Many medical residency programs that are educating the next generation of obstetricians and gynecologists are facing a treacherous choice.
If they continue to provide abortion training in states where the procedure is now outlawed, they could be prosecuted. If they don’t offer it, they risk losing their accreditation, which in turn would render their residents ineligible to receive specialty board certification and imperil recruitment of faculty and medical students.
The quandary became clear last month, when the Accreditation Council for Graduate Medical Education formally reaffirmed its longstanding requirement that OB-GYN residency programs make abortion training available.
“You have a legal body, the state, saying abortion is a crime and an accrediting body saying it’s a crucial part of training,” said Mary Ziegler, a law professor at the University of California, Davis, who specializes in the history of abortion. “I can’t think of anything else like that.”
Teaching the procedures used for abortions has long been a required element of the OB-GYN residency curriculum in the United States.
“We feel that abortion, or evacuating the uterus, is a core procedure for OB-GYN. It’s also used for management of miscarriages and complications of pregnancy like infection and bleeding,” said Dr. John Combes, a spokesman for the council, which accredits more than 12,000 medical residencies. “So it’s a technique that has to be learned.”
To avoid running afoul of state laws that restrict abortion, a program can maintain accreditation by arranging for residents to do a clinic rotation in a state where abortion is legal, the council said. But some program directors fear that route could also be fraught with legal peril.
More than two dozen program directors and residents in abortion-restrictive states declined to be interviewed by The New York Times about their plans, citing the advice of lawyers. Those who did speak emphasized that they did so on their own behalf and not as representatives of their institutions.
Some faculty said that with lawmakers increasingly looking to block citizens from getting abortions out of state, they feared that establishing out-of-state training could make them vulnerable to private lawsuits or even charged with aiding and abetting a crime. Attorneys general from Oklahoma, Tennessee and Texas, among the states that ban abortion, did not respond to requests for comment about whether they would press such cases.
Ken Paxton, the Texas attorney general, has already crossed swords with the council. Last year, before the right to abortion was struck down, he issued an opinion saying that Texas residency programs did not have to make abortion training mandatory.
Read More on Abortion Issues in America
A recent analysis in Obstetrics and Gynecology estimated that about 45 percent of the country’s 286 OB-GYN residency programs were located in states likely or certain to ban abortion, affecting about 2,600 of the country’s 6,000 residents. The authors reported that in 2020, 92 percent of residents said they had access to abortion training, a number they predicted could now plummet to 56 percent.
Dr. Nikki Zite, a professor at the OB-GYN residency program at the University of Tennessee College of Medicine in Knoxville, Tenn., where doctors who perform abortions can be charged with a felony, said her program has been seeking out-of-state rotations for its residents.
“But our surrounding states are tenuous,” she said. “Virginia and North Carolina seem safe for now while South Carolina goes back and forth. And everything could change in one election cycle. ‘Wait and see’ is a really hard place to practice medicine and a really hard place to train residents to practice medicine.”
Dr. Christina Francis, the incoming head of the American Association of Pro-Life Obstetricians and Gynecologists, who practices in Fort Wayne, Ind., a state whose near-total abortion ban has been suspended by a judge, called the council’s accreditation requirement coercive.
“Rather than attempting to force training programs to arrange for residents to be transported out of state for abortion training, the council should re-evaluate altogether its requirement,” she said.
Although programs must offer that training, the council permits a resident to opt out for religious or moral reasons.
Dr. Francis said abortion training is not essential to OB-GYN practice and that residents could learn how to evacuate the uterus by managing miscarriages.
“This assertion that without doing abortions physicians will be less well-trained is completely false,” she said.
Dr. Kate Dielentheis, an associate director at an OB-GYN residency program in Milwaukee, Wis., where abortion is banned, said residents, who typically treat patients in a hospital, rarely get the volume of miscarriages in that setting to become proficient, which is what they would gain during a rotation at a clinic that provides abortion care.
“What happens where there is a complication?” she said. “That’s what volume in medical training is all about. It’s about being able to anticipate those complications and know how to handle them.”
Her program is negotiating to place residents in rotations at an Illinois clinic. It is also contending with other fallout: Dr. Dielentheis said that a doctor they had been courting to join their faculty just turned them down, citing the Wisconsin ban.
One center, the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning, at the University of California, San Francisco, which has provided training to departments nationwide since 1999, reported that 22 of its program partners were in abortion-restricted states. It is helping connect many to programs in abortion-protected states.
The practical obstacles are daunting, including an overwhelming demand for limited slots; differing state regulations for malpractice insurance and licensing; and housing costs.
With applications for next year’s class of residents underway even as state abortion laws mutate, program directors in restricted regions are struggling with what assurances about abortion training they can make to candidates.
That is among the reasons that many medical students have said they are applying only to programs where abortion is legal. Public health experts predict that in a few years, patients in abortion-prohibited states, where the ranks of obstetricians are already shrinking, will experience even greater barriers to reproductive health care.
A reviewing committee of the accreditation council debated whether simulation modeling, a staple of medical education that is a precursor to direct care, would suffice for residents who could not travel to another state. In abortion training, for example, residents watch videos and practice on low-tech uterine models, including papayas. The committee decided that simulation was not an acceptable substitute.
The council has made abortion training a component of its family planning requirements since at least the mid-1980s. But by the mid 1990s, when the number of abortion clinics was decreasing and threats against providers were rising, the council stated its requirements explicitly.
Around that time, Congress passed another in a series of “federal conscience” provisions ensuring that programs — as well as individuals — refusing to perform abortions and therefore risking loss of accreditation could not be discriminated against by such means as losing federal or state funding.
Even if funding for programs that resist offering abortion rotations is guaranteed, the effect of the council’s citation, probation or denial of accreditation is potent, said Greg Care, a lawyer who represents residents. Medical students won’t apply to a program without accreditation, he said, “And a lot of academic medical centers live and die on residents being cheap labor.”
Dr. Maja Grzejdziak, a first-year OB-GYN resident at Texas Tech University Health Science Center, El Paso, said that residents would then have to transfer to complete their training. “It would be a big deal for the community, because residents take care of so many people at nonprofit hospitals especially,” she said.
According to Dr. Combes from the council, last year several OB-GYN programs received citations for not providing what reviewers determined to be sufficient experience in abortion training.
Already the new laws have made the recruiting of medical students to states with abortion bans difficult. Dr. Zite, the treasurer for the Tennessee chapter of the American College of Obstetricians and Gynecologists, fears that programs providing the full suite of training will lure top-tier candidates away from programs like hers. Although many medical students apply to her program specifically to work with Appalachian patients, she said, “Will they still sign up with us, hoping we are able to get over all the hurdles to provide them training out of state?”
The uncertainty has also shaken medical students, who typically apply for residencies in their last year of medical school. Obstetrics and gynecology is a competitive field. According to the National Resident Matching Program, last year there were 2,044 applicants in obstetrics and gynecology for 1,503 slots.
Ariana Traub, a second-year medical student at Emory University in Atlanta, helped conduct a survey of third- and fourth-year medical students about the impact of the abortion turbulence. Although more than three-quarters of 500 responses came from students applying to fields other than OB-GYN, overall, 60 percent said they would not apply to programs in states with abortion restrictions.
One student commented: “I would have likely chosen to apply to OB-GYN if the field was not going to become a political nightmare.” But some agreed with the restrictions. One student wrote that performing an abortion violated the professional oath to do no harm to life.
“Abortion management is about so much more than a procedure,” Ms. Traub said, adding that residents learn to set aside their own personal biases as they sit with a patient wrestling with a difficult decision.
Gabrielle Magalski, a fourth-year medical student in New Orleans, said that residency directors have told candidates that because programs in states where abortion is legal are drawing the most applications, they will be even harder to get into. Although she supports abortion rights, she has applied to programs where abortion is banned.
“Your values are put to the test,” she said. “Of course abortion matters, but first of all we just want to be trained as OBs.”