A fourth-year medical student, Tema, faced an abrupt interruption to her education earlier this year. A state law banning abortion after six weeks went into effect hours after the U.S. Supreme Court overturned Roe v. Wade, and two days later, the clinic where her school provided first-hand abortion experience shut down.
“I’d do my patients a great disservice if I’m not trained in abortion,” said Tema, who is planning to become a family planning doctor, and asked that she be identified only by her first name for fear of repercussions by her medical school. “I’m going into a career where I care about reproductive health, I need to understand all aspects of it.” Without help from the school, Tema had to find an alternative herself, and will travel abroad next month to observe abortions being performed in a clinic in London.
She’s not alone. As a wave of extreme restrictions on abortion sweeps the United States, medical schools and residency programs are struggling to ensure future doctors are adequately prepared. Some are pairing up with training programs in other states that allow abortions, but there simply aren’t enough spaces available. Medical Students for Choice (MSFC), a grassroots organization that helps students get in-person abortion training, realized as states began changing abortion laws — even before the Supreme Court’s Dobbs ruling — that students would have to go overseas.
“When Texas went dark and was no longer providing abortion, that had ripple effects all up the Midwest,” said Pamela Merritt, executive director of MSFC. “Each state that moved to ban abortion created an overwhelming increase of patients in clinics, which means it’s really hard to get the clinics to commit to taking the time to training students in the U.S.”
Since the Dobbs decision, Merritt estimated around 10% to 15% of the roughly 5,000 U.S. students who participate in MSFC have expressed interest in abortion training outside the country. The demand is roughly triple what it was before abortion restrictions started to roll out, she said, and MSFC isn’t able to arrange abortion experience for all students.
Given the size of the U.S., Merritt expects it to soon be home to the largest number of students looking to go abroad through her program. But MSFC is a global organization, and she said American students can’t be prioritized above those from other countries with restrictive abortion laws looking for training. Sending students abroad is only a partial solution for a medical education system struggling to adapt to restrictions and fast-changing laws.
Abortion training has long been a standard feature of medical education. It is one of the most common procedures in the U.S., even more common than appendectomies, and The American College of Obstetricians and Gynecologists (ACOG) recommends all medical schools teach abortion, though students can opt out and in-person experience isn’t required.
The procedure typically used for surgical abortion, dilation and curettage (D&C), also is used for other health conditions, such as miscarriage management, to detect cancer, treat ectopic pregnancy, and remove the placenta after childbirth. There are already higher rates of maternal mortality in states with more abortion restrictions, according to a study published last year, and experts expect this gap to widen as more doctors are under-trained in reproductive health. “That’s only going to get worse,” said Sadia Haider, director of family planning at Rush University Medical Center in Chicago.
Without the opportunity to see abortions first-hand, Tema felt her medical education would fall short and worried she would be a less competitive candidate for residency programs in states that allow abortion. And so the 25-year-old will travel to the British Pregnancy Advisory Service (BPAS) Richmond clinic in London in November, where she will get a week of in-person experience watching abortions being performed. MSFC provided a stipend, which Tema said will cover nearly all of her expenses; the rest she will pay out of pocket.
“It’s important, for my future patients, to have that skill set so I can explain to them what goes on, so patients can be informed and make proper decisions for their own health care,” she said. The idea that she can’t get this experience in the U.S. and must go abroad is “kind of crazy,” she added.
BPAS has welcomed international students for years, though previously they largely came from closer to the U.K., such as Northern Ireland, or traveled from Africa. Now, the overwhelming majority of applicants are from the United States, said Pearl Hudson, the BPAS program coordinator, and these students’ applications all cite their struggle to learn about abortion in the U.S.
Patricia Lohr, medical director of BPAS, was trained in the United States and participated in a MSFC externship in California more than two decades ago. Seeing the positive impact of abortion first-hand was transformative, she recalled: “It set me on the path I’ve been on for the whole of my career.” And so, when she joined BPAS, she was keen to create the same opportunities for current medical students.
During their week-long visit, students are mentored by BPAS staff and are exposed to several phases of abortion care: pre-abortion assessments, surgical abortion, medical abortion, screening for sexually transmitted infections, and contraception delivery. The in-person experience is critical, said Lohr, both to gain clinical knowledge and build empathy.
“It’s important they hear the stories and what sits underneath people’s decisions about terminating or continuing a pregnancy,” she said. “It’s a good way of teaching students to be non-judgmental and compassionate in the medical environment, in the way they should be for any medical procedure, but is sometimes not done as well for people seeking abortion.”
The experience is as important for future OB-GYNs as for those going down a different medical path entirely. Every single doctor will encounter patients who’ve had both abortions and complications from abortions, said Lohr, and medical students should understand the procedure even if they’re not providing it.
Merritt said that, in addition to sending U.S. students to the U.K., MSFC is talking with Canadian clinics to arrange placements.
Although ACOG recommends medical schools include abortion health care in their curricula, it is not a requirement for school accreditation. And, while both schools and students can of course look for training partnerships in states where abortion is still permitted, many students have been left to figure out their education alone. “My school basically didn’t say anything,” said Tema. (She asked not to name the school, as the administration was previously upset with students who asked them to support abortion publicly, and she was worried about being penalized.)
Half of medical schools pre-Dobbs provided just one lecture or no abortion training, according to a study from Stanford University. State medical schools are overseen by the same legislators that create abortion restrictions, and Merritt said she’s heard from some programs that would like to pair with abortion practices out of state, but are wary about repercussions.
“You’re fighting for the integrity of the residency program. You’re also fighting to maintain a good relationship with the state legislature,” she said. “Some [medical schools] are still so risk averse, they’re shutting down all access. They’re in a political pickle.”
So sensitive is the topic that medical school faculty were overwhelmingly hesitant to speak with a reporter about the changes in regulation post-Dobbs. STAT reached out to around 60 faculty members who either did not respond or were unwilling to talk, citing lack of permission from their school. One professor who looped in the University of Pittsburgh Medical Center’s media relations team was told not to engage: “This is not something we would like to participate in. Please ignore at this time,” wrote the public relations manager in an email sent to both the professor and STAT. (This summer, 1,200 UPMC staff signed a public letter warning the university was “in danger of complicity” for not affirming the importance of abortion health care.)
Medical school students tend to practice in the state where they graduate. But many students interested in family planning and reproductive health care are now eager to move to a state where they can perform abortions. Tema is one of those planning to leave Ohio for residency: “Because I’m a Black woman, the Venn diagram is almost a circle of where I’d feel more comfortable and can perform abortion,” she said.
The same web of regulations and restrictions shutting down medical school abortion training is also undermining residency programs. Unlike medical schools, OB-GYN residencies are required to provide access to clinical experience in abortion. This means that hospitals that can’t fulfill this requirement risk being penalized, or even losing accreditation, and there is a scramble to try and partner with training programs in states where abortion is permitted.
The demand is overwhelming. Of 6,000 OB-GYN residents in the U.S., more than 2,600, or 44%, won’t have access to in-state abortion training, according to a study published in Obstetrics & Gynecology. “We don’t have the ability to find programs for every single resident,” said Jody Steinauer, director of the Bixby Center for Global Reproductive Health at the University of California, San Francisco. She also runs the Ryan Residency Training Program, which supports training for obstetrics and gynecology residents and has so far managed to connect 22 residency programs with ones in states that permit abortion.
Some OB-GYN residents will inevitably be left under-prepared to provide reproductive health care. “Programs are having a really hard time,” Steinauer said. “You can’t learn to do an abortion virtually, you have to do direct abortion care.”
Haider, from Rush University Medical Center in Chicago, said the medical center partnered with St. Vincent Hospital in Indianapolis, Ind., more than a year ago to work with their residents, and is setting up a partnership with the Medical College of Wisconsin. But they’ve had to turn down other facilities.
“Many other institutions reached out to us to partner,” said Haider. “We already have our own trainees here. There’s only so much clinical capacity. We will not be able to accommodate every request.”
Last month, the Accreditation Council for Graduate Medical Education (ACGME), which evaluates and sets standards for medical residency programs, confirmed its long-standing requirement that programs offer in-person abortion training — whether by providing it themselves or, in states where abortion is prohibited, by making arrangements for residents to visit another state. “This is a core part of training, we have to have programs offer it or make arrangements,” said John R. Combes, ACGME’s chief communications and public policy officer. “We’ve told programs they’ll be evaluated against these requirements, as they always have.”
A program that fails to provide access to abortion training will be given an “area for improvement” citation, said Combes, though a single citation does not necessarily mean accreditation will be revoked. Programs have only just started making arrangements, and so the full data on how they’ve managed to respond won’t be available until next summer, he added.
There is already a shortage of 8,800 OB-GYNs, according to ACOG, and the abortion restrictions are expected to create a divide among states, limiting the number of residents in restrictive states who can receive proper training while driving fully prepared physicians toward states where they can freely practice.
“It’s critical that every OB-GYN learns the basic skills to empty the uterus,” said Steinauer. All OB-GYN residents should understand both medical and surgical abortion, she said, and have the skills for pre-op assessment, counseling, and post-abortion care. Although residents can learn how to perform a D&C as part of miscarriage treatment, care for miscarriages is spread across primary care doctors, OB-GYNs, and the emergency room. This makes it hard for residents to be exposed to enough cases during their training.
“You can spend a few weeks in an abortion care setting and see a lot of people, so get a more concentrated experience,” said Steinauer. “If your experience is just once in a while, you don’t get as good skills.”
Residents who have access to abortion training feel more competent at handling miscarriages too, according to research published in Obstetricians and Gynecologists. There are a few dedicated early-pregnancy-loss clinics, which see a higher number of miscarriages and could potentially give residents similar skills, added Steinauer, but such centers are relatively unusual.
Just as institutions responding to increased restrictions in their home states are struggling to adapt, those in other states are overwhelmed with an increased workload. Rush’s partnerships require a huge amount of administrative work, trying to figure out travel and out-of-state licenses, said Haider, as well as adding to clinical demands. “It’s an added layer of stress you have to rope into the already busy clinical environment,” she said.
Given the wave of abortion clinic closures across the U.S., facilities that do provide abortions are “really really busy.” said Steinauer. They are struggling to meet patient needs, she said, and there’s only so many additional residents they can take on. “There’s too many residents in programs in banned states,” she said. “I’m really worried about it.”