Faculty Bibliography

CONTEXT: Physicians are regularly confronted with research that is funded or presented by industry. OBJECTIVE: To assess whether physicians discount for conflicts of interest when weighing evidence for prescribing a new drug. DESIGN AND SETTING: Participants were presented with an abstract from a single clinical trial finding positive results for a fictitious new drug. Physicians were randomly assigned one version of a hypothetical scenario, which varied on conflict of interest: 'presenter conflict', 'researcher conflict' and 'no conflict'. PARTICIPANTS: 515 randomly selected Fellows in the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network; 253 surveys (49%) were returned. MAIN OBJECT MEASURES: The self-reported likelihood that physicians would prescribe the new drug as a first-line therapy. RESULTS: Physicians do not significantly discount for conflicts of interest in their self-reported likelihood of prescribing the new drug after reading the single abstract and scenario. However, when asked explicitly to compare conflict and no conflict, 69% report that they would discount for researcher conflict and 57% report that they would discount for presenter conflict. When asked to guess how favourable the results of this study were towards the new drug, compared with the other trials published so far, their perceptions were not significantly influenced by conflict of interest information. CONCLUSION: While physicians believe that they should discount the value of information from conflicted sources, they did not do so in the absence of a direct comparison between two studies. This brings into question the effectiveness of merely disclosing the funding sources of published studies.

PURPOSE: To examine relationships between pharmaceutical representatives and obstetrician-gynecologists and identify factors associated with self-reported reliance on representatives when making prescribing decisions. METHOD: In 2006-2007, questionnaires were mailed to 515 randomly selected physicians in the American College of Obstetricians and Gynecologists' Collaborative Ambulatory Research Network. Participants were asked about the information sources used when deciding to prescribe a new drug, interactions with sales representatives, views of representatives' value, and guidelines they had read on appropriate industry interactions. RESULTS: Two hundred fifty-one completed questionnaires (49%) were returned. Seventy-six percent of participants see sales representatives' information as at least somewhat valuable. Twenty-nine percent use representatives often or almost always when deciding whether to prescribe a new drug; 44% use them sometimes. Physicians in private practice are more likely than those in university hospitals to interact with, value, and rely on representatives; community hospital physicians tend to fall in the middle. Gender and age are not associated with industry interaction. Dispensing samples is associated with increased reliance on representatives when making prescribing decisions, beyond what is predicted by a physician's own beliefs about the value of representatives' information. Reading guidelines on physician-industry interaction is not associated with less reliance on representatives after controlling for practice setting. CONCLUSIONS: Physicians' interactions with industry and their familiarity with guidelines vary by practice setting, perhaps because of more restrictive policies in university settings, professional isolation of private practice, or differences in social norms. Prescribing samples may be associated with physicians' use of information from sales representatives more than is merited by the physicians' own beliefs about the value of pharmaceutical representatives.

OBJECTIVE: To examine obstetrician-gynecologists' knowledge, opinions, and practice patterns related to cesarean delivery on maternal request. METHODS: Questionnaires were mailed to 1,031 American College of Obstetricians and Gynecologists Fellows in February 2006, with a response rate of 68%. The questionnaire queried respondents' demographic characteristics, practices and attitudes surrounding vaginal and cesarean deliveries, knowledge and beliefs regarding the risks and benefits of elective and nonelective cesarean delivery, and counseling practices and department policies for cesarean delivery on maternal request. RESULTS: About half of respondents believe women have the right to cesarean delivery on maternal request, and a similar percentage acknowledge having performed at least one cesarean delivery on maternal request. Fifty-eight percent of respondents note an increase in patient inquiries regarding cesarean delivery over the past year, yet most of their practices do not have a policy regarding this procedure. Respondents attribute the increase in inquiries to the increase of information from the media and to convenience. Respondents cited more risks than benefits of cesarean delivery on maternal request, and nearly all discuss these risks with patients who are considering one. Females were more negative toward cesarean delivery on maternal request than males and endorsed more risks and fewer benefits. There were no relationships between assessment of risks and benefits or practice with clinician age or patient characteristics. CONCLUSION: Most obstetrician-gynecologists in this study recognized an increased demand for cesarean delivery on maternal request within their practices, while believing that the risks of this procedure outweigh the benefits. Clinicians would benefit from strong evidence regarding risks and benefits, evidence that is crucial to guiding policy making with regard to cesarean delivery on maternal request. LEVEL OF EVIDENCE: III

Obesity is a serious medical condition that significantly impacts the health of pregnant and nonpregnant women. Although obstetrician-gynecologists have reported that they are knowledgeable of the health risks associated with obesity, they have also reported that their knowledge of weight assessment and management is inadequate. The purpose of this article is to review the proper procedures for assessing and managing obesity. By properly assessing obesity and constructing individualized weight management plans for those affected, obstetrician-gynecologists can help reduce the prevalence of obesity in women of childbearing ages. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to explain the impact of obesity on the health of nonpregnant and pregnant women, summarize the methods of distinguishing overweight from obesity, and recall the proper weight management programs for and assessments of obesity in women

OBJECTIVES: To describe obstetrician-gynecologists' opinions of preconception care (PCC) and ascertain patient uptake for this service. METHODS: A questionnaire was mailed to 1105 ACOG members in August 2004. RESULTS: There was a 60% response rate. Most physicians think PCC is important (87%) and almost always recommend it to women planning a pregnancy (94%); 54% do so with women who are sexually active. Around a third (34%) thought their patients usually do not plan their pregnancies and 49% said very few pregnant patients came in for PCC. Of those who obtain PCC, they were believed to do so more likely to assure a healthy pregnancy (83%) than because of an elevated risk for birth defects (20%). Of 11 issues presented, cigarette smoking and folic acid supplementation were rated the most important for PCC counseling; exercise and environmental concerns were the least important. CONCLUSIONS: Physicians are willing to provide PCC but few patients are accessing such services

OBJECTIVE: To examine the knowledge and prescribing practices of obstetrician-gynecologists regarding hormone therapy in light of the published evidence from the Women's Health Initiative study on combined estrogen + progestin. DESIGN: A survey questionnaire was sent to 2,500 randomly selected Fellows of the American College of Obstetricians and Gynecologists in November of 2003; 705 surveys were returned. Of those, 644 reported their specialty as obstetrics and/or gynecology and those responses are reported. RESULTS: A majority of physicians that completed their residency before 1995, both men and women, were not convinced by the WHI research results and disagreed with the decision to end the trial. Physicians that rated themselves very confident about their ability to interpret the scientific literature were more likely to be unconvinced by the results and to disagree with the decision to end the trial. In general, physicians that completed their residency more recently rated the benefits of hormone therapy lower and the risks higher. A majority of respondents (53.3%) reported that their prescribing practices were unlikely to change; however, 29.6% reported that they would be somewhat less likely and 9.5% dramatically less likely to prescribe hormone therapy. Physicians reported that their patients were less likely to request hormone therapy (91.8%) and were more likely to discontinue use (93.0%). CONCLUSION: Physicians that have been in practice longer were more positive about the risks and benefits of HT, and were more skeptical about the recent research. The published data seem to have affected patient preferences and to have had some effect on physician prescribing practices

In recent years, obstetrician-gynecologists have taken on a greater role in the provision of primary care. Mental health has been a topic worthy of further exploration as a result of the high prevalence rates of women presenting in gynecologic settings with depressive, anxiety, or eating-disordered symptoms. The detrimental effects of psychopathology have been well documented in the literature, especially if present during pregnancy. This article provides a review of the literature in the area of clinical practice related to mental health among obstetrician-gynecologists based on searches of the Psyc Info and MEDLINE databases. Lack of recognition and underdiagnosis are common problems that need to be addressed by focused educational initiatives. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall the importance of screening for various types of mental disease during an ob/gyn visit; describe the detrimental effects of psychopathology, especially during pregnancy; and explain the importance of educational initiatives in detecting and treating mental disorders

OBJECTIVES: To re-assess obstetrician-gynecologists' knowledge of neonatal encephalopathy and cerebral palsy after publication of the ACOG/AAP Task Force report. STUDY DESIGN: A questionnaire investigating knowledge of neonatal encephalopathy and cerebral palsy was mailed to 1060 members of ACOG, 337 of whom participated in a similar study in 2001. RESULTS: There was a strong association between familiarity with ACOG documentation and knowledge of neonatal encephalopathy (NE) and cerebral palsy (CP) (p<0.001). As with obstetricians surveyed in 2001, knowledge gaps remain. Performance was better on practices questions than knowledge questions. About one-third (34.2%) of the physicians said their knowledge of neonatal encephalopathy was poor or deficient; the majority (76%) rated their residency training as inadequate to marginal. CONCLUSION: The results indicate better knowledge of neonatal encephalopathy and cerebral palsy among physicians more familiar with the Task Force report. There is a clear need for emphasis on these topics during training and continuing medical education

OBJECTIVE: To assess the impact of self-reported familiarity with published guidelines on knowledge, implementation, and opinions of obstetrician-gynecologists regarding carrier screening for cystic fibrosis. METHODS: A questionnaire pertaining to cystic fibrosis screening guidelines was mailed to 1,165 members of the American College of Obstetricians and Gynecologists. RESULTS: Sixty-four percent of questionnaires were returned. Statistical analyses were limited to the 632 respondents whose primary medical specialty was gynecology (GynOnly) or obstetrics and gynecology (ObGyns). More ObGyns had thoroughly read or skimmed the guidelines (67.1%) than had GynOnlys (41.6%). Correctly responding to basic questions regarding cystic fibrosis was associated with having read the guidelines, although responding to a more complex question was not. Familiarity with the guidelines was associated with correctly identifying the recommendations for offering screening, with practice implementation of cystic fibrosis screening, and with self-ratings of qualifications and training to offer screening and to provide counseling. In contrast, familiarity with the guidelines was not associated with ObGyn's opinion that burden of disease is likely to be influential in patient acceptance of screening. Physicians who had thoroughly read the guidelines were more likely to disagree that the cystic fibrosis screening test is too inaccurate to risk influencing reproductive decision making (thoroughly read = 79% disagree, skimmed = 69%, not read = 58%, not heard of it = 50%). CONCLUSION: There was a strong association between self-reported familiarity with the American College of Obstetricians and Gynecologists/American College of Medical Genetics guidelines and physicians' knowledge, implementation, and ratings of training for offering cystic fibrosis carrier screening

OBJECTIVE: To assess obstetrician-gynecologists' current practice patterns and opinions regarding vaginal birth after cesarean delivery (VBAC). STUDY DESIGN: Questionnaires were mailed to a random sample of 1,200 American College of Obstetricians and Gynecologists (ACOG) fellows in July 2003. Information was gathered on percentage of cesarean and VBAC deliveries performed, factors influencing changes in these rates in the past 5 years, hospital protocol regarding VBAC and factors influencing the recommendation of VBAC. RESULTS: Fifty-three percent of questionnaires were returned to ACOG after 3 mailings. Approximately 49% of respondents reported that they were performing more cesarean deliveries than they were 5 years earlier. The primary reasons for this increase were the risk of liability and patient preference for delivery method. More than 25% of physicians reported that they practiced in hospitals that do not follow the ACOG guidelines with respect to resources and immediate availability. Almost all (98.2%) respondents agreed that they knew the risks and benefits of VBAC. However, only 61% reported feeling competent in determining which patients will have a successful VBAC. CONCLUSION: Obstetrician-gynecologists seem to be aware of the risks and benefits of VBAC; however, there is some doubt as to who should be offered a trial of labor and what predicts a successful VBAC