State's med schools may become abortion hub

Experts say bans across US will cut training access

By: Lindy Washburn
NorthJersey.com
USA Today Network - New Jersey

..... In the wake of the recent U. S. Supreme Court decision overturning Roe v. Wade, patients who want abortions won't be the only ones affected by new state restrictions. Medical students who want to learn about abortion may also be hampered by the abortion bans adopted in many states.
..... And for medical-school graduates who want to specialize in OB-GYN, the decision could make medical-residency slots in states such as New Jersey - where abortion rights are protected - more competitive.
..... Even now, fewer than 70 positions are available each year in New Jersey's four-year OB-GYN residence programs. With 45% of such programs nationally in states that are certain or likely to ban abortions in light of the Supreme Court decision in Dobbs v. Jackson, competition for those slots is likely to intensify.
..... Some are worried that the pipeline from medical students to abortion providers will shrink - and fewer doctors will know how to do abortions, whether by medication or as an in-clinic procedure.
..... "I am really worried about training and how that will look," said Dr. Kristyn Brandi, a New Jersey abortion provider who testified last week [07/15/2022] before a U.S. Senate committee as national board chair of Physicians for Reproductive Health. "Half of the states will go dark - they won't be able to provide abortion care to patients.
..... "That means half of the [medical] residents or medical students in the country are not going to learn about abortion," she said. "They're never going to see one."

'Papaya workshop'

..... Abortion are discussed briefly as part of the curriculum in required and elective course in New Jersey medical schools. Third- and fourth-year students have clinical rotations in obstetrics and gynecology where they may observer abortions being performed. Residency programs in obstetrics and gynecology, as week as family medicine, often include stints at reproductive health centers and family planning clinics.
..... And a medical student's experience in New Jersey can include something called a "papaya workshop" hosted by chapters of Medical Students for Choice, a national group with members at several New Jersey med schools. The workshops are unofficial and voluntary. They involve a demonstration of abortion techniques with a tropical fruit.
..... It turns out that "a small papaya is a pretty good approximation of a uterus in early pregnancy," said Eshani Dixit, a former leader of the Rutgers Robert Wood Johnson Medical School chapter. "The stem would be what we approximate to be the cervical opening."
..... With a faculty member as an instructor, 30 to 40 Rutgers medical students gather at annual workshops on the New Brunswick campus to learn how to suction and curettage a uterus by practicing on papayas, said Dixit, who completed medical school this year. [2022] they also practice inserting an IUD, or intrauterine device, in the fruit.
..... Other students have volunteered to accompany patients to and from abortion procedures, observing the procedure while serving as supportive helpers, or "abortion doulas."
..... Talking with the patients was a vital counterpoint to her classroom instruction, said Ritka Tamarisa, who graduated from Rutgers New Jersey Medical School this year and began an OB_GYN residency in Illinois. "In medical school, you're taught so much medicine - all these pathologies," she said. "You forget that patients have lives and families, struggles and hardships."
..... She recalled one women who was in the second trimester of a desired pregnancy and had learned that the fetus had a fatal defect. Tamarisa held the patient's hand and talked with her in the preoperative holding area and as they wheeled her into the operation room - a cold and noisy space that was intimidating to the patient, she said.
..... "I always carried a Kleenex in my pocket," Tamarisa said. "I could pull it out discreetly and hand it to them, let them know, 'It's OK if you want to cry. This is a safe space for crying.' "
..... Tamarisa, who grew up in Arizona, and Dixit, who grew up in New Jersey, both want to be abortion providers. Tanarisa chose her residency program based on whether it would include abortion training, and Dixit is choosing where to apply for residency based on the legal status of abortion in the states where the program are located.

Impact on obstetric care

..... In states where abortion is now banned or likely to be, OB-GYNs and family practice physicians are unlikely to get clinical practice in induced abortion. Abortion may not even be discussed as an option for women with an unwanted pregnancy.
..... The American College of Obstetrics and Gynecology recommends sue of the terms "abortion" or Induced abortion" rather then "elective abortion" or "abortion on demand" to avoid implying a judgment about the motivation or medical need of the patient. It uses the terms "spontaneous abortion," "Miscarriage" and "early pregnancy loss" interchange-ably.
..... A study published earlier this year [2022] predicted :dramatic implications for obstetrics and gynecology residency training" in states that would restrict abortion if Roe v. Wade were overturn. Of 286 accredited obstetrics and gynecology residency programs with current residents, 45% are in states certain or likely to ban abortion, the researchers from UCLA and the University of California at San Francisco Medical School found. As a result, 2,638 of the 6,007 current obstetrics and gynecology residents would be certain or likely to lack access to in-state abortion training, the researchers wrote.
..... Medical residents tend to practice in the states where they trained. Some experts warn of a gap developing between states where abortion is permitted and those where it is not, when it comes to the level of obstetric care. Physicians who want to specialize in management of high-risk pregnancies, for example, might be more inclined to practice in states where pregnancy terminations would be unlikely in education about abortion could an impact beyond the students who plan to become OB-GYNs or family medicine specialists, abortion rights advocates warn.
..... "Every single medical student should be able to articulate medically accurate information about abortion and family planning," said Pamela Merritt, executive director of Medical Students for Choice. "It's very important for doctors in every single branch of medicine to be knowledgeable in this area."

'Fear mongering'

..... But physicians who oppose abortion, including some who practice obstetrics and gynecology, say these warning are exaggerated.
..... At the hearing where Brandi, the New Jersey abortion provider, testified last week, [07/12/2022] Senator Roger Marshall, A Kansas Republican who said he had delivered 5,000 babies during a 25-eyar career as an OB-GYN, accused abortion rights advocates of "fear mongering."
..... Even in the wake of the Dobbs decision, "Women with miscarriages and topic pregnancies will be treated in every state without exceptions," he said. Doctors will know how to perform emergency abortions - which are allowed by law - whenever a pregnant women's life is at risk. "Life of the mom will continue to be honored, and Plan B remains over the counter," Marchall said.
..... OB-GYN residents in programs where induced abortion are not performed don't miss out on learning required skills, Dr. Johnny Voltz, a former board member of Conscience in residency, said in an interview. The nonprofit group helps medical students match with suitable residency programs when they want to avoid situations where they would be required to perform abortions or tubal ligations or prescribe birth control.
..... "In the vast majority of situations, the training for an elective abortion vs. a miscarriage or spontaneous abortion will be the same," said Voltz, who completed his residency at a Catholic hospital this year [2022] and began practicing in Louisiana.
..... OB-GYN residents and Family practice resident learn how to empty the uterus of tissue by dilation and evacuation (D&E) or dilation and curettage *D&C) - the same procedures sued for induced abortion - by treating patients who have miscarriage. They learn to prescribe medication that accomplishes the same thing, if the miscarriage occurs in the first 10 weeks of a pregnancy. He and other residents were able to fulfill their certification requirements as OB-GYNs easily at his Catholic hospital, Voltz said. "We got our numbers for abortion by treating miscarriages," he said.

Travel rotation to states with no bans

..... Routine abortion training has been required as part of residency programs for OB-GYNs by the Accreditation Council for Graduate medical Education since 1996, with an opt-out provision for those who have a moral objection. It's not clear yet what will happen to the accreditation of programs in states where bans or severe restrictions on abortion take effect.
..... One proposed solution is to establish travel rotations for residents to go to states where abortion access is protected fro that part of their training. But the logistics would be challenging for 2,600 people, or 44% of current residents.
..... In countries where abortion are illegal, training in how to do them safely has been conducted on ships anchored in international waters, said Merritt, of Medical Student for Choice. The group has chapters in 28 countries.
..... In the United States, the group provides opportunities for medical students to shadow abortion providers and observe abortion care in clinical settings outside their home institutions - and offsets travel expenses, if necessary. It also holds abortion training sessions, such as the papaya workshops, where students learn without actual patients.
..... New Jersey has spots for fewer than 70 applicants a year at the 15 hospitals with OB-GYN residencies, according to a database maintained by the American Medical Association. Nationally, there are more than 50 applicants for each OB-GYN residency slot. The already intense competition may increase as prospective specialists turn away from states with abortion bans.
..... New Jersey has taken steps to ensure abortion access for patients who can't get care elsewhere. The Legislature codified the right to an abortion in state law and enacted measures that bar extradition of patients or providers to states where abortion is criminalized, and that prohibit prosecutors from cooperating with out-of-state investigations for that purpose.
..... But little effort has been made so far to enable providers form abortion-restricted states to learn her about abortion and the related counseling and follow-up care.
..... Will the state's residency programs - six of them associated with the state university - expand to meet the potential need? That may depend on federal funding through Medicare and Medicaid. A spokesman for Rutgers said no one was available to speak about the programs.
..... As advocates of abortion rights focus on the immediate needs of patients from states with restrictive laws, the long-term need for physicians education in abortion care can't be ignored, some argue. "If you don't have abortion providers," said Merritt, "then you don't have abortion access."

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