Future of Abortion Training for Medical Residents Is Bleak

YouOn 2021, Dr. Mallika Govindan (a Mount Sinai Health System family physician resident) received some disappointing news. Even though she had pursued a career in medicine in order to become an abortion provider—and had chosen a residency in New York City, where she felt she would get the best training—she wouldn’t be able to learn how to provide abortion care locally. Planned Parenthood New York City had to reduce its abortion training program due to pandemic warnings.

Govindan had spent many months looking into other opportunities and applying to scholarships. She traveled to Chicago in February 2022 for twelve days of training on abortion with a nonprofit reproductive health care organization.

It was hard for Govindan to get abortion training—but in Chicago, she kept hearing murmurs that it might soon get even tougher for medical residents like her. Her abortion specialists said it might be more difficult to train residents if she was not careful. Roe v. WadeThey were overturned. As clinics in Chicago struggle to cope with rising demand from abortion-seeking patients from countries that ban the practice, some may consider ceasing to train residents from outside-of-state.

Govindan is concerned that making the training for abortion more accessible to doctors could make it difficult for patients to receive proper care. “There’s such a shortage of doctors and providers as a whole,” she says. “The [number] who are willing to do this is even smaller.”

The logistics of abortion training for doctors is a nightmare in America. ACGME requires that obstetricians offer training. Residents can, however, opt out. A typical rotation involves a week-to-month-long stay at an abortion clinic. However, these facilities are scarce. Nearly 90% of U.S. counties do not currently have a clinic that provides abortion care—meaning the ones that do exist are likely to be overrun by both patients and trainees if Roe v. WadeThis has been overturned. An article by American College of Obstetricians and Gynologists (ACOG), published in April states that nearly 44% of U.S. ob-gyns are currently trained in states likely or certain to ban abortion. Roe v. Wadebe repealed.

In a statement, an ACGME spokesperson said the organization is preparing for the Supreme Court’s decision. “Should it become illegal in some states to perform aspects of family planning, the ACGME is exploring alternative pathways for completing this training. At this time, the ACGME requirements remain the same”—including that all ACGME-accredited ob-gyn programs must have family-planning curriculum and “experiential training in the complications of abortions and the opportunity for direct procedural training in terminations of pregnancy. Access to experience with induced abortion must be part of the curriculum in order to ensure that physicians in training have the opportunity to gain the experience necessary to care for all of their patients’ needs.” Programs that restrict abortions or other family-planning services “must arrange for such resident training to occur at another institution.”

In a state like Utah, it’s already hard to be an ob-gyn, says Dr. David Turok, associate professor in the University of Utah department of obstetrics and gynecology and chief of the division of family planning. A state law enacted in 2017 requires doctors to tell their patients seeking abortions several lies that aren’t backed by science, Turok says, including a requirement to say that the abortion medication mifepristone is reversible. Providers are also required by law to give patients pain medication—for the fetus—20 weeks or more into a pregnancy, which doctors say is scientifically unfounded. However, the restrictions on abortion are likely to be enforced. Roe v. Wade ended would be “on a whole different level,” Turok says.

Turok has already made plans to take his ob-gyns to training in other states should Utah outlaw abortions. It is anticipated that this will happen within the next 24 hours. RoeThis is overturned. One other option may be simulated procedures—such as practicing techniques on a dummy—which are common in residency programs. However, he fears it won’t be good enough. “By limiting the care and limiting the training, you’re essentially compromising the quality of the care,” he says. “I’m not worried; I’m terrified.”

The United States has a problem with abortion training, particularly for those that are not performed in the first trimester. Research published in 2018 by the American Journal of Obstetrics and GynecologyOnly 71% of the residency directors that responded to a survey believed their ob/gyn graduate was competent in first-trimester abortion. 66% thought residents had sufficient training in medication abortion. Only 22% thought that their ob/gyn graduate was competent in any other methods of abortion, such as dilation or aspiration.

This lack of knowledge could be partly due to accessibility issues. ACOG reports that some residents in ob-gyn program are required to schedule training. This can prove difficult for many. Other patients may face hospital restrictions, which limit the location and method of the procedure. Many religiously affiliated hospitals don’t provide abortion services at all.

Dr. Debra Stulberg is chair of family medicine at the University of Chicago and the training director at Midwest Access Project (MAP), a reproductive health care nonprofit that helps connect residents—including Govindan—to abortion training. She said that MAP receives a lot more inquiries from religious hospital residents than from those in other specialties, who might need the same training as an ob/gyn. Family medicine doctors, in particular, are major providers of abortions in the U.S., especially in underserved rural areas—but often aren’t provided the proper training. “Even if they have [the] opportunities,” says Stulberg, “they may be only a few days in a clinic and not enough to really develop the competency that they need.”

Many of these residents have to travel abroad to supplement their education. But that won’t be a solution to the drastic shortage of training opportunities that could develop if abortion is all of a sudden illegal in many states, says Dr. Kavita Vinekar, an ob-gyn specializing in complex family planning who co-authored the ACOG commentary. “[It] won’t be feasible at this scale,” she says. “The reality is that we are never going to be able to arrange for close to 44% of our residents to travel away from their home institutions, away from hospitals that completely rely on residents to function, to be able to obtain the necessary training.” She and her co-authors suggest that residency programs may need to instead beef up miscarriage training, which overlaps with abortion training, and incorporate simulations to help make up for this deficit.

Resident programs with a high turnover of residents face additional financial challenges. A hospital’s budget for graduate medical education, which is paid through Medicare, doesn’t travel with the resident, so new funds must be found to pay their salary during the part of the family-planning rotation that includes abortion training and can last several weeks, says Dr. Laura MacIsaac, professor and associate director of Fellowship in Family Planning at Icahn School of Medicine at Mount Sinai. “I have visiting residents that come to New York with that request, but we do have so, so many requests, and we really can’t honor all of them,” says MacIsaac.

Turok, from the University of Utah, worries that states that outlaw abortion won’t be as appealing for ob-gyns to learn or eventually practice in. These are the states that will likely ban abortion. Roe is overturned “don’t realize that they’re digging a major hole into the quality of medical care that they will be able to provide and the people that they will be able to train and retain in their states,” says Turok. “What health care provider wants to practice in a state where they can’t provide the full range of services to their patients?”

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