• July 29, 2014

As States Limit Abortion, Future Doctors Fight for Training

As States Try to Curb Abortion, Future Doctors Fight for Training 1

Medical Students for Choice

Carolyn Payne, president of the Medical Students for Choice chapter at the U. of Toledo, told medical students at an activism workshop how she advocated for including abortion in her school's first- and second-year curricula.

By imposing restrictions on abortion clinics, more and more state legislatures are trying to limit Roe v. Wade. Now a university medical center has aided that effort, raising questions about whether its actions are in the best interests of medical education and public health.

In April the University of Toledo Medical Center, after criticism from Ohio Right to Life, declined to renew a so-called transfer agreement with one abortion clinic and stopped arranging one with another. The agreements establish that clinics may move a patient to a hospital in an emergency. Without them, a clinic can't operate in Ohio, limiting opportunities for valuable training experience for medical students and residents.

The university's president, Lloyd A. Jacobs, says its hospital will "take patients in our emergency room from anywhere, anytime, from any background, under any circumstance." But seeking "a more neutral position," he wants to free his state institution from transfer agreements with abortion clinics.

No other local hospital will sign the agreements. One clinic, Center for Choice, said last week that it was closing; Capital Care Network will probably close in July, when its agreement with the university expires.

Carolyn Payne, a rising third-year medical student at the University of Toledo and president of its chapter of Medical Students for Choice, says that isn't right. She and about 15 other students volunteered at Center for Choice, working with counselors and a doctor to learn abortion care. She will now have to go to another city—an hour away—to learn this common medical procedure.

Nearly a third of all American women will have an abortion by age 45, according to the Guttmacher Institute, which studies and advocates for reproductive health and rights. Yet lectures and rotations covering abortion are surprisingly scant in medical-school education, especially in the South and Midwest. And if abortion isn't taught in medical schools, a shortage of doctors who perform them will make Roe v. Wade irrelevant.

'Shoot the Abortionist'

Medical Students for Choice was started 20 years ago by Jody Steinauer, now an associate clinical professor of obstetrics and gynecology at the University of California at San Francisco. In early 1993, she and other medical students across the country received a "jokebook," mailed to their homes, that included "Q: What would you do if you were in a room with Hitler, Mussolini, and an abortionist, and you had a gun with only two bullets? A: Shoot the abortionist twice."

About the same time, Dr. Steinauer learned that only 12 percent of ob-gyn residency programs, where medical-school graduates practice under the tutelage of physicians, were teaching the procedure—a big drop from a decade earlier.

Then, in March 1993, David Gunn, an obstetrician who performed abortions, was shot and killed in Pensacola, Fla. "Of course we have to fight for this," Ms. Steinauer told herself. "How can we let politics and stigma determine what future physicians are learning?"

Taking a year off from medical school, she helped found a nonprofit that would eventually tap into growing numbers of pro-choice students.

Medical Students for Choice now has 159 chapters in the United States and 12 other countries, including Ireland (a rich environment for student activism despite abortion's being illegal there). With 10,000 student members, the group's staff of seven, based in Philadelphia, works with those like Ms. Payne in Toledo—helping draft petitions, get faculty support, and examine legal aspects of the university's decision to end its agreement with the local clinics.

The group, whose motto is "creating tomorrow's abortion providers and pro-choice physicians," also holds two-day training institutes on specific topics, bringing students from all over who apply. It offers a reproductive-health "externship," in which students concerned about gaps in abortion teaching at their own medical schools can spend a month at a school with comprehensive reproductive-health training. And it holds annual family-planning conferences in the United States, Canada, and, this fall, an international meeting in Dublin.

Before the Toledo clinic crisis, Medical Students for Choice was helping Ms. Payne advocate for classroom education about abortion. In May she outlined her strategy in Atlanta, at an MSFC Activist Training Institute, to 20 students from as far away as Newfoundland and California.

She described showing the chair of her school's ob-gyn department what the different hours of lectures were spent on in students' first years—two hours on organ donation, for example, whereas abortion was never discussed. "I made the case that, you know, organ donation is important, but this is how many organ transplants occur in the United States in a year"—about 28,000—"and this is how many abortions"—about 1.2 million. Don't you think if we are talking about organ donations, she had asked the chair, we should talk about abortions, too?

A study published in 2009 by Dr. Steinauer and others found that a third of medical schools include no discussion of elective abortion in the first and second, or preclinical, years. "People don't know what aspect of medicine they're going into" in the preclinical years, she said. If their courses skirt one of the most common procedures, how can they decide?

And in the third year, when students make rounds with physicians, get hands-on training, and decide what kind of doctors they want to be, only a third of them get lectures on abortion, said Douglas W. Laube, a professor at the University of Wisconsin School of Medicine and a former president of the American College of Obstetricians and Gynecologists. "Slightly less than half are offered some sort of a clinical experience," said Dr. Laube, who is also board chair of Physicians for Reproductive Health.

By contrast, 84 percent of medical schools cover the mechanism and/or history of Viagra, Dr. Steinauer's study found.

Fiscal Pressures

The teaching of abortion is, of course, fraught with controversy. Many medical schools, with active Christian Medical & Dental Associations and other antiabortion groups, are careful about "not offending people," said Michelle Brown, a student at the University of North Carolina's School of Medicine, at the activism meeting.

And state universities rely on legislatures to vote for, and governors to sign, financing measures for new buildings. An administrator, not wanting to offend antiabortion lawmakers, would be reluctant to "ask why students aren't afforded the opportunity to learn comprehensive reproductive health, including abortion," said Dr. Laube.

Or, as state funds grow scarce, teaching hospitals merge with faith-based ones that object to abortion. In response to such mergers in Seattle, Planned Parenthood expanded its training opportunities to accommodate medical residents.

Access to clinics, where most abortions take place, can be curtailed, as in Toledo. Antiabortion activists, who once protested at clinics' doors, now lobby for an array of legislative strategies to close them. In North Dakota and elsewhere, new laws, being challenged in the courts, require hospital-admitting privileges for abortion providers, many of whom come from out of state. Given the political climate, hospitals don't want to get involved. The requirement forced the closure of one of two clinics in Knoxville, Tenn., last year.

Compliance Problems

Some medical professionals say preclinical students don't need to learn about abortion. Early medical school "concentrates on anatomy, physiology, and molecular biology, neurobiology," says Dr. Jacobs, of the University of Toledo.

Dr. Jacobs was head of the Medical University of Ohio, which merged with Toledo in 2006, when he was appointed leader of the new institution. He notes that the Accrediting Council for Graduate Medical Education requires abortion training and experience to be offered in ob-gyn residency programs. "Residents at the appropriate level will be exposed to these things," he says.

Indeed, Medical Students for Choice counts the council's requirement among its early successes. Partly a result of the activist group's first nationwide petition drive, the requirement has been in place since 1996. In response, Congress voted to maintain the federal funds and legal status of medical colleges that do not offer abortion training, whether accredited or not.

About 20 percent of the 100 programs reviewed each year are found to be noncompliant, according to the council. They have at least four years to change their curricula before being revisited by the review committee.

While most ob-gyn residencies now offer the training in some form, about 40 percent still don't integrate it into their rotations.

At Toledo, Dr. Jacobs promises to "meet the requirements for all procedures that are required for good practice by the accrediting body," by sending residents to train in other towns "in the immediate vicinity."

But the nearest abortion clinic is in Ann Arbor, Mich., an hour away, says Ms. Payne. Training in another state poses problems with regulations and licensing. And the now-closed Center for Choice trained not only University of Toledo residents but those from Wright State University, in Dayton. Fewer clinics for the same number of residents means more travel and scheduling issues.

Medical Students for Choice lists on its Web site those residencies that offer comprehensive training. The Kenneth J. Ryan program, for example, finances more than 60 such programs at the 242 ob-gyn residencies in the United States. But not only obstetricians provide abortions. Family doctors, surgeons, and other physicians do, too. The accrediting council requires the training only in ob-gyn residencies.

So future residents who want to learn abortion care have to think carefully about where to apply.

Lois Backus, executive director of Medical Students for Choice, came to the group after opening clinics for Planned Parenthood in three states. The biggest challenge, she told the students here, was "finding a doctor." That's not surprising; according to a 2011 study by the Guttmacher Institute, 87 percent of counties in the United States have no abortion providers. And while 97 percent of ob-gyn doctors encountered patients seeking abortions, only 14.4 percent performed them, according to a 2011 study by Debra B. Stulberg, a University of Chicago researcher, and others.

"What will you say," Ms. Backus asked the students in Atlanta, when a member of your family asks, "Why do you have to provide abortions?"

"Sarah," a student from Florida who asked not to use her real name, will soon start her residency in obstetrics. "Because if I don't do them," she replied, "who will?"

This month in Ohio, the Senate added language to a proposed state budget that would forbid public hospitals to make transfer agreements with abortion clinics. If that measure survives, the state would be in the unusual position of requiring the agreements with hospitals while forbidding public hospitals from making them.

"It's a paradox," wrote Ms. Payne, the chapter president, who was back in Ohio, studying for exams. Once those were done, she wrote, she planned to "regroup activism from the med-student end."

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