States With Abortion Bans Are Losing a Generation of Ob-Gyns

States With Abortion Bans Are Losing a Generation of Ob-Gyns
Written by Techbot

Shira Fishbach, a newly graduated physician, was sitting in an orientation session for her first year of medical residency when her phone started blowing up. It was June 24, 2022, and the US Supreme Court had just handed down its decision in Dobbs v. Jackson Women’s Health Organization, nullifying the national right to abortion and turning control back to state governments.

Fishbach was in Michigan, where an abortion ban enacted in 1931 instantly came into effect. That law made administering an abortion a felony punishable by four years in prison, with no exceptions for rape or incest. It was a chilling moment: Her residency is in obstetrics and gynecology, and she viewed mastering abortion procedures as essential to her training.

“I suspected during my application cycle that this could happen, and to receive confirmation of it was devastating,” she recalls. “But I had strategically applied where I thought that, even if I didn’t receive the full spectrum, I would at least have the support and the resources to get myself to an institution that would train me.”

Her mind whirled through the possibilities. Would her program help its residents go to an access-protecting state? Could she broker an agreement to go somewhere on her own, arranging weeks of extra housing and obtaining a local medical license and insurance? Would she still earn her salary if she left her program—and how would she fund her life if she did not?

In the end, she didn’t need to leave. That November, Michigan voters approved an amendment to the state constitution that made the 1931 law unenforceable, and this April, Governor Gretchen Whitmer repealed the ban. Fishbach didn’t have to abandon the state to learn the full range of ob-gyn care. In fact, her program at the University of Michigan, where she’s now a second-year resident, pivoted to making room for red-state trainees.

But the dizzying reassessment she underwent a year ago provides a glimpse of the challenges that face thousands of new and potential doctors. Almost 45 percent of the 286 accredited ob-gyn programs in the US now operate under revived or new abortion bans, meaning that more than 2,000 residents per year—trainee doctors who have committed to the specialty—may not receive the required training to be licensed. Among students and residents, simmering anger over bans is growing. Long-time faculty fear the result will be a permanent reshaping of American medicine, driving new doctors from red states to escape limitations and legal threats, or to protect their own reproductive options. That would reduce the number of physicians available, not just to provide abortions, but to conduct genetic screenings, care for miscarriages, deliver babies, and handle unpredictable pregnancy risks.

“I worry that we’re going to see an increase in maternal morbidity, differentially, depending on where you live,” says Kate Shaw, a physician and associate chair of ob-gyn education at Stanford Medicine. “And that’s just going to further enhance disparities that already exist.”

Those effects are not yet visible. The pipeline that ushers medical graduates through physician training is about a decade long: four years of school plus three to seven years of residency, sometimes with a two-year, sub-specialty fellowship afterward. Thus actions taken in response to the Dobbs decision—people eschewing red-state schools or choosing to settle in blue states long-term—might take a while to be noticeable.

But in this year, some data has emerged that suggests trends to come. In February, a group of students, residents and faculty surveyed 2,063 licensed and trainee physicians and found that 82 percent want to work or train in states that retain abortion access—and 76 percent would refuse to apply in states that restrict it. (The respondents worked in a mix of specialties; for those whose work would include performing abortions, the proportion intending to work where it remains legal soared above 99 percent.)

Then in April, a study from the Association of American Medical Colleges drawing on the first round of applications to residency programs after Dobbs found that ob-gyn applications in states with abortion restrictions sank by 10 percent compared to the previous year. Applications to all ob-gyn programs dropped by 5 percent. (Nationwide, all applications to residency went down 2 percent from 2021 to 2022.)

Last month, two preliminary pieces of research presented at the annual meeting of the American College of Obstetricians and Gynecologists uncovered more perturbations. In Texas—where the restrictive law SB8 went into effect in September 2021, nine months before Dobbs—a multi-year upward trend in applications to ob-gyn residency slowed after the law passed. And in an unrelated national survey, 77 percent of 494 third- and fourth-year medical students said that abortion restrictions would affect where they applied to residency, while 58 percent said they were unlikely to apply to states with a ban.

That last survey was conducted by Ariana Traub and Kellen “Nell” Mermin-Bunnell, two third-year medical students at Emory University School of Medicine in Atlanta—which lies within a state with a “fetal heartbeat” law that predates Dobbs and that criminalizes providing an abortion after six weeks of pregnancy. The law means that students in clinical rotations are unlikely to witness abortions and would not be allowed to discuss the procedure with patients. It also means that, if either of them were to become pregnant while at med school, they would not have that option themselves.

Before they published the survey, the two friends conducted an analysis of how bans would affect medical school curricula, using data collected in the summer of 2022. They predicted that only 29 percent of the more than 129,000 medical students in the US would not be affected by state bans. The survey gave them a chance to sample med students’ feelings about those developments, with the help of faculty members. They also founded a nonprofit, Georgia Healthcare Professionals for Reproductive Justice. “We’re in a unique position, as individuals in the health care field but not necessarily medical professionals yet,” Traub says. “We have some freedom. So we felt like we had to use that power to try to make change.”

Ob-gyn formation is caught between opposing forces. Just over half of US states have passed bans or limitations on abortion that go beyond the Roe v. Wade standard of fetal viability. But the Accreditation Council for Graduate Medical Education, a nonprofit that sets standards for residency and fellowship programs, has always required that obstetric trainees learn to do abortions, unless they opt out for religious or moral reasons. It reaffirmed that requirement after the Dobbs decision. Failure to provide that training could cause a program to lose accreditation, leaving its graduates ineligible to be licensed.

The conflict between what medicine demands and state laws prevent leaves new and would-be doctors in restrictive states struggling with their inability to follow medical evidence and their own best intentions. “I’m starting to take care of patients for the first time in my life,” says Mermin-Bunnell, Traub’s survey partner. “Seeing a human being in front of you, who needs your help, and not being able to help them or even talk to them about what their options might be—it feels morally wrong.”

That frustration is equally evident among trainees in specialties who might treat a pregnant person, prescribe treatments that could imperil a pregnancy, or care for a pregnancy gone wrong. Those include family and adolescent medicine, anesthesiology, radiology, rheumatology, even dermatology and mental health.

“I’m particularly interested in oncology, and I’ve come to realize that you can’t have the full standard of gynecologic oncology care without being able to have access to abortion care,” says Morgan Levy, a fourth-year medical student in Florida who plans to apply to ob-gyn residency. Florida currently bans abortion after 15 weeks; a further ban, down to six weeks, passed in April but has been held up by legal challenges. In three years of med school so far, Levy received one lecture on abortion—in the context of miscarriage—and no clinical exposure to the procedure. “It is a priority for me to make sure that I get trained,” she says.

But landing in a training program that encourages abortion practice is more difficult than it looks. Residency application is an algorithm-driven process in which graduates list their preferred programs, and faculty rank the trainees they want to teach. For years, there have been more applicants than there are spaces—and this year, as in the past, ob-gyn programs filled almost all their slots. What that means, according to faculty members, is that some applicants will end up where they do not want to be.

“Students and trainees do exert their preferences, but they also need to get a training spot,” says Vineet Arora, the dean for medical education at the University of Chicago Pritzker School of Medicine and lead author on the survey published in February. “Would they forgo a training spot because of Dobbs? That’s a tall order, especially in a competitive field. But would they be happy about it? And would they want to stay there long term?”

That is not a hypothetical question. According to the medical-colleges association, more than half of residents stay to practice in the states where they trained. But it’s reasonable to ask whether they would feel that loyalty if they were deprived of training or forced to relocate. “If even a portion of the 80 percent of people who prefer to practice and train in states that don’t have abortion bans follow through on those preferences, those states that are putting in abortion bans—which often have workforce shortages already—will be in a worse situation,” Arora says.

An ACOG analysis estimated in 2017 that half of US counties, which are home to 10 million women, have no practicing ob-gyn. When the health care tech firm Doximity examined ob-gyn workloads in 2019, seven of the 10 cities it identified as having the highest workloads lie in what are now very restrictive states. Those shortages are likely to worsen if new doctors relocate to states where they feel safe. The legal and consulting firm Manatt Health predicted in a white paper last fall: “The impact on access to all OB/GYN care in certain geographies could be catastrophic.”

Faculty are struggling to solve the mismatch between licensing requirements and state prohibitions by identifying other ways residents can train. They view it as protecting the integrity of medical practice. “Any ob-gyn has to be able to empty the uterus in an emergency, for abortion, for miscarriage, and for pregnancy complications or significant medical problems,” says Jody Steinauer, who is vice-chair of ob-gyn education at UC San Francisco.

Steinauer directs the Kenneth J. Ryan Residency Training Program, a 24-year-old effort to install and reinforce clinical abortion training. Even before Dobbs, that was hard to come by: In 2018, Steinauer and colleagues estimated that only two-thirds of ob-gyn residency programs made it routine, despite accreditation requirements—and that anywhere from 29 to 78 percent of residents couldn’t competently perform different types of abortion when they left training. In 2020, researchers from UCSF and UC Berkeley documented that 57 percent of these programs face limitations set by individual hospitals more extreme than those set by states.

Before Dobbs, the Ryan program brokered individual relocations that let trainees temporarily transfer to other institutions. Now it is working to set up program-to-program agreements instead, because the logistics required to visit for a rotation—the kind of arrangements Fishbach dizzily imagined a year ago—are more complex than most people can manage on their own. And not only on the visiting trainee: Programs already perform delicate calculations of how many trainees they can take given the number of patients coming to their institutions and the number of faculty mentors.

Only a few places have managed to institutionalize “away rotations,” in which they align accreditation milestones, training time, and financing with other institutions. Oregon Health & Science University’s School of Medicine is about to open a formal program that will accept 10 to 12 residents from restrictive states for a month each over a year. Oregon imposes no restrictions on abortion, and both the med school’s existing residents and the university’s philanthropic foundation supported the move.

“I’m very concerned about having a future generation that knows how to provide safe abortion care—because abortion will never go away; becoming illegal only makes it less safe,” says Alyssa Colwill, who oversees the new program and is an assistant professor of obstetrics and gynecology. “There are going to be patients that are going to use unsafe methods because there’s no other alternative. And providers are going to be placed in scenarios that are heartbreaking, and are devastating to watch.”

The accreditation council now requires programs that cannot train their own residents in abortion to support them in traveling somewhere else. But even at schools that are trying to accommodate as many learners as possible, trainees can attend for only a month—the maximum that fully enrolled programs in safe states can afford. After that, they must go back home, leaving them less-trained than their counterparts. As faculty look forward, they fear a slow spiral of decay in obstetric knowledge.

This isn’t imaginary: Already, research has shown that physicians practicing in red states are less likely to offer appropriate and legal procedures to treat miscarriages. Receiving abortion training, in other words, also improves medical care for pregnancy loss.

“Ultimately, I do not think there is capacity to train every resident who wants training,” says Charisse Loder, a clinical assistant professor of ob-gyn at the University of Michigan Medical School, who directs the program where Fishbach is training. “So we will have ob-gyn residents who are not trained in this care. And I think that is not only unfortunate, but puts patients in a position of being cared for by residents who don’t have comprehensive training.”

Doing only short rotations also returns residents to places where their own reproductive health could be put at risk. Future physicians are likely to be older than in previous generations, having been encouraged to get life experience and sample other careers before entering med school. Research on which Levy and Arora collaborated in 2022 shows that more than 11 percent of new physicians had abortions during their training. Because of the length of training, they also may be more likely to use IVF when they are ready to start families—and some reproductive technologies may be criminalized under current abortion bans.

As a fourth and final-year psychiatry resident, Simone Bernstein had thought about abortion restrictions through the lens of her patients’ mental health, as she talked to them about fertility treatment and pregnancy loss. As cofounder of the online platform Inside the Match, she had listened to residents’ reactions to Dobbs (and collaborated on research with Levy and Arora). She had not expected the decision to affect her personally—but she is in Missouri, a state where there is an almost complete ban on abortion. And this spring, she experienced a miscarriage at 13 weeks of pregnancy.

“I was worried whether or not I could even go to the hospital, if my baby still had a heartbeat, which was a conversation that I had to have with my ob-gyn on the phone,” she says. “It didn’t come to that; I caught the baby in my hands at home, hemorrhaging blood everywhere, and the baby had already passed away. But until that moment, I didn’t recognize the effects that [abortion restrictions] could have on me.”

This is the reality now: There exist very few places in the US where abortion is uncomplicated. Faculty and their trainees do not expect that to change, except for the worse. Staying in the field, and making sure the next generation is prepared, requires commitment that they will have to sustain for years.

“Part of the reason why I sought advanced training in abortion and contraception is because I think there will be a national ban,” says Abigail Liberty, an ob-gyn and fellow in her sixth postgraduate year at OHSU. “I think it will happen in our lifetime. And I see my role as getting as much expertise and training as I can now and providing care while I can. And then coming out of retirement, when abortion will be legal again, and training the next generation of physicians.”

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