidelines than those trained later (P <.001). Only 8% of the entire sample rated their knowledge of antenatal corticosteroids as comprehensive; most (68%) rated it as adequate. Respondents rated residency training as a much better source of antenatal corticosteroid knowledge than medical school.
Conclusion: Most obstetrician-gynecologists reported using antenatal corticosteroids; however, in general, many were not aware of more recent information regarding potential risks. This survey suggests that a multipronged educational approach is warranted to update obstetrician-gynecologists about antenatal corticosteroids.

Carrier Screening for Cystic Fibrosis Among Maryland Obstetricians Before and After the 1997 NIH Consensus Conference

Doksum T, Bernhardt BA, Holtzman NA
Genet Test. 2001;5:111-116

The 1997 National Institutes of Health (NIH) Consensus Conference on Cystic Fibrosis (CF) testing recommended that carrier screening be offered to all pregnant women and couples planning a pregnancy. We surveyed 492 Maryland Ob-Gyns before and after the consensus conference to: (1) assess whether obstetricians changed their practice regarding CF carrier testing, and (2) identify the factors associated with changing practice patterns, including awareness of the statement, and knowledge about CF. Fifty-six percent (275) responded to the first mail questionnaire and 107 obstetricians responded to both questionnaires. In 1998, only 18% of respondents to the second questionnaire were familiar with the NIH statement, but 43% reported discussing testing with patients with no family history, a significant increase from 1997, when only 20% reported discussing testing. Less than one-third correctly answered six multiple-choice knowledge questions about CF and carrier testing. In multivariate analysis, knowledge and familiarity with the NIH consensus statement were not associated with beginning to discuss CF carrier testing after the CF conference with their patients without a family history.

Survey of Obstetrician-Gynecologists in the United States About Toxoplasmosis

Jones JL, Dietz VJ, Power M, et al.
Infect Dis Obstet Gynecol. 2001;9:23-31

Background: Although the incidence of toxoplasmosis is low in the United States, up to 6000 congenital cases occur annually. In September 1998, the Centers for Disease Control and Prevention held a conference about toxoplasmosis; participants recommended a survey of the toxoplasmosis-related knowledge and practices of obstetrician-gynecologists and the development of professional educational materials for them.
Methods: In the fall of 1999, surveys were mailed to a 2% random sample of American College of Obstetricians and Gynecologists (ACOG) members and to a demographically representative group of ACOG members known as the Collaborative Ambulatory Research Network (CARN). Responses were not significantly different for the random and CARN groups for most questions (p value shown when different).
Results: Among 768 US practicing ACOG members surveyed, 364 (47%) responded. Seven per cent (CARN 10%, random 5%) had diagnosed one or more case(s) of acute toxoplasmosis in the past year. Respondents were well-informed about how to prevent toxoplasmosis. However, only 12% (CARN 11%, random 12%) indicated that a positive Toxoplasma IgM test might be a false-positive result, and only 11% (CARN 14%, random 9%) were aware that the Food and Drug Administration sent an advisory to all ACOG members in 1997 stating that some Toxoplasma IgM test kits have high false-positive rates. Most of those surveyed (CARN 70%, random 59%; chi2 p < 0.05) were opposed to universal screening of pregnant women.
Conclusions: Many US obstetrician-gynecologists will encounter acute toxoplasmosis during their careers, but they are frequently uncertain about interpretation of the laboratory tests for the disease. Most would not recommend universal screening of pregnant women.

Issues in Primary Care

Prevalence and Physician Awareness of Symptoms of Urinary Bladder Dysfunction

Goepel M, Hoffmann JA, Piro M, Rubben H, Michel MC
Eur Urol. 2002;41:234-239

Purpose: To determine awareness of bladder dysfunction and attitudes towards its management among office-based physicians.
Materials and Methods: A total of 211,648 patients consulting office-based primary care physicians (PCPs), gynaecologists (OBGs) or urologists (UROs) for any reason were given a questionnaire of four questions related to symptoms of bladder dysfunction. The physicians were asked to discuss the answers with their patients and to choose from a list of suspected diagnoses. They were also asked whether medical therapy would be initiated and/or the patient referred to a specialist.
Results: Patients (57%) had a least one symptom of bladder dysfunction, with increased frequency being most common (41.9%), and symptoms of stress incontinence (30.6%), urgency (24.3%) and urge incontinence (20.2%) less frequent. However, patients with symptoms of overactive bladder (OAB), mixed incontinence or stress incontinence according to the questionnaire remained undiagnosed by their physician in 57.5, 47.5 and 38.1% of cases, respectively. When a diagnosis was suspected by the physician, it often did not match what would be expected based on the questionnaire, and in half of all cases did not result in medical treatment.
Conclusions: Bladder dysfunction is highly prevalent among patients consulting an office-based physician for any reason, but remains undiagnosed in many cases and untreated despite diagnosis in many others. Since various effective treatment options are available for bladder dysfunction, educational programs for patients and physicians appear necessary to improve the quality of diagnosis and treatment for this wide-spread condition.

Referral Patterns for Gynaecologic Cancers and Precancerous Conditions

Gagliardi A, DePetrillo D, Elit L
J Obstet Gynaecol Can. 2002;24:553-558

Objectives: (1) To determine a gynaecologist's preference for delivering primary surgical care to women with gynaecologic cancer or precancerous conditions; (2) to determine referral patterns for gynaecologic cancers and precancerous conditions; (3) to outline barriers to the current gynaecologic oncology service provision in Ontario; (4) to understand, from a gynaecologist's perspective, the acceptable waiting times from referral to subspecialty consultation; and (5) to determine a gynaecologist's interest in following patients after more specialized management for gynaecologic cancer.
Methods: The survey instrument was designed and pretested. The survey was mailed to 541 gynaecologists in Ontario.
Results: The response rate was 49.4%. Of the gynaecologists who responded, 75.3% trained in Ontario; 57.3% had community-based practices; and 55% indicated they surgically treated women with invasive cancers. The invasive cases treated most commonly were endometrial cancer (96.4%), followed by ovarian cancer (86.1%). Ninety-one percent of gynaecologists referred their patients to the closest cancer centre with a gynaecologic oncologist on staff. Seventy-five percent of gynaecologists were interested in delivering follow-up care for women who had treatment for cancer, provided that follow-up guidelines were made available.
Conclusion: Gynaecologists were interested in providing follow-up care to women who received cancer care by subspecialists. Gynaecologists requested continuing education on gynaecologic cancers and guidelines for follow-up care. Issues surrounding the process of referral and communication with gynaecologists were seen as areas for improvement. The results of this survey will be pivotal in setting goals for a provincial gynaecologic oncology program.

Practice Trends in Outpatient Obstetrics and Gynecology: Findings of the Collaborative Ambulatory Research Network, 1995-2000

Hill LD, Erickson K, Holzman GB, Power ML, Schulkin J
Obstet Gynecol Surv. 2001;56:505-516

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.

5-Year Mammography Rates and Associated Factors for Older Women

Van Harrison R, Janz NK, Wolfe RA, Tedeschi PJ, Huang X, McMahon LF Jr.
Cancer. 2003;97:1147-1155

Background: Major national interventions occurred in the early and mid-1990s to increase mammography screening rates among older women. The current study examined mammography utilization by older women during this period. Relation between mammography utilization and demographic measures and health care-related factors also were examined.
Methods: A cross-sectional design examined variations in mammography during the 5 years between 1993 to 1997 in a representative sample of 10,000 female Medicare beneficiaries in Michigan age >or= 65 years in 1993. Medicare and census data were used. Separate analyses were performed for having undergone any mammogram and, for the 5680 women who had undergone a mammogram, the number of mammograms. Relations were examined between mammography utilization and 15 demographic variables (e.g., age and African-American race) and health care-related variables (e.g., inpatient admissions and number of physicians involved in care).
Results: In the 5 years 43% of older women had no evidence of having undergone a mammogram. Those with any mammogram averaged 2.8 mammograms. Meaningful independent predictors of both having undergone a mammogram and having more than one mammogram were more physicians involved in care, fewer inpatient admissions, and younger age. Having undergone a mammogram also was found to be associated with seeing an obstetrician/gynecologist.
Conclusions: Even with screening mammography as a covered benefit and after several national informational campaigns, the current study found that in 5 years, 60% of older women either had not undergone a mammogram or had undergone only 1. Intervention efforts should emphasize screening based on functional status, not age. This message should be targeted to physicians as well as to older women without claims for recent mammograms and who are likely to be in good health. Copyright 2003 American Cancer Society.

Vaccination

Vaccination and Perinatal Infection Prevention Practices Among Obstetrician-Gynecologists

Schrag SJ, Fiore AE, Gonik B, et al.
Obstet Gynecol. 2003;101:704-710

Objective: To assist efforts to improve adult vaccination coverage by characterizing vaccination and infectious disease screening practices of obstetrician-gynecologists.
Methods: A written survey of demographics, attitudes, and practices was mailed to 1063 American College of Obstetricians and Gynecologists Fellows, including the Collaborative Ambulatory Research Network (n = 413) and 650 randomly sampled Fellows.
Results: Seventy-four percent of Collaborative Ambulatory Research Network members and 44% of nonmembers responded. A majority (Collaborative Ambulatory Research Network members: 60%; nonmembers: 49%) considered themselves primary care providers. Fewer than 60% routinely obtained patient vaccination or infection histories. Most screened prenatal patients for hepatitis B surface antigen (89%) and rubella immunoglobulin G antibody (85%). Sixty-four percent worked in practices that offered at least one vaccine; the most common were rubella (52%) and influenza (50%). Ten percent worked in practices that offered all major vaccines recommended for pregnant or postpartum women. Despite recommendations to provide influenza vaccine to pregnant women during influenza season, only 44% did so; among those who did not, 14% reported a belief that pregnant women do not need influenza vaccine. Provision of vaccine was associated with working in a multispecialty practice (adjusted odds ratio [OR] 2.6, 95% confidence interval [CI] 1.6, 4.1) and identifying as a primary care provider (adjusted OR 1.9; 95% CI 1.3, 2.7). The most common reasons for not offering vaccines were cost (44%) and a belief that vaccines should be provided elsewhere (41%).
Conclusion: The high proportion of obstetrician-gynecologists who do not offer vaccines or screen for vaccine and infection histories suggests missed opportunities for prevention of maternal and neonatal infections.

The Obstetrician-Gynecologist's Role in Adult Immunization

Gonik B, Fasano N, Foster S
Am J Obstet Gynecol. 2002;187:984-988

Vaccine-preventable diseases (VPDs) account for significant morbidities and mortalities in the United States on an annual basis. Despite generally successful childhood vaccine programs, adults remain underimmunized against a variety of common VPDs. Lack of both physician and patient awareness contribute to this deficiency. All primary care providers, including obstetrician-gynecologists, must address this need in their office practices. Clear and authoritative adult vaccine recommendations are established and easily accessible by the clinician. Pregnancy is not an absolute contraindication to vaccine administration. In fact, certain vaccines are specifically indicated during pregnancy in the interest of the mother and her unborn child. Women frequently identify gynecologists as their sole providers of care, further emphasizing the need for attention to this health maintenance activity. New vaccine initiatives, in particular those focused on early newborn infectious conditions, sexually transmitted diseases, and cancer prevention, will likely place the obstetrician-gynecologist at the forefront of this important clinical issue.

Influenza Vaccination During Pregnancy. Patients' and Physicians' Attitudes

Silverman NS, Greif A
J Reprod Med. 2001;46:989-994

Objective: To identify potentially remediable attitudinal factors among women and their physicians that may present barriers to influenza vaccination during pregnancy.
Study Design: We conducted a prospective survey study administered concurrently during influenza season (January-March 2000) to postpartum women in an urban, high-volume medical center and to practicing obstetricians in the metropolitan Los Angeles area. Analyses focused on individual questions' relation to the outcomes of: (1) patients' receipt of influenza vaccine during the recently completed pregnancy, and (2) physicians' discussion of influenza vaccine with their pregnant patients.
Results: Surveys were completed by 242 postpartum women and 113 physicians. Among the women, 22% had discussed influenza vaccine with their physicians during pregnancy, with only 8% of respondents having been vaccinated. Significantly more physicians stated that they discussed vaccination with their patients than did women (74% vs. 22%; P < .001). Physicians were more likely to recommend vaccine if they were aware of current Centers for Disease Prevention and Control guidelines (RR = 2.6, 1.1-5.9), gave vaccinations in their offices (RR = 1.2, 1.01-1.4) and had been vaccinated against influenza themselves (RR = 1.9, 1.3-2.8).
Conclusion: Influenza vaccination during pregnancy occurred infrequently in this study cohort, and a significant discrepancy was seen between patients' and physicians' impressions of whether its use or recommendation had been discussed. Gaps existed in both groups' understanding of potential benefits of influenza vaccine for both pregnant women and their newborns. The survey results suggest potential strategies for targeting improved educational programs for physicians and patients to improve influenza vaccination rates for pregnant women.

Weight Management

Obstetrician-Gynecologists' Views on the Health Risks of Obesity

Power ML, Holzman GB, Schulkin J
J Reprod Med. 2001;46:941-946

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.

Obstetricians and Maternal Body Weight and Eating Disorders During Pregnancy

Abraham S
J Psychosom Obstet Gynaecol. 2001;22:159-163

Intrauterine growth restriction (IUGR) is associated with maternal prepregnancy body mass index (BMI), body weight gain during pregnancy and smoking, eating and weight-losing behaviors. The aim of this pilot study was to examine the practices of obstetricians to determine whether more can be done to prevent IUGR and 'do no harm' to the body image of women during pregnancy. Obstetricians (n = 67) who reported delivering an average of 125 babies in the previous year completed a questionnaire that enquired about their antenatal practice of maternal weighing, history taking and referral of pregnant women. No doctor calculated the prepregnancy BMI. Women (90%) were weighed during some or all antenatal visits, usually by the nurse-receptionist, but one-third of the obstetricians did not refer to these body weight records. Most obstetricians asked women about their cigarette smoking and alcohol intake before pregnancy, and during pregnancy discussed supplements and nausea and vomiting. Fewer than 50% of doctors asked about depression, body weight control and disordered eating. One-third of doctors were not aware of having seen a woman with an eating disorder in the previous year. Obstetricians who asked about eating disorders were more likely to ask about depression, and obstetricians in private practice were significantly less likely to ask women about a history of depression and to refer women to a psychologist or psychiatrist Obstetricians could improve antenatal care by asking about body weight and calculating prepregnancy BMI, and investigating weight-losing behavior and psychological or psychiatric problems such as eating disorders.

Depression and Mood Disorders

Effects of a Depression Education Program on Residents' Knowledge, Attitudes, and Clinical Skills

Learman LA, Gerrity MS, Field DR, van Blaricom A, Romm J, Choe J
Obstet Gynecol. 2003;101:167-174

Objective: To determine whether an interactive educational program would improve obstetrics and gynecology residents' knowledge, attitudes, confidence, and skills in caring for depressed patients.
Methods: We recruited 74 residents from eight residency programs to attend the Depression Education Program, which consists of a 1-hour lecture and two 2-hour workshops combining discussion, diagnosis and treatment tools, critique of a videotape, practice with feedback, and audiotape self-assessment. Before and after the program, participants 1) completed a questionnaire measuring knowledge, attitudes, and reported actions taken with a recent depressed patient; 2) received a standardized patient visit; and 3) kept lists of patients they suspected were depressed. Clinic patients completed a depression screening questionnaire. To assess improvement, we used paired t tests, McNemar chi2 tests, and multivariate models adjusting for training site.
Results: The education program led to 3-month improvements in participants' reported use of formal diagnostic criteria (38% before, 66% after; P =.004), clinical actions documented for suspected depression (P =.035), and perceived self-efficacy in depression care (P <.001). Perceived preparedness to diagnose depression, treat with medications, and comanage with a mental health practitioner improved (P <.05 for each). Small improvements in clinical behaviors with standardized patients and clinic-based depression detection rates were not statistically significant.
Conclusion: The Depression Education Program improved residents' knowledge, confidence, and reported clinical actions with depressed patients, but did not improve most objectively assessed outcomes.

Obstetrician-Gynecologists' Attitudes Towards Premenstrual Dysphoric Disorder and Major Depressive Disorder

Hill LD, Greenberg BD, Holzman GB, Schulkin J
J Psychosom Obstet Gynaecol. 2001;22:241-250

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.

Identifying Physicians Likely to Benefit From Depression Education: a Challenge for Health Care Organizations

Gerrity MS, Williams JW, Dietrich AJ, Olson AL
Med Care. 2001;39:856-866

Background: Few methods exist to identify physicians who might benefit from depression education.
Objectives: To develop a measure of physicians' confidence or self-efficacy in caring for depressed patients and assess it's reliability and validity.
Research Design: A national sample of primary care physicians were surveyed and exploratory factor analysis (EFA) was used to identify factors underlying physicians' responses to 26 items. We named the factors, selected items with factor loadings > or = 0.50 for final scales, and tested a priori hypotheses about self-efficacy.
Subjects: 1) Random cross-sectional sample of family physicians, internists, obstetrician-gynecologists, and pediatricians (n = 5,369) and 2) 49 general internists and family physicians participating in a prepost evaluation of a depression workshop.
Results: In the national sample, 3,712 physicians were eligible and 2,104 responded. Forty-six percent were female, and 51% were family physicians and general internists. EFA identified 5 factors, the first of which was called Self-Efficacy (4 items, alpha = 0.86). More family physicians (64%) had confidence (self-efficacy) in caring for depressed patients compared with general internists (33%), obstetrician-gynecologists (16%), and pediatricians (6%) (P < 0.001). Few physicians intended to change their care of depressed patients (10%) or take CME on depression (24%). Of the 49 physicians attending a depression workshop, 76% reported high self-efficacy after the workshop versus 50% before it (P = 0.013).
Conclusions: This study supports the reliability and validity of the Self-Efficacy scale as one method to identify physicians who might benefit from interventions. New approaches are needed because physicians are unlikely to change.

Violence and Substance Abuse Screening and Management

Spouse/Partner Violence Education as a Predictor of Screening Practices Among Physicians

Sitterding HA, Adera T, Shields-Fobbs E
J Contin Educ Health Prof. 2003;23:54-63

Introduction: Spouse/partner violence is a major public health problem that affects 3 to 6 million women per year. Many studies show that the majority of health care practitioners do not detect or respond to cases of spouse/partner violence in their practice. Research suggests that there are potential barriers to reporting or detecting this problem. A barrier often cited is lack of proper education or training regarding spouse/partner violence. The objective of this study was to determine if physicians who received spouse/partner violence education at various stages of their careers were more likely to screen patients for spouse/partner violence.
Methods: A survey was developed and administered to family physicians and obstetricians/gynecologists in Virginia. The data were analyzed to determine screening practice and spouse/partner violence education among respondents. Four different educational opportunities were analyzed to determine potential determinants of screening.
Results: All respondents who had spouse/partner violence education were more likely to screen every patient than those who were lacking this education. Receiving lectures during residency training was found to be a significant predictor of screening every patient for spouse/partner violence among respondents.
Discussion: Screening every patient for exposure to spouse/partner violence is the ideal situation. This study indicates that education about spouse/partner violence has a significant impact on screening tendencies if provided during a physician's residency program.

How Physicians Feel About Assisting Female Victims of Intimate-Partner Violence

Garimella RN, Plichta SB, Houseman C, Garzon L
Acad Med. 2002;77(12 Pt 1):1262-1265

Purpose: To assess the feelings of physicians about assisting female victims of intimate-partner violence (IPV), and to examine factors related to positive and negative feelings about assisting victims of IPV.
Method: In 1998, a total site sample of 150 physicians practicing in a large general hospital in the area of Virginia Beach, Virginia, was surveyed by questionnaire via the mail. Four specialties were represented: emergency medicine, family practice, obstetrics-gynecology, and psychiatry. The questionnaire asked about medical training and training in assisting victims of IPV. The physicians' feelings about working with victims of IPV were measured on a nine-item, five-point semantic differential scale.
Results: A total of 76 physicians responded to the questionnaire (response rate = 51%). Only a minority (11%) had overall positive feeling scores about assisting victims of IPV. While most physicians reported that it was "significant work," the great majority also felt that it was difficult, low-paying, and stressful. Training in assisting victims of IPV, in medical school or afterwards, did not appear to influence feelings about assisting victims of IPV. However, physicians who were white and who were married (the majority of the respondents) were significantly more likely than the other respondents to feel negatively about providing services to victims of IPV.
Conclusion: Graduate medical education and training programs need to address the association of negative feelings with helping women harmed by IPV, because these feelings may interfere with the appropriate screening, referral, and treatment of these victims.

The Impact of Perceived Barriers on Primary Care Physicians' Screening Practices for Female Partner Abuse

Chamberlain L, Perham-Hester KA
Women Health. 2002;35:55-69

Objectives: Our purpose was to examine primary care physicians' screening practices for female partner abuse in different clinical situations and to investigate the relationship between perceived barriers and screening practices.
Methods: A cross-sectional survey was mailed to Alaska physicians practicing in the following specialties: family practice, internal medicine, obstetrics/gynecology and general practice.
Results: The survey response rate was 80 percent (305/383). The majority (85.7%) of primary care physicians screened often or always when a female patient presents with an injury, but they rarely screened at initial visits (6.2%) or annual exams (7.5%). More than one-third of respondents estimated that 10% or more of their female patients had experienced some type of intimate partner abuse. Several barriers to screening described in the literature were not predictive of physicians' screening practice patterns. Physicians' perceptions that abuse is prevalent among their patients and physicians' beliefs that they have a responsibility to deal with abuse were the only variables independently associated with screening at initial visits and annual exams. The only variable predictive of screening when a patient presents with an injury was physicians' perceived prevalence of abuse.
Conclusion: Primary care physicians have not integrated screening for partner abuse into routine care. Strategies to increase awareness of the high prevalence of abuse in the primary care setting and to educate providers on the negative health effects of victimization can help physicians to acknowledge their responsibility in addressing abuse and the importance of screening at routine visits. Further rigorous studies are needed to identify and evaluate predictors of screening for abuse.

Barriers to Screening for Domestic Violence

Elliott L, Nerney M, Jones T, Friedmann PD
J Gen Intern Med. 2002;17:112-116

Context: Domestic violence has an estimated 30% lifetime prevalence among women, yet physicians detect as few as 1 in 20 victims of abuse.
Objective: To identify factors associated with physicians' low screening rates for domestic violence and perceived barriers to screening.
Design: Cross-sectional postal survey.
Participants: A national systematic sample of 2,400 physicians in 4 specialties likely to initially encounter abused women. The overall response rate was 53%.
Main Outcome Measure: Self-reported percentage of female patients screened for domestic violence; logistic models identified factors associated with screening less than 10%.
Results: Respondent physicians screened a median of only 10% (interquartile range, 2 to 25) of female patients. Ten percent reported they never screen for domestic violence; only 6% screen all their patients. Higher screening rates were associated with obstetrics-gynecology specialty (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.31 to 0.78), female gender (OR, 0.51; CI, 0.35 to 0.73), estimated prevalence of domestic violence in the physician's practice (per 10%, OR, 0.72; CI, 0.65 to 0.80), domestic violence training in the last 12 months (OR, 0.46; CI, 0.29 to 0.74) or previously (OR, 0.54; CI, 0.34 to 0.85), and confidence in one's ability to recognize victims (per Likert-scale point, OR, 0.71; CI, 0.58 to 0.87). Lower screening rates were associated with emergency medicine specialty (OR, 1.72; CI, 1.13 to 2.63), agreement that patients would volunteer a history of abuse (per Likert-scale point, OR, 1.60; CI, 1.25 to 2.05), and forgetting to ask about domestic violence (OR, 1.69; CI, 1.42 to 2.02).
Conclusions: Physicians screen few female patients for domestic violence. Further study should address whether domestic violence training can correct misperceptions and improve physician self-confidence in caring for victims and whether the use of specific intervention strategies can enhance screening rates.

Screening and Intervention for Illicit Drug Abuse: A National Survey of Primary Care Physicians and Psychiatrists

Friedmann PD, McCullough D, Saitz R
Arch Intern Med. 2001;161:248-251

Background: Illicit drug abuse causes much morbidity and mortality, yet little is known about physicians' screening and intervention practices regarding illicit drug abuse.
Methods: We mailed a survey to a national sample of 2000 practicing general internists, family physicians, obstetricians and gynecologists, and psychiatrists to assess their screening and intervention practices for illicit drug abuse.
Results: Of 1082 respondents (adjusted response rate, 57%), 68% reported that they regularly ask new outpatients about drug use. For diagnosed illicit drug abuse, 55% reported that they routinely offer formal treatment referral, but 15% reported that they do not intervene. In multivariate logistic regression models, more optimal screening and intervention practices were associated with psychiatry specialty, confidence in obtaining the history of drug use, optimism about the effectiveness of therapy, less concern that patients will object, and fewer perceived time constraints.
Conclusions: Most physicians reported that they ask patients about illicit drug use, but a substantial minority inadequately intervene in diagnosed drug abuse. Initiatives to promote physician involvement in illicit drug abuse should include strategies to increase physicians' confidence in managing drug problems, engender optimism about the benefits of treatment, dispel concerns about patients' sensitivity regarding substance use, and address perceived time limitations.