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The Choices We Have

Lauren

The choices we have depend on our ability to take advantage of them, and this is particularly important when it comes to reproductive choice. Frankly, a lack of doctors willing and able to perform the procedure will render the right to abortion meaningless. WaPo follows one medical student’s journey and just how difficult it is to get training.

She had joined Medical Students for Choice, an abortion education group with chapters on 135 U.S. campuses, as soon as she arrived at Maryland. The nation’s abortion doctors were graying, and unless a new generation took their place, the right to abortion might be rendered meaningless. Lesley imagined herself being part of that new generation. But would her support for abortion translate into action?

“I won’t know until I’m faced with doing it, but I think I would absolutely be able to provide [abortions],” she said. “It’s walk the walk, instead of talk the talk. I want my actions to be consistent with my words.”

How medical students choose to become abortion providers is in some ways no different from how they choose to become cardiac surgeons or pediatric neurologists. They explore the specialty and test themselves in it, finding some connection to a patient or a mentor that ignites their passion. Except for one difference: Medical students must explore abortion largely on their own.

Thirty-five years after the U.S. Supreme Court legalized abortion in Roe v. Wade, any mention of abortion is rare in the first three or four years of medical school, when students must zero in on a specialty and eventually apply for residency training. Even in Maryland, where about 61 percent of voters approved a referendum guaranteeing abortion in 1992 and which has the fourth-highest abortion rate in the country, abortion is not taught in any formal lectures at the state’s flagship medical school. The subject is viewed as too controversial, despite the fact that, according to the nonprofit National Center for Health Statistics, abortion remains among the most common surgical procedures for reproductive-age women. Nevertheless, many people, including some of Lesley’s friends, believe abortion is the murder of an unborn child and should not be legal, much less taught to future doctors.

Suggested Reading:
Is there a doctor in the house?
Medical Students For Choice

33 thoughts on The Choices We Have

  1. This is really interesting. I wonder how many lectures are devoted to vasectomy?

    It shocks and saddens me that “moral” stances against abortion have translated into effective stances against protecting the health and lives of women. No one would let an untrained doctor to do even the most basic procedure, yet the medical system does not prepare doctors to perform this sensitive, challenging, and invasive procedure.

  2. As a nurse, I agree that there are many med students out there who are not comfortable performing abortions for religious reasons, however, I don’t think it’s the controversy that keep the majority of them away. They’re staying away for financial reasons. Specialiaties mentioned in the above narrative are very lucritive and hard to pass up, given that the average med student can owe as much as $300K in student loans when they’re finish. Not to mention high malpractice insurance too. So for them, abortion procedures that cost around $700 don’t pay well as well open heart surgery for $100K or a multi-organ transplants, which can cost around $600K (that price doesn’t include the cost of
    all the medicines the patient has to take – $22K).

    Come to think of it, you can’t get a bone set for the price of an abortion procedure.

  5. ThickRedGlasses, it was something OBGYNs would learn how to do until about six years ago when christianist med students challenged that being taught a procedure they objected to was a violation of their religious freedom. Since then it’s been an elective study. I’m pretty sure there’s an article about it on this very site somewhere.

  6. I work at the Medical Students for Choice National Office. I can tell you that very few ob/gyn residency programs offer abortion training. Unless the hospital in which a residency takes place performs abortions, residency programs tend not include training. Most abortions take place in private clinics, not hospitals – so if a resident wants to learn how to perform abortions, many times they have to arrange for training on their own. Medical Students for Choice facilitates such training through the Reproductive Health Externship Program, which helps match medical students and residents with an abortion provider for first hand training and offers a travel stipend while they train.

    And a note to Maureen – most med students and residents don’t learn much about vasectomies, either. Or contraception. The majority of medical students spend more time learning about Viagra than all forms of contraception combined. MSFC just held its Annual Meeting about 10 days ago – it drew over 500 medical students, all to learn about the stuff they don’t get in school: contraception, pregnancy options and fetal anomalies counseling, abortion, and other topics. The conference includes hands-on skills workshops, as well – this year there were sessions on Implanon insertion, Manual Vacuum Aspiration (used in both first trimester abortions and post-miscarriage management), and the No Scalpel Vasectomy procedure.

    The lack of abortion providers is a very real problem that is threatening women’s health care. MSFC is working to increase the number of providers and improve reproductive health care. I’m proud to work there and support their mission!

  7. I guess that explains why the BEST medical library for reproductive health in Philadelphia resides at the Planned Parenthood @ 11th & Locust and not at one of the many fine medical school libraries in town.

  8. Nicole – do you have more details about that learning more about Viagra than contraception claim? Or can you tell me where to look (textbooks, syllabi)?
    I want to be able to use this information with the stupid people. Thanks in advance.

  9. I was at that Med Students for Choice conference!

    I want to mention a few points about the story. The tool that is described, the tenaculum, is used for other procedures, too, such as IUD insertion. And, the procedure for an early abortion, a D & C, is necessary for other indications, such as a retained placenta or an incomplete abortion (a miscarriage that does not pass on its own.) Politicizing and refusing to do the procedure not only makes someone a poor ob/gyn, practically, but also insults women who need to have them done.

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  11. Bleh – that statistic is a result of a curriculum mapping project performed by MSFC a few years ago. The results of the study are in the process of being published, but you can see the survey students were asked to complete here. MSFC is also planning a followup study over the next year to see how and where curriculum has improved since the last study.

  12. Let me clear up some misconceptions here:

    1) The vast majority of medical schools offer elective abortion experiences to med students, usually via Planned Parenthood or private clinics which provide abortions.

    2) Abortion training is not, and should NOT be mandatory for medical school. There is no mandatory training for any particular type of surgery.

    3) 95% of OB/GYN residency programs also offer elective abortion training. I think this is totally appropriate. I’m flat out opposed to making the training mandatory, as NARAL is pushing for.

    4) To say that med students learn more about Viagra than contraception is a load of BS. Every medical school has some curriculum on contraceptives. Viagra is covered only in the sense of using it as a vasodilator for things like pulmonary hypertension. Its not studied in the context of erectile dysfunction in the medical school setting.

    5) I’ve got no problem with med schools and OB/GYN residency programs being required to provide elective abortion training for those who want to receive it. It should be a part of the accreditation process. But I will fight to make sure that it never moves into mandatory training as NARAL and other groups are pushing for.

    6) I support measures to block any harassment/intimidation of abortion providers. If you want to increase the # of abortion providers, this is the best way to proceed.

  13. I’ve long held that the threat of violence against abortion providers (a threat that, from anecdotal evidence, is brushed off by many in the law-enforcement community) is something that is itself being used to deny women the access to the abortion choice.

    If there are no practicioners available, no medical procedure, however allowable under law it may be, will be performed.

    As for Ob-Gyn doc, I’d wait on the publication of the curriculum survey before I’d characterize it as BS.

    Medical surgical abortions are a life-saving procedure, and need to be as mandatory as any other procedure for those training to be doctors.

    If you are unwilling to put the welfare of the patient against the mental reservations you have about a procedure you should not be training as a doctor at all. Stay as an LPN or an NP, and avoid the responsibility.

    To say that you, as a doctor in a specialty that would require the performance of a life-saving procedure for a patient should be given a “pass” on that procedure being taught is absurd, as is the situation where the medical school itself has to pass the responsibility of the training to an outside entity.

    The attitude that says “I don’t wanna!”in regards to a medical student not even getting familiarization via *lecture* is akin to the attitude from those druggists who claim that *they* can refuse to provide medications that have been properly prescribed because *they* want to say “I don’t wanna!” And It looks, from this side of the screen, that it’s for the same reason — a concerted effort to provide the choice to competent women to make informed and effective decisions about their own reproductive health and choices.

  14. I’ve long held that the threat of violence against abortion providers (a threat that, from anecdotal evidence, is brushed off by many in the law-enforcement community) is something that is itself being used to deny women the access to the abortion choice.

    Yes, and this is where the efforts should be focused to increase the # of abortion providers, not making the training mandatory.

    As for Ob-Gyn doc, I’d wait on the publication of the curriculum survey before I’d characterize it as BS.

    The claim is that Viagra has more exposure in med school curricula than contraception does. Thats absolutely, unequivocably false. I’ve been involved in curriculum at 3 different medical schools, and I’m familiar with how other medical schools work as well. Its an outrageous lie.


    Medical surgical abortions are a life-saving procedure, and need to be as mandatory as any other procedure for those training to be doctors.

    Med schools should be required to offer it as an elective, but it should NOT be mandatory training. I provide emergency abortion services, about once per month at the busiest academic medical center on the east coast. I dont provide elective abortion services. For pregnancies that threaten a woman’s life/health in which abortion is medically warranted, there is adequate provider supply to meet demand. The problem is the elective abortion services where doctors get harrassed on a daily basis.

    While abortions are sometimes indicated for emergency reasons, thats not sufficient to make it mandatory training. The following are life saving procedures that are NOT mandatory training in medical school:

    1) Intubation
    2) Tracheostomy
    3) Appendectomy
    4) Thoracotomy
    5) Needle decompression thoracocentesis in treatment of tension pneumothorax
    6) Cricothyroidotomy
    7) Chest tube insertion
    8) Central line placement
    9) Some med schools dont even mandate ACLS training

    The list goes on and on. Now of course some of those things are picked up by med students, but NONE of them is required training to graduate.

    If you are unwilling to put the welfare of the patient against the mental reservations you have about a procedure you should not be training as a doctor at all. Stay as an LPN or an NP, and avoid the responsibility.

    WTF? You do realize that nursing is an entirely different profession from medicine, right? Why would somebody “stay” as a LPN/NP? Do you think thats how doctors start out as, nurses who change their mind and decide to get the MD instead?

    To say that you, as a doctor in a specialty that would require the performance of a life-saving procedure for a patient should be given a “pass” on that procedure being taught is absurd, as is the situation where the medical school itself has to pass the responsibility of the training to an outside entity.

    I’m not saying they should be given a pass. By all means require them to offer elective training. But making it MANDATORY for every single med student or every single OB/GYN, is absolutely absurd.

    BTW, I’ve worked at training programs where abortion training was mandatory (back in the 70s) and it was an unmitigated disaster. It pushes people further away from the specialty, the supply of abortion providers was unchanged, and women’s access to reproductive health services got worse. Exposing people to abortion training doesnt persuade people to do it. They either choose to do it or not, but making it mandatory wont do anything.. Like I said, if you want more providers, get rid of the harassment/intimidation factor. THATS the real problem.

    The attitude that says “I don’t wanna!”in regards to a medical student not even getting familiarization via *lecture*

    Is that what this is about, lectures? They’re practically useless for procedure teaching, regardless of whether its abortion or anything else. Mandatory lectures or abortion observation/training wont do anything to create more abortion providers. All it does is breed resentment and push people AWAY from the field. Contrary to popular opinion around here, the OB/GYN field is an umbrella with a lot of different models of care that dont require abortion training.

  15. I think med students objecting to abortion on religious grounds are being coddled way too much. If they don’t want to learn to provide medical care where doing so upsets their moral sensibilities, then as far as I’m concerned, they can do something else. A doctor’s job is to provide medical care, not to impose their religious or moral beliefs on patients. Abortion is an important component of women’s reproductive health, and for medical schools to avoid teaching it is toxic to women’s health.

  16. I would really like to see OBY/GYN DOC’s source for the information stated. It clearly doesn’t measure up with what medical students and residents are telling us.

  17. Oops –my bad. in the above screed:

    “a concerted effort to provide the choice to competent women to make informed and effective decisions about their own reproductive health and choices.”

    Should read:

    “a concerted effort to deny the choice to competent women to make informed and effective decisions about their own reproductive health and choices.”

  18. Nicole, OB/GYN DOC probably gets a lot of his resource material from the “Journal of Obstetrics and Gynecology” along with the JAMA, AMA, US Department of HHS (particularly the NIH and the CDC).

    Although the Accreditation Council for Graduate Medical Education (ACGME) requires medical schools to teach abortion procedures to OB/GYN residents, more than half of OB/GYN residency programs nationwide do not adhere to the requirement.

  19. “5) I’ve got no problem with med schools and OB/GYN residency programs being required to provide elective abortion training for those who want to receive it. It should be a part of the accreditation process. But I will fight to make sure that it never moves into mandatory training as NARAL and other groups are pushing for.”

    I’m curious: why? What do medical students stand to lose if abortion training is mandatory?

  20. “Exposing people to abortion training doesnt persuade people to do it.”

    Very true. It does, however, train them how to perform them. In the interest of women’s health, that in itself is significant. There could be a hundred protestors, but if the only three docs in town don’t *know* how to perform an abortion, then the shit’s still the same.

  21. You all do realize that if a woman miscarries, it’s a good idea for her to get a D&X to prevent her from going septic, right? You do realize that there are times (fetal death in the womb, incomplete miscarriage, polyp removal, etc) when these procedures are not only thecompassionate way to go, but better for the woman’s health? Here’s a handy-dandy booklet in PDF form to outline just why D&X/D&C procedures are often necessary. And if, in the course of your work as an OBGYN they are necessary to do, you should damn well know how to do them.

    Oh, wait. The people whose health is affected are women, so they don’t count. Sorry. I keep forgetting.

  22. We live in an insane society when it comes to health care. Is it even remotely surprising that reproductive health care is being ruined too?

  24. I actually think it makes sense to allow med students to opt out of performing abortions — it is a difficult moral issue for a lot of people, and I don’t think anyone should be compelled to do it.

    That said, it should be offered alongside all of the other standard ob/gyn curriculum, and students should have the chance to opt out of actual abortion procedures (they should still be taught how to perform emergency D&C and D&X procedures for the reasons Sheelzebub states).

    The point isn’t to “persuade” people to become abortion providers. The point is that medical school is supposed to train doctors to do their jobs. Not every doctor needs to be trained in every single procedure, but they should probably be trained in the procedures that are common and important in their field. It’s ridiculous that doctors have to go to outside, special settings in order to receive training for one of the most common surgical procedures.

  25. Isn’t it currently mandatory to learn how to perform circumcision? And to have to prove your proficiency by performing one? I’ve seen this become a tricky moral issue for feminist med students. Do we, in the US, have a history of educating in a pro-moral, rather than a pro-ethical manner?

  27. Isn’t it currently mandatory to learn how to perform circumcision?

    No, its not. Like I said before, there is no mandatory procedure training in med school. Thats true for abortions, its true for intubations, its true for vasectomies, etc

  28. And if, in the course of your work as an OBGYN they are necessary to do, you should damn well know how to do them.

    I already stated that I do in fact perform emergency abortions. I just dont offer electives.

    Mandating training does not equal competence and it wont improve access to abortions either. Under your model, you will have a bunch of resentful OB/GYNs who were forced to observe/perform a few abortions during training. What will inevitably happen is that they wont perform those services once they are in the workforce. EMTALA laws dont require the provision of services in the context of incompetent providers, so when a 25 weeker with PPROM and chorio presents to the ER and the OB/GYN docs on staff havent done an abortion for the last 20 years, guess what happens. They ship the patient to an outside hospital like mine where I do the abortion.

    Its the same deal for all procedures. An ER doc who has not done a thoracotomy in 10 years is not required by EMTALA to provide such a service, even if the life of the patient is in jeapordy. It requires the HOSPITAL to provide such services, but it gives exceptions for docs who are insufficiently trained/experienced to do it themselves.

    Mandating abortion training will reduce the whole pool of OB/GYNs, meaning less surgeons in gyn-onc to remove a cancerous ovary or uterus for example. Like I said, OB/GYN is an umbrella term for a bunch of different subspecialties in which you can be a competent practitioner without ever actually doing an abortion.

    I’d much rather the emergency abortion patients be sent my way rather than be subjected to a rural OB/GYN whose last abortion was 20 years ago as part of their “mandatory” abortion training. The care for women is BETTER when they have experienced people doing the work. Mandating the training wont alter that.

  29. Very true. It does, however, train them how to perform them. In the interest of women’s health, that in itself is significant. There could be a hundred protestors, but if the only three docs in town don’t *know* how to perform an abortion, then the shit’s still the same.

    Its not that significant when you actually get down in the trenches of the real world instead of theorizing in a forum. Here’s the scenario:

    1) OB/GYN docs in a given geographical area have never done an abortion before, they get requests for both emergency and elective abortions.

    2) OB/GYN docs went thru “mandatory” training in med school/residency. However, they still wont offer elective services, and they arent competent enough to provide emergency services, therefore they refer all the emergencies out to a tertiary academic medical center like mine, where I do them.

    3) OB/GYN docs went thru mandatory training, and they decide to offer elective/emergency abortions as part of their career, THAT THEY OTHERWISE WOULD NOT HAVE DONE WITHOUT THE MANDATORY TRAINING. They dont have to refer patients out, and women have better access to reproductive services in general.

    I submit to you that scenario #3 is so rare as to be a pipe dream, and that comes from 30+ years experience in both rural OB/GYN clinics and major academic medical centers. Either people desire to offer abortion services, or they dont. Mandatory training wont change anything.

    There are 2 main reasons why docs dont offer abortions:

    1) Moral opposition
    2) Too much associated baggage with the field (i.e. intimidation)

    You’re never going to get group #1 to offer abortions, regardless of whether you make the training mandatory or not. They wont be required to do emergency abortions either, because they dont do them on a regular basis and arent required by EMTALA laws to offer services for which they are not experienced/competent enough to provide.

    Instead of using a blunt instrument like mandatory training that WONT SOLVE THE PROBLEM AND WILL DECREASE THE NUMBER OF PEOPLE GOING INTO THE OB/GYN FIELD, we should work on the real problem which is intimidation. Unlike mandatory training, eliminating harassment/intimindation WILL BRING A LOT OF OB/GYN AND OTHER DOCS OUT OF THE WOODWORK to provide abortions.

  30. Tim: maybe. But it’s hard to ruin what was only adequate and short lived in the first place. And even if it was adequate (to the male perspective?) during the 80’s and 90’s, it doesn’t mean that it wasn’t under constant threat and bullying (which is why we are where we are right now).

    I’m not really arguing with you! Just bitter. 🙂

  32. Like I said before, there is no mandatory procedure training in med school.

    Am I the only one who was scared by that statement? There is NO mandatory procedure training in med school?! Then what the hell are they learning??

    I’m gonna start asking my docs a hellova lot more questions before they touch my body. The first being, “Have you ever done this before???”

  33. Oh, and OB/GYN Doc,

    Stopping harassment and mandating training are not two mutually exclusive remedies. As lawyers, we work to make more laws to help stop harassment. We also depend on doctors to push for more mandatory training. It’s not like it’s an either/or proposition.

    Plus, you seriously are scaring me about the under-training of doctors.

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