Future of abortion training for medical residents is bleak

In 2021, Dr. Mallika Govindan, a primary care physician at the Mount Sinai Health System, received some disappointing news. Although she had pursued a career in medicine to become an abortion counselor — and opted for a residency in New York City, where she believed she would receive the best education — she would not be able to learn how to provide abortion care locally. Due to pandemic precautions, Planned Parenthood New York City, which trains many medical residents, had to scale back its abortion training program.

Govindan has spent months researching other options and applying for scholarships. In February 2022, she traveled to Chicago for 12 days of abortion training with a non-profit reproductive health organization.

It was hard for Govindan to get abortion training, but in Chicago she kept hearing murmurs that it might soon be even harder for medical assistants like her. The abortion providers who mentored her said training residents could become more challenging if: Roe v. Wade were overthrown; As clinics in places like Chicago expand their capacity to meet the rising demand for abortion care from people traveling from states where the procedure is banned, they may decide to stop educating out-of-state residents to handle the influx of patients. to catch.

Govindan worries that making abortion training even less accessible to doctors will make it much more difficult for people to get good care. “There is such a shortage of doctors and health care providers as a whole,” she says. “The [number] who are willing to do so is even smaller.”

Abortion training for medical residents is already a logistical nightmare in the U.S. Ob-gyn residencies are required by the Accreditation Council for Graduate Medical Education (ACGME) to offer abortion training in order to become accredited, although residents can opt-out if they wish. Training usually consists of a rotation of weeks or months at a local abortion clinic or hospital. But these sites are scarce. Nearly 90% of U.S. counties currently do not have a clinic that provides abortion care – meaning existing clinics are likely to be overrun with patients and interns as well as Roe v. Wade is tipped over. According to an article published by the American College of Obstetricians and Gynecologists (ACOG) in April, nearly 44% of current ob-gyn residents in the U.S. train in states that are certain or likely to ban abortion. Roe v. Wade be withdrawn.

In a statement, an ACGME spokesperson said the organization is preparing for the Supreme Court’s decision. “When it becomes illegal in some states to conduct aspects of family planning, the ACGME is exploring alternative avenues to complete this training. At this time, the ACGME requirements remain the same” – including that all ACGME-accredited midwifery programs must have a family planning curriculum and “experiential training in the complications of abortion and the opportunity for direct procedural training in pregnancy terminations.” Access to induced abortion experience should be part of the curriculum to ensure that junior doctors have the opportunity to gain the experience needed to meet all of their patients’ needs.” Programs that restrict abortions or other family planning services “must ensure that such training for residents takes place in another institution.”

Being a midwife in a state like Utah is already difficult, says Dr. David Turok, an associate professor in the Department of Obstetrics and Gynecology at the University of Utah and chief of the family planning department. A state law enacted in 2017 requires doctors to tell their abortion patients several lies that are not backed up by science, Turok says, including a requirement to say the abortion drug mifepristone is reversible. Providers are also required by law to give patients painkillers – for the fetus – 20 weeks or more into a pregnancy, which doctors say is scientifically unfounded. But the looming abortion restrictions as: Roe v. Wade would end up “on a whole different level,” Turok says.

Turok is already planning to send its ob-gyn residents to other states for training should Utah ban abortions, which is expected to happen immediately after. roe is tipped over. Another option could be simulated procedures, such as practicing techniques on a dummy, which are common in residency programs. However, he fears it won’t be good enough. “By limiting care and limiting training, you are essentially compromising the quality of care,” he says. “I’m not worried; I’m scared.”

There are signs that abortion training in the US is already inadequate, especially for first-trimester abortions. According to research published in 2018 in the American Journal of Obstetrics and Gynecology, only 71% of residency directors who responded to a survey found their ob-gyn graduates adept at an abortion procedure common early in pregnancy called first-trimester aspiration, and only 66% felt that the residents were adequately trained in drug abortion. Only 22% of directors thought their ob-gyn graduates were proficient in other abortion techniques, including dilation and aspiration, which are commonly used in the second trimester.

That lack of knowledge may be partly due to access issues. In some ob-gyn programs, residents are responsible for fitting the training into their schedule themselves, which can be tricky, while others face restrictions in their hospitals that limit where and how the procedure is performed, according to ACOG. Many religiously affiliated hospitals do not offer abortion services at all.

dr. Debra Stulberg is president of family medicine at the University of Chicago and director of education at Midwest Access Project (MAP), a nonprofit reproductive health care organization that helps residents, including Govindan, receive abortion training. She says MAP gets a lot of questions from residents of religious hospitals, as well as residents in specialties whose programs don’t always offer a lot of abortion training, but who may need it just as much as a midwife. General practitioners in particular are major providers of abortions in the US, especially in deprived rural areas, but often do not receive the proper training. “Even if they have [the] opportunities,” says Stulberg, “maybe they’re only in a clinic for a few days and not enough to really develop the competence they need.”

To supplement their education, many such residents eventually have to travel to other states. But that won’t solve the drastic educational shortfall that could arise if abortion suddenly becomes illegal in many states, says Dr. Kavita Vinekar, a gynecologist who specializes in complex family planning and co-author of the ACOG Commentary. †[It] not feasible on this scale,” she says. “The reality is that we will never be able to move nearly 44% of our residents away from their home facilities, away from hospitals that rely entirely on residents to function, to receive the necessary training. She and her co-authors suggest that residency programs should instead reinforce miscarriage training, which overlaps with abortion training, and include simulations to help make up for this deficit.

Finances are another obstacle to residency programs that hire or lose residents to travel. A hospital’s college graduate medical education budget, which is paid through Medicare, does not travel with the resident, so new funds must be found to pay their salary during the portion of the family planning rotation that includes abortion training, which may take several weeks. take time, says Dr. Laura MacIsaac, professor and associate director of Fellowship in Family Planning at the Icahn School of Medicine at Mount Sinai. “I have visiting residents who come to New York with that request, but we have so, so many requests, and we really can’t honor them all,” MacIsaac says.

Turok, of the University of Utah, worries that states that ban abortion won’t be as attractive for ob-gyns to learn or eventually practice. States likely to ban abortion in case roe “Don’t realize they’re digging a big hole in the quality of medical care they’ll be able to provide and the people they’ll be able to train and retain in their country,” Turok said. “What healthcare provider wants to practice in a state where they cannot provide the full range of services to their patients?”

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