Abortion is one of the most common surgical procedures performed in the United States, according to the Guttmacher Institute, with an estimated one-third of women having had an abortion by age 45. In 2005, 1.21 million abortions were performed. Despite the prevalence of abortion, the training of the procedure varies tre-mendously by medical school and geographic region.
In North America, abortion is seen as a privacy issue through a politically charged prism and, even though the procedure has been legal since the 1973 Roe v. Wade ruling, various states have enacted laws that serve to curtail access to abortion and, by extension, training. In addition, many medical schools have firm an-ti-abortion policies or are affiliated with religious hospitals that ban the practice.
According to a research article published in Contraception magazine last April, medical schools commonly dedicated more “preclinical class time to [Viagra] than to all elective abortion topics combined.” A survey of abortion education in medical school conducted in 2005 by Dr. Eve Espey and others noted that 44 percent
of schools offered no formal preclinical elective abortion education and that 25 percent of OB-Gyn clerkships reported no formal education about abortion training. The Guttmacher Institute reported 1,787 providers in 2005, down from 2,908 in 1982. Eighty-seven percent of U.S. counties have no abortion providers.
Louisa Pyle, immediate past president of Medical Students for Choice (MS4C) and a third-year in an M.D./Ph.D. program at the University of Alabama at Birmingham (UAB), believes that in the last five years, there’s been more access to abortion training than there was in the early to late 1990s, but there’s still less compared to the early 1970s. As she notes, today’s “graying” providers had experience in OB wards that saw as many cases of incomplete abortion and sepsis as births, “so the need for appropriate, physician-trained abortion providers [after Roe v. Wade] was incredibly clear to them.” Training dropped off in the 1990s, which Pyle attributes partially to complacency: As the memory of back-alley abortions faded, a whole generation of people, including medical students, has never seen what happens when abortion is forced underground.
Dan Murphy, a fourth-year at the New York College of Osteopathic Medicine in Old Westbury, New York, who is currently applying for OB-Gyn residency, acknowledges that a lack of abortion training during preclinical years is a “common complaint” for groups like MS4C, then adds, “but I kind of agree that it’s not the proper place for it because abortion is surgical, and you just don’t learn surgery in your first year of medical school. It’s something you have to learn by experience…. If you look at any number of procedures that are similar in length or risk to abortion, you don’t hear about any of them during your first year of med school.”
However, Pyle firmly believes it is “essential” that groundwork is laid during the first few years of medical school. Surgical procedures may not be taught then, but students certainly learn about the circumstances of such procedures: “For example, we may not know the intimate details of how to perform an early-term abortion, but we should have enough knowledge to appropriately counsel someone on a pregnancy test. There are a lot of components that are absolutely appropriate for the first and second year.”
Groups like MS4C view abortion as an integral part of women’s health services, a view that is shared in parts of the world such as Scandinavia, where “abortion care and a full range of contraception is readily available and affordable, and an expected part of women’s health care as it’s delivered by physicians,” observes Lois Backus, MS4C’s executive director.
Considering how much time women spend trying to get pregnant, not get pregnant, or being pregnant, Pyle thinks it’s important to include abortion in the preclinical experience—particularly, according to Guttmacher statistics, since almost half of all pregnancies are unplanned. But, admits Pyle, “most medical students don’t think about abortion training because they haven’t been told they need to think about it.”
Opposition to abortion, whether it comes in the form of major protesting activities or increased “targeted regulation of abortion providers” laws—laws designed to decrease access through parental notification requirements, waiting periods or detailed requirements like mandatory hallway widths—can act as challenges and barriers to abortion training. However, Pyle feels that a lack of education and training has less to do with politics than insufficient exposure to “evidence-based, accurate information about reproductive health.”
Nonetheless, abortion is polarizing and divisive enough that students can opt out of training on moral and ethical grounds. But, as Pyle points out, medical students are exposed to other behaviors and practices that they may not personally condone and, ultimately, she feels it’s a disservice to students’ future patients not to be informed on all aspects of reproductive health, including abortion.
Each medical school has a different culture when it comes to abortion training, and discerning what a school offers isn’t always easy. Because few medical students enter school contemplating being abortion pro-viders, many don’t know until they get on campus that their options may be curtailed. Those few students who are forward-thinking enough could look for institutions that have family planning fellowships on campus and post-residency training. Those programs could indicate that the school has allies to help students get training during medical school, even if it’s not part of the standard curriculum, Pyle says.
The Espey survey found that regional culture affects medical education, and training is difficult in states where there are few or no providers. South Dakota has only one clinic, administered by Planned Parenthood in Minnesota. The doctor flies in from Minnesota, making hours available for training extremely limited.
Medical schools are certainly not above the efforts of protesters, either. At least one Midwestern medical school campus was picketed with six-foot photos of aborted fetuses. No other topic has the potential to expose students to a gauntlet of picketers that requires them, says Backus, to “be more committed and thick-skinned.” For others, says Dr. Beth Jordan, medical director of the Association of Reproductive Health Professionals, obstacles make students more galvanized.
On the other end of the spectrum, notes Jordan, there are institutions like the University of California, San Francisco (UCSF), which has, she says, a “liberal, great crowd where they place women’s health first and foremost” and which provides many training opportunities.
One major barrier to direct clinical training, Backus says, is that most students coming from a “hostile” insti-tution can’t get malpractice insurance to cover their presence at a clinic. There are other roadblocks. Some state schools are under edicts from the state legislature prohibiting them from providing training at their facilities.
In some schools, abortion training is prohibited by the board of directors and faculty members. In some cases, students opposed to the training have been able to change the curriculum. UAB, at one point, had a one-hour lecture on abortion as part of the standard preclinical curriculum, Pyle says, but a handful of students expressed their opposition, and the school opted to remove the lecture rather than spark controversy.
Still, Backus says, interested medical students can sometimes change the curriculum, even in hostile school environments if they “make a very professional case for the need for that information.”
Pyle attends school with students who protest at abortion clinics, but she notes that she can still collaborate and be friendly with groups like Medical Students for Life to discuss the importance of contraception and other areas of common ground. “I’m glad they were willing to talk with me about their views, and I’m really glad they were willing to listen to me on mine.”
Murphy’s OB rotation happened to be at a Catholic hospital, but most of the attendings were supportive of him seeking abortion training at an outside clinic. Much abortion training occurs at places like Planned Parenthood, in private settings and at stand-alone clinics, making it the only medical procedure that is forced outside of an academic setting and giving it a clandestine tinge. But, says Jordan, “Just because it’s not offered at a medical school doesn’t mean that it’s underground. It means that it’s harder and there are more obstacles.”
Pyle isn’t sure that she’ll get any abortion training at UAB. Her workaround has been to identify “safe allies” among the faculty and find out what’s in the existing curriculum that she can use. If it’s not there, she says, medical students have to create it, which is where groups like MS4C and Planned Parenthood come in, with lecturers and training experiences. “If we aren’t getting the education,” Pyle says, “we’re going to find it.”
MS4C has worked through its network to help medical students, even in places where training isn’t directly available. Every year it sends 80 to 100 students to reproductive health externships. Ideally, admits Backus, this training would be integrated into the normal curriculum, and MS4C would be obsolete.
Ultimately, believes Jordan, abortion training is about funding and politics. “We just need to make sure that it’s a priority for academic centers or medical schools to make sure training is available,” she says, “and that our legislators act with the best science and support legislation that doesn’t restrict women’s health choices in order to allow providers to keep making the best choices for women.”
Training in Residency
The Accreditation Council for Graduate Medical Education (ACGME) requires exposure to induced abortions as an essential component of the OB-Gyn residency with the caveat that “no program or resident with a reli-gious or moral objection shall be required to provide
training in or to perform induced abortions.” Regardless, no residents get off the hook from learning how to deal with complications of abortion. Residency programs with a religious, moral or legal restriction that prohi-bits residents from performing abortions within the institution must not, continues the ACGME, impede resi-dents “who do not have religious or moral objections from receiving education and experience in performing abortions at another institution.”
The Kenneth J. Ryan Residency Training Program in Abortion and Family Planning, started in 1999 and coordinated by the Bixby Center for Global and Women’s Reproductive Health at UCSF, is a key source of training and curriculum content for residents. Considering how long abortion has been legal in America, says Dr. Uta Landy, the founder and national director of the program, “it took us a very long time to pay attention to the fact that abortion was not properly integrated into medical education” for both students and residents. When abortion was legalized, the initial focus was on making it accessible, she notes, and it was a while before anyone started looking ahead to the future and sustainability, and realized that in order to ensure the “continuation of women’s health through safe legal abortions, it needed to be addressed in the context of medical education.”
There are more than 50 Ryan programs around the country, focused mainly on academic hospitals and OB-Gyn departments.
The program provides startup funding and technical support to medical schools so they can permanently integrate family planning training and research at their schools. Al-though the program is geared to residents, many medical students are exposed to training during rotations, notes Landy.
Beth Rogers is a freelance writer based in Bethesda, Maryland. Direct comments regarding this story to tnp@amsa.org.