The future of abortion training for resident physicians is bleak
In 2021, Dr. Mallika Govindan, a family medicine resident at Mount Sinai Health System, received some disappointing news. Even if she had pursued a career in medicine in order to become an abortionist – and had chosen a residency in New York, where she believed she would get the best training – she would not be able to learn how to provide abortion care. abortion. locally. Due to pandemic precautions, Planned Parenthood New York City, which trains many medical residents, had to scale back its abortion training program.
Govindan spent months researching other options and applying for scholarships. In February 2022, she traveled to Chicago for 12 days of abortion education with a nonprofit reproductive health care organization.
It was hard for Govindan to get abortion training, but in Chicago, she kept hearing whispers that it might soon become even harder for medical residents like her. Abortion providers overseeing her said residency training could become more difficult if Roe vs. Wade were overthrown; as clinics in places like Chicago expand their capacity to meet the growing demand for abortion care from people from states where the procedure is banned, they may decide to stop training residents from outside of the state to cope with the influx of patients.
Govindan worries that making abortion education even less accessible to doctors will make it much harder for people to get proper care. “There’s such a shortage of doctors and providers overall,” she says. “The [number] who are willing to do so is even smaller.
Abortion training for medical residents is already a logistical nightmare in the United States. Obstetrics and Gynecology residents are required by the Accreditation Council for Higher Medical Education (ACGME) to provide abortion education in order to be accredited, although residents can opt out if they wish. . Training usually consists of a one-week or one-month rotation at a local abortion clinic or hospital. But these sites are rare. Nearly 90% of U.S. counties do not currently have a clinic offering abortion care, meaning those that do exist are likely to be overrun by both patients and interns if Roe vs. Wade is overturned. According to an article published by the American College of Obstetricians and Gynecologists (ACOG) in April, nearly 44 percent of current obstetrics residents in the United States are training in states that are certain or likely to ban abortion. Roe vs. Wade be 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 avenues to complete this training. At this time, the ACGME requirements remain the same,” including that all ACGME-accredited obstetrics and gynecology programs must have a family planning program and “experiential training in complications of abortions and the possibility of direct procedural training in terminations of pregnancy.” Experience with induced abortion should be part of the curriculum to ensure that doctors in training have the opportunity to gain the experience necessary to manage all of their patients’ needs. or other family planning services “must arrange for such residency training to take place at another facility.”
In a state like Utah, it’s already difficult to be an obstetrician, says Dr. David Turok, associate professor in the University of Utah’s department of obstetrics and gynecology and chief of the division of family planning. . A state law enacted in 2017 requires doctors to tell their abortion-seeking patients several lies that aren’t supported by science, Turok says, including a requirement to say the abortive drug mifepristone is reversible. . Providers are also required by law to give patients painkillers – for the fetus – 20 weeks or more after a pregnancy, which doctors say is scientifically unfounded. But the impending restrictions on abortion if Roe vs. Wade finished would be “on a whole new level,” says Turok.
Turok already plans to send his obstetrics residents to other states for training if Utah bans abortions, which should happen immediately after. deer is overturned. Another option may be simulated procedures, such as practicing techniques on a manikin, which are common in residency programs. However, he fears that this is not enough. “By limiting care and limiting training, you essentially compromise the quality of care,” he says. “I’m not worried; I’m terrified.”
There are signs that abortion education is already lacking in the United States, particularly for abortions beyond those administered in the first trimester. According to a study published in 2018 in the American Journal of Obstetrics and Gynecology, only 71% of residence directors who responded to a survey thought their midwifery graduates were proficient in a common abortion procedure in early pregnancy called first-trimester aspiration, and only 66% felt residents were competent enough. trained in medical abortion. Only 22% of directors thought their midwifery graduates were proficient in other abortion techniques, including dilation and aspiration, commonly used in the second trimester.
This lack of knowledge could be, in part, due to problems of access. In some obstetrics and gynecology programs, residents are responsible for fitting training into their own schedules, which can be cumbersome, while others face restrictions in their hospitals that limit where and how the procedure is performed, according to ACOG. Many faith-affiliated hospitals do not offer abortion services.
Dr. Debra Stulberg is chair of family medicine at the University of Chicago and director of education at the Midwest Access Project (MAP), a nonprofit reproductive health care organization that helps connect residents, including including Govindan, to abortion training. She says MAP gets a lot of requests from residents of religious hospitals, as well as specialty residents whose programs don’t always offer a lot of abortion education, but who may need it as much as a doctor. obstetrician. Family physicians, in particular, are the primary providers of abortions in the United States, especially in underserved rural areas, but often do not receive the proper training. “Even though they have [the] opportunities,” says Stulberg, “they may only be spending a few days in a clinic and not enough to really develop the skills they need.”
To complete their training, many of these residents must travel to other states. But that won’t be a solution to the drastic shortage of educational opportunities that could develop if abortion is suddenly illegal in many states, says Dr. Kavita Vinekar, an obstetrician-gynecologist specializing in complex family planning and co- author of the ACOG Commentary. “[It] won’t be feasible on this scale,” she says. “The reality is that we can never get nearly 44% of our residents to travel away from their home facilities, away from hospitals that rely entirely on residents to operate, so they can get the training they need. She and her co-authors suggest that residency programs may instead need to reinforce miscarriage training, which overlaps with abortion training, and incorporate simulations to help fill this gap.
Finances are another hurdle for residency programs that hire or lose residents to travel. A hospital’s budget for higher medical education, which is paid for by Medicare, does not travel with the resident, so new funds must be found to pay his salary during the rotation portion of family planning which includes abortion training and can last several weeks. says Dr. Laura MacIsaac, professor and associate director of the Family Planning Fellowship at the Icahn School of Medicine at Mount Sinai. “I have visiting residents who come to New York with this request, but we have so, so many requests, and we really can’t honor them all,” MacIsaac says.
Turok of the University of Utah worries that illegal abortion won’t be as attractive for obstetricians to learn or possibly practice. States likely to ban abortion in this case deer is knocked down “do not realize that they are driving a major hole in 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 cannot provide the full range of services to their patients? »
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