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    How the repeal of Roe v. Wade will affect training in abortion and reproductive health

    The U.S. Supreme Court decision will make it harder for future OB-GYNs and other providers to learn to perform abortions. But it will affect other forms of medical training, too, including miscarriage management, counseling patients, and emergency care.

    A female patient of African descent is sitting on the examination table during a medical check up with a doctor. They are wearing face masks to prevent the spread of germs.

    The U.S. Supreme Court decision to overturn Roe v. Wade has seismically shifted the landscape of abortion in the United States.

    But it will also have a profound impact on the education of tens of thousands of medical trainees, among them OB-GYN residents who are required to learn abortion-related procedures such as those done after miscarriage.

    “The widespread criminalization of an aspect of health care and the effect we expect on medical education is unprecedented,” says Scott Sullivan, MD, a spokesperson for the American College of Obstetricians and Gynecologists (ACOG), the country’s largest OB-GYN professional organization.

    Some data help convey the post-Roe education picture: Nearly half of OB-GYN residency programs are located in the 26 states certain or likely to outlaw abortions following the Dobbs v. Jackson Women’s Health Organization decision.

    That calculation is based on the projected response of state legislatures to the decision, which effectively permits states to outlaw abortions. Some states could enforce antiabortion laws dating back decades. Others recently passed “trigger laws” that ban most abortions after Roe is overturned.

    Although it will take time to assess the fallout of the decision, medical educators — whether in OB-GYN or in other affected fields like family medicine and internal medicine — say the impact on medical training will be sweeping.

    For one, restrictive laws could significantly reduce opportunities to learn a procedure that sometimes is lifesaving.

    “Many people who generally oppose abortion still believe it should be available to save a mother’s life,” says Margaret Boozer, MD, a professor of obstetrics and gynecology at the University of Alabama at Birmingham Heersink School of Medicine. “I worry that limited opportunities to train mean that future patients may be cared for by providers who don’t have the skills necessary in such situations.”

    “The widespread criminalization of an aspect of health care and the effect we expect on medical education is unprecedented.”

    Scott Sullivan, MD
    American College of Obstetricians and Gynecologists

    Other educators worry that abortion bans would curtail training in related reproductive procedures.

    “So much of abortion-related education is the same as or closely connected with other forms of OB-GYN care,” says Janis Orlowski, MD, AAMC chief health care officer. “This includes miscarriage management, emergency procedures such as excessive uterine bleeding, and in some cases, taking a biopsy. We now need to make sure that learners have access to the necessary training so they can continue to provide patients with high-quality care.”

    Meanwhile, educators are quickly pivoting to assess the post-Roe fallout, including how to meet related professional recommendations and requirements. For example, OB-GYN residents unable to fulfill their required training might need to complete rotations in states that still allow abortions.

    “Clearly, the Supreme Court decision affects every level of medical education,” says Lauren Thaxton, MD, MBA, an assistant professor of women’s health at The University of Texas at Austin Dell Medical School. “Given the possible generational impact on future providers, it’s hard right now for educators to triage and prioritize. We still need to figure out what all this will mean.”

    The landscape for residents

    Every resident at an accredited OB-GYN program must have access to abortion training . That’s according to requirements set by the Accreditation Council for Graduate Medical Education (ACGME), which establishes standards for residency programs and monitors compliance with them.

    Any resident with religious or ethical objections can opt out of abortion training. But they still must learn how to discuss the procedure with patients and handle complications from it.

    In addition, ACGME milestones — recommended performance markers — state that residents should be able to perform abortions using surgical and nonsurgical methods by the time they finish their training.

    On the ground, OB-GYN abortion education generally covers medications for terminating a pregnancy as well as procedures that empty the uterus such as dilation and curettage. But the extent of exposure varies widely both between and within states. “The programs I work with may provide education for two days or for 20,” says Ashley Brant, DO, MPH, an academic medicine OB-GYN in Ohio who prefers not to identify her institution. The disparities exist partly because Ohio tightly limits abortion access at hospitals it funds, she adds.

    Ohio is one of the many states that are expected to outlaw or significantly restrict abortion quite soon. So, what will OB-GYN residency look like in a post-Roe world?

    Educators point to one key anticipated outcome: a significantly steeper climb for residents learning about miscarriages and related OB-GYN issues.

    “The same skill that’s used for abortion procedures is also used in a variety of other lifesaving instances like miscarriage management that require the uterus to be emptied,” says Kavita Vinekar, MD, an OB-GYN at the David Geffen School of Medicine at UCLA in Los Angeles.

    In theory, residents could instead simply learn miscarriage management skills, she says. But when it comes to learning procedures, “the way you master a skill is by doing it over and over. Volume is everything.” And where abortion is practically out of the picture, that exposure declines significantly, she says.

    Even before Roe was overturned, learning opportunities were extremely limited in Missouri, says David Eisenberg, MD, MPH, associate director of the Division of Family Planning at Washington University School of Medicine in St. Louis.

    “I recently took care of a patient with renal and liver failure who had to end her pregnancy to potentially save her life,” he says, but strict rules regarding abortion consent forms prevented his resident from participating in the procedure. “In order to be trained to competency, all our OB-GYN residents have to go to Illinois,” he says.

    That’s just a short trip, but observers say residents in many other states will have to temporarily relocate to receive abortion training. In Texas, for example — where since September a law has banned most abortions after six weeks — two Dell Med OB-GYN residents just completed a month-long rotation in California, says Thaxton.

    “The same skill that’s used for abortion procedures is also used in a variety of other lifesaving instances like miscarriage management that require the uterus to be emptied.”

    Kavita Vinekar, MD
    David Geffen School of Medicine at UCLA

    Eisenberg expects OB-GYN training to change in other ways, too. “When patients wait for abortions or they’re hard to come by, they show up with more severe complications and high-risk pregnancies that otherwise might have been discontinued. Those are the kinds of cases learners are going to see much more.”

    OB-GYN residents are hardly the only ones whose training will be affected, say educators.

    “Family medicine doctors also do abortion care, but unlike OB-GYN residents, residents in family medicine aren’t mandated to learn about abortion,” though many do learn the procedure during their residency training, says Sarah Prager, MD, a professor of obstetrics and gynecology at the University of Washington (UW) School of Medicine in Seattle. “In some states, these residents simply may no longer be able to access that training.”

    Observers expect changes for emergency medicine residents, too, based partly on an anticipated rise in self-managed abortions. “We hope that the vast majority of self-managed abortions will be just taking [abortion] pills, which is usually safe,” says Prager. “But some of what we expect to see will be scarier than that.”

    What students can expect

    Abortion-related training for medical students, meanwhile, is likely to be much more varied.

    ACOG recommends that all medical schools provide abortion education, and educational guidance from the Association of Professors of Gynecology and Obstetrics (APGO) goes further. “Regardless of personal views about abortion,” students should be knowledgeable about its public health importance, techniques, and potential complications, APGO states. Students also should be able to provide “nondirective counseling” surrounding unintended pregnancies, it adds.

    To be clear, none of this is required. However, at least 80% of medical schools reported providing curricular content related to abortion in 2021, according to AAMC data .

    But the extent and form of medical school abortion-related education ranges significantly. “Education about abortion is highly variable,” says Sarah Horvath, MD, assistant professor of obstetrics and gynecology at Penn State Health Milton S. Hershey Medical Center. “Before I got here, students discussed only the ethics of abortion.” Now they receive a one-hour lecture during their OB-GYN course that covers all the basic biomedical information.

    Observers expect such lectures to continue — unless states pass laws that restrict abortion-related education.

    And as with residency training, observers expect students’ clinical learning opportunities — usually offered in year 3 or 4 during medical clerkships — to drop significantly.

    UW’s Prager notes that her school — one of only two in a wide region — trains students on campuses throughout five states. If any of them bans abortion, some shuffling may ensue. “Some students will have to request that their family medicine or OB-GYN rotation gets moved to one of our states where that’s offered,” she says. Elsewhere across the country, students who want abortion-related education can explore “away rotations” at institutions in other states, but that will depend on available capacity, experts say.

    Meanwhile, in Texas, Thaxton had to pivot away from plans to expand reproductive health education for students to instead focus on residents. She had intended to develop a new rotation in complex family planning, “but that effort got derailed,” she says. “We had to focus 100% of our energy on meeting residency requirements to maintain accreditation.”

    Residency is also on the minds of medical students. Those who want abortion training may wonder whether they should apply only to programs in states with broader abortion access instead of applying to those that might make more sense for many other reasons including odds of acceptance. And some students may ponder this weighty question: Should they openly share their personal views on abortion to ensure a good residency fit?

    UW’s OB-GYN program, for one, won’t consider applicants who don’t want abortion training. “So many places can’t offer abortion education,” says Prager. “It would be a waste of our resources to accept OB-GYN residents who aren’t interested in being exposed to that training.”

    Leaders revamp education

    Leaders of medical schools and teaching hospitals are already crafting educational solutions for a post-Roe world.

    Many are focused on meeting ACGME abortion-related requirements. Although the ACGME has been exploring alternative options for completing this training, prior to the Dobbs decision it said accreditation requirements would remain the same .

    “I’m definitely worried about how we will meet this requirement if abortion is no longer legal in our state,” says Boozer.

    Like others, Boozer is already looking into sending residents for training stints in states with wider abortion access. There’s a long list of steps to pull that off, though: find a partnering institution that can take on additional trainees; deal with schedules, costs, and travel; and unravel complex licensing and insurance requirements.

    “It’s a huge lift,” says Thaxton, who also worries about the strain on educators in states where abortion remains legal. “They’ll likely be trying to see a massive influx of patients while also providing education. It’s really difficult to teach in that situation.”

    Meanwhile, Thaxton has already devised new ways to teach dilation and evacuation, a procedure used in the second trimester to either empty the uterus following a miscarriage or perform abortions. “Our residents were saying they didn’t feel comfortable graduating and managing second-trimester pregnancy loss,” says Thaxton. So she quickly pivoted to provide simulation trainings, using a small watermelon to stand in for a uterus.

    “We are determined to train our learners fully and to care for our patients in all of their reproductive needs.”

    Margaret Boozer, MD
    University of Alabama at Birmingham School of Medicine

    Often, educators say they will need to create brand-new curricular content.

    In Michigan, where Roe overrode a 1931 law criminalizing abortion, Michigan Medicine experts help lead an abortion-related task force.

    “We’ve been preparing to drastically alter the education of our students and residents,” says Dee Fenner, MD, chair of the Department of Obstetrics and Gynecology at Michigan Medicine in Ann Arbor.

    Fenner’s plans include increased training in helping patients with self-managed medical abortion — which involves taking two pills that can be prescribed via telemedicine — and birth control options. She and her team have begun creating a comprehensive curriculum on these topics for trainees in such fields as internal medicine and pediatrics.

    Beyond clinical skills, educators are looking at teaching trainees to counsel patients grappling with abortion restrictions. “So many factors impact women who have limited access to abortion care. There is a significant mental health piece, for example,” says Boozer.

    “Alabama law does not currently restrict the way I speak with patients about abortion,” Boozer adds, but she wonders whether that may change. “This is a very real fear, that my hands may be tied in helping my patients.”

    Looking at all that lies ahead, Boozer sees a great deal of work. “We are determined to train our learners fully and to care for our patients in all of their reproductive needs,” she says.