Collateral damage from the Dobbs decision

States with abortion bans may lose their next-gen OB-GYNs if their medical schools fail to offer abortion training option

Medical schools in the states that ban abortion are still required to provide access to hands-on training in the procedure for residents looking to become OB-GYNs, a specialty in short supply in many areas of the U.S.

The key word is access. The voluntary rotation, which residents can opt out of on moral or religious grounds, was included in the latest update of the Accreditation Council for Graduate Medical Education’s guidelines for OB-GYN training programs.

Medical schools that fail to provide that option for their OB-GYN trainees who want it — and that’s a large majority — risk losing accreditation, according to the ACGME, which would jeopardize their graduates’ ability to become licensed as OB-GYNs. Every state medical licensing board requires graduation from an accredited medical school residency program before licensing in their specialty.

The newly reaffirmed education guidelines are roiling the medical education landscape. A recent national survey of third- and fourth-year medical students by student researchers at Emory University in Atlanta found over three-quarters of 490 respondents will take abortion access into account when applying for residency programs.

Since most doctors begin practice near where they receive their advanced training, the Supreme Court’s decision to overturn Roe v. Wade could further exacerbate the maldistribution of physicians over the next several decades. The 23 states banning or severely restricting abortion, mostly in the South and Midwest, are already suffering from severe shortages of OB-GYNs and family physicians.

“To choose a state where I will be limited or I wouldn’t have full access is essentially shortchanging myself and my future patients on the quality of care that I can provide,” Deborah Fadoju, a fourth-year Ohio State medical student told the Associated Press. Although Ohio’s “fetal heartbeat” law banning abortion after six weeks of pregnancy was temporarily blocked in the courts, Fadoju said she is now looking at programs along the East Coast, where many states have passed laws preserving abortion rights.

How will we offer this option?

The updated ACGME requirements have sent medical schools in states that now ban or sharply restrict abortion scrambling to come up with alternatives. For instance, the University of Wisconsin, where an 1849 law banning abortion is now in effect, is negotiating with several out-of-state institutions to provide that rotation for its prospective OB-GYNs.

“We don’t have any definite finalized action plans we can share at this point,” Dr. Robert N. Golden, dean of the U. of W.’s School of Medicine and Public Health, told me. “We’re working really hard to ensure our OB-GYN residents get comprehensive training and meet the recently reaffirmed accreditation requirements. We’re exploring out-of-state options.

“As you can imagine, any such option is not straightforward,” he continued. “You can’t just flip the switch. We want to ensure they have appropriate training in an outstanding clinical spot. Then there are the more mundane considerations like housing and transportation. We’re making progress. We’ll come up with a good plan for all of the residents in our four-year program.”

Prior to the reinstatement of the 1849 law, Planned Parenthood clinics in Wisconsin, now shut down, provided the training ground for OB-GYN and family physician residents. Shortly after the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision, the Planned Parenthood organization in neighboring Illinois allowed Wisconsin providers to continue their practice at its Waukegan clinic, which is just over the state line. It’s since seen a tenfold increase in abortions.

Rush University Medical Center in Chicago has set up a partnership with St. Vincent Hospital in Indianapolis to provide training for its OB-GYN residents. It is also looking at setting up a partnership with the Medical College of Wisconsin. “Many other institutions reached out to us to partner,” Sadia Haider, director of family planning at Rush, told StatNews, the online health care news service. “We already have our own trainees here. There’s only so much clinical capacity. We will not be able to accommodate every request.”

Start-ups to the rescue

To help meet the crush of out-of-state demand, a recently established non-profit in Rockford, which is just a few hours from Madison, plans to open a new family planning clinic early next year. The independent Rockford Family Planning Foundation will provide the full range of family planning services not just for the fourth largest city in Illinois, which lacks its own abortion clinic, but for women seeking reproductive health services from neighboring Wisconsin and Iowa, which passed a “fetal heartbeat” law in 2018. (A copy of the non-profit’s prospectus and a link to make a donation can be found at the end of this article.) It is also hoping to forge links with medical schools in nearby Wisconsin and Iowa, which have highly restrictive anti-abortion laws.

But many OB-GYN trainees in southern states that banned abortion will not have a nearby option because they are surrounded by states that also banned the procedure. The University of Alabama at Birmingham, in a prepared statement, confirmed the updated ACGME guidelines required “all programs in the U.S. that certify OB-GYNs to teach the knowledge of how to perform an abortion, including those that take place following a miscarriage.” And it agrees schools must “make optional training available to residents in a medical setting for those who choose to supplement their classroom education … through an off-site organization.”

But the UAB medical school public relations department did not respond to my follow-up email asking whether it will provide support for residents in making the necessary arrangements, including financial support for travel and housing. A spokeswoman for the University of Mississippi Medical Center declined to comment.

The ACGME initially attempted to placate medical schools operating in Republican-controlled states that have banned all or almost all abortions. The first draft of its guidelines, issued in June around the time of the Dobbs decision, included the following paragraph:

For programs in jurisdictions where legal restrictions on induced abortions prevent satisfaction of the requirement for clinical experience in induced abortions and a resident is unable to travel to another jurisdiction for such structured clinical experience, programs must provide the resident with a combination of didactic activities, including simulation, and assessment on performing a uterine evacuation (surgical and medical) and communicating pregnancy options.

But that loophole was eliminated when the final draft was issued in mid-September. “The approved revisions reaffirm the need for education and training in comprehensive family planning, including clinical experience in induced abortion,” a spokeswoman for ACGME said in an email. “The proposed use of didactic activities, including simulation and assessment to meet the induced abortion requirements in some situations, was removed from the proposed revisions. It was determined that the skills learned through clinical experience are a core component of education and training in this specialty.”

The professional society weighs in

While the accreditation organization wouldn’t release the comments it received during the 45-day comment period to its initial proposal, the trade association for academic medical centers and OB-GYNs’ professional society vociferously voiced support for maintaining the requirement. Here’s what Dr. Maureen G. Phipps, CEO of the American College of Obstetricians and Gynecologists had to say:

Regardless of whether an obstetrician-gynecologist chooses to provide abortion care, it is critical that every OB-GYN is able to meet the needs of their patients with confidence and expertise, whether that means being able to provide patient-centered counseling about abortion, managing pregnancy loss, or appropriately managing emergencies involving pregnancy complications. Abortion is essential healthcare, and comprehensive medical training must include training around abortion. Training in abortion allows physicians to gain not only the skills and knowledge to provide medication abortion and abortion procedures, but also skills, expertise and confidence in treating patients who present with pregnancy loss and urgent and emergent complications of pregnancy. Preventing obstetrics and gynecology residents from accessing critical training in abortion care because of uninformed legislative interference will create harmful effects and damage to patients that cannot be undone for years to come.

Dr. Alison Whelan, the chief academic officer for the Association of American Medical Colleges, expressed concern for the impact state abortion bans will have on the viability of OB-GYN training programs in those states. “Residency programs in restrictive states have concerns about the reduced number of applicants to their programs,” she said. “Their residents want full training.”

There’s even concerns that residents fear putting themselves in legal jeopardy should their only learning experiences involve working with a physician who provides an abortion to save the life of the mother, only to find themselves facing legal charges over their decision. “They fear the possibility of legal action for what they consider core training. That legal action could be civil or criminal. As a junior, junior physician, as you’re thinking about doing three or four years of training to be the best doctor you can be, do I have to talk to my lawyer to find out if I can get trained?” she said. “That’s pretty chilling.”

She also noted the impact the restrictions will have on the number of applicants looking to fill OB-GYN residency slots in states with abortion bans. “They are young women of child-bearing age,” Whelan said. “They are making not just professional decisions about their training, but personal decisions about whether they can get the health care they need in the place where they might settle down as a physician.”

Opposition to the updated ACGME guidelines came from the American Association of Pro-Life Obstetricians and Gynecologists. “The ACGME’s requirements forcing training in elective abortion are coercive and discriminatory against pro-life residents and medical institutions,” said Dr. Donna Harrison, CEO of AAPLOG, in a prepared statement. “This coercion is for no medical reason whatsoever, as OB-GYN residents have ample training emptying a uterus at any gestational age when the baby has already died in miscarriages.”

“It is entirely unnecessary and violates conscience rights to refuse certification to medical institutions whose values do not allow for the intentional killing of preborn human beings for no medical reason,” she said.

The statement ignores two facts. First, the hands-on training in providing abortions is completely voluntary; the guidelines allow anti-abortion physicians-in-training to opt out of that part of the program. Second, schools that do not offer elective abortions, which has been the case for many state-supported schools, can always contract out the hands-on-training to outside organizations that do.

I’ll give the last word to Dr. Golden, dean of the University of Wisconsin School of Medicine, who called his state’s abortion ban “a disastrous public policy.”

“As much as it’s going to be really problematic for the training of the next generation of OB-GYN physicians, it’s even more destructive in the lives of countless numbers of women,” he said. “It will limit access. It will disproportionately limit access to the most vulnerable populations, people who don’t have the resources to travel to Illinois or California to get necessary abortions.

“In terms of training, it is really, really bad. There are many medical situations that require termination of the pregnancy to save the life of the woman. There are complications across the board that weren’t given adequate consideration in Wisconsin in 1849 when the law was passed. Speaking strictly from a medical and public health perspective,” he concluded, “the Dobbs decision will be devastating of the health of women and the training of the doctors who are providing overall care for women.”

If you’re interested in donating to the Rockford Familly Planning Foundation, click on this link. You can read a copy of its prospectus here:

Rockford Family Planning Foundation Prospectus

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