Fourth-year medical student Mackenzie Bennett was on a conference call when news broke that Roe v Wade had been overturned. The topic was telehealth and medication abortion.
“We stopped the meeting, we just had to log off and sit in those feelings for a minute. It was honestly really devastating,” says Bennett, who is pursuing dual medical and public health degrees specializing in OB-GYN at Emory School of Medicine in Atlanta.
In coming weeks, Georgia will probably ban most abortions after six weeks. For students like Bennett pursuing their medical education in states poised to ban abortion services, the ruling impacts not just the training they will receive, it leaves them grappling with the personal, moral and practical challenges of a common (and sometimes, life-saving) healthcare procedure becoming criminalized. Clinical training opportunities for providing abortions are already limited in the US – typically, students who want that training have to seek it out. In the wake of Roe’s overturning, those opportunities will become even more limited, forcing some students to travel out of state to seek out full-spectrum training, potentially prompting an exodus of medical students from the states banning abortion services.
The medical institutions they attend are left wondering how their OB-GYN programs will be able to give students the required clinical training to maintain their accreditation. That clinical experience involves observation of, and hands-on training in, uterine evacuation procedures, including medication abortion, first-trimester aspiration abortion, and dilation and evacuation (D&E) – procedures used not just for induced abortions, but also for miscarriage management and other aspects of reproductive healthcare.
“If we can’t show that we’re providing enough of an experience for them to gain competency in that area, then that threatens the accreditation of any program that’s meeting that challenge,” says Dr Carrie Cwiak, an Emory professor of obstetrics and gynecology, and director of the medical school’s family planning division. “That’s what we’re potentially concerned about.”
Some of Bennett’s classmates have raised concerns about the what-ifs: what happens if an ectopic pregnancy rolls into the emergency department? What does this mean for cancer treatment? “It has implications for everyone’s practice and everyone’s personal life,” says Bennett, who is a member of Medical Students for Choice. “I think people are realizing that this impacts them no matter what specialty they’re pursuing. It’s incredibly far-reaching.”
Medical students are weighing implications of Roe’s reversal on both professional and personal levels. “As someone who has a uterus and can get pregnant, this will affect me personally,” says Laura Rush, a second-year student at a different medical school in Georgia (the school did not want students giving its name). “But also as future physicians, potentially OBs, who want to treat our patients with empathy and using evidence-based medicine, it feels like it’s disregarding a lot of that.”
Sachi Shastri, a second-year student at the same school, is considering a career in either OB-GYN or psychiatry. She says that the news, while not a surprise, was still shocking – as is the sense that her future career could be in jeopardy. “I don’t think I let myself believe that this future was so close and so present.”
She says peers at her school who previously never expressed opinions about abortions are now speaking up. Rush adds that in the wake of the supreme court ruling, there was an increase in signups for her campus’s chapter of Medical Students for Choice.
There is only one accrediting body for OB-GYN residency training in the US, The Accreditation Council for Graduate Medical Education (ACGME). In response to the supreme court decision, ACGME is proposing possible changes to its rules for OB-GYN programs: in states where laws prevent students from receiving clinical experience, programs will have to provide students access to training in a state that does. (Students with religious or moral objections can opt out.) While some medical students – OB-track or otherwise – seek out elective travel rotations already as a way to broaden their experience, Cwiak points out that abortion bans could make these travel rotations mandatory – a financial and logistical burden for some students.
Cwiak says when it comes to abortion education lectures won’t change, and educators might increasingly incorporate simulations with models. “In medical education, we need to ensure that people have direct observation of the care we provide, and participation in that care, under supervision,” says Cwiak. “Especially when you’re talking about procedures: you have to develop a skill, and confidence in that skill, and make sure you’ve done enough cases to learn that skill adequately.”
To learn those skills, some students are limiting their residency options to states where abortion is legally protected. “I think that’s a large undertone of the conversations I’m having with other medical students, especially ones that are in their last year like me, as we’re applying for residency,” Bennett says. “This has a major impact on where you can get trained, and what kind of training you can get.” And, by extension, where medical trainees choose to eventually practice.
Others are concerned that the training they have already lined up in restricted states will no longer be available to them. “I’ve got a rotation lined up in reproductive health [in Georgia] where I would get that training on doing medical abortions, and I’m worried that I won’t be able to get the training I want,” says Ben Haseen, a medical student at Atlanta’s Morehouse School of Medicine. Haseen adds that, as a transgender man, access to reproductive care is a personal issue, not just a professional one. “It’s a big deal for me, because medical access is my biggest passion,” he says.
“With the restrictive laws, you likely will see a behavioral change, that people will make decisions about where they choose to train, where they choose to practice, depending on the legislative landscape [in that state],” explains Cwiak. “If states and their legislations are interfering with your ability to practice safe, effective, ethical healthcare, like abortion care, you could understand that people would be reticent about training and practicing there.”
It’s an ethical dilemma for some trainees: leave their state to seek out the training they want, or stay and try to train and practice within the legislative confines of their state. “I’m very conflicted because I do not want to leave the south,” says Haseen. “I love being in the south because I love the patients here. I’m at this crossroads where I could get training up north and then come back, but I also don’t want to leave my patients here and abandon them.”
With over half the country’s states likely to ban or severely restrict abortion, students and educators alike are also concerned that an exodus of providers from these states, will further compound healthcare disparities and worsen existing public health crises. (Data show that states with abortion restrictions have higher maternal mortality rates. In Georgia, half of the state’s counties lack a single OB-GYN provider, and maternal mortality rates are among the worst in the country.)
The people who live in these states “still deserve an excellent quality of care and excellent doctors with world-class training, just like everywhere else in the country”, says Bennett. “But if people feel like they can’t get a full education here, they’re not going to want to come here, and that just makes everything worse down the line.”