How Ob/Gyn Programs Provide Abortion Training Post Dobbs

When the US Supreme Court overturned Roe v. Wade abortion rights last year, residency programs and ob/gyn residents in states that ban or restrict abortions began scrambling to find alternative training sites to fulfill required clinical rotations in the procedure.

The Accreditation Council for Graduate Medical Education requires ob/gyn residents ― unless they have a religious or moral exemption ― to undergo abortion training to complete their programs. In states with bans or restrictions on family planning services or abortions, resident training must be received at institutions that are out of state.

Some residency programs are just beginning to coordinate out-of-state training, while others are further along in their offerings. There's no formal matching process, and it remains unclear who will cover the costs of residents training elsewhere for a month.

These uncertainties, along with lack of coordination about malpractice, clinical rotations, and limited faculty, leave some program directors skeptical they'll be able to keep up with demand for out-of-state slots. They are also wary of harming their own residents' educational and clinical opportunities.

A third-year ob/gyn resident, who didn't want to give her name or residency program for fear of backlash against her home institution, told Medscape Medical News that the Catholic-affiliated site is trying to avoid drawing attention to its minimal abortion training in a restrictive Midwest state. She knew after the Supreme Court's decision in Dobbs v. Jackson she'd have to look outside the program for more complex abortion training.

While she could learn dilation and curettage or other first trimester or early second trimester procedures at the Midwest program, she said she couldn't learn dilation and evacuation.

A mentor at her program connected her with a residency program at the University of New Mexico (UNM), where she recently started a 5-week family planning rotation. She is the first out-of-state resident hosted by UNM. Currently, UNM has six ob/gyn residents per class year, for a total of 36, and six family planning fellows.

The ob/gyn resident is staying with a friend at no cost, and her home institution still pays her salary. But she still must pay the mortgage on a home she can't live in while away and misses being part of a community where she's built a life over the past 2 years.

"There's a part of you that's just angry that you can't do this for the women...in your state," she said. "Unfortunately, there isn't a formalized program for ob/gyn residents interested in more advanced training to be matched with a program that has the ability to offer that training. It's very much a word-of-mouth and who-you-know situation. For people without those connections, it can be difficult to obtain this training unless they are interested in a formal fellowship."

This year, about 1500 ob/gyn residents matched into 280 residency programs, according to the National Residency Matching Program.

Alyssa Colwill, MD, assistant professor of obstetrics and gynecology at Oregon Health and Science University's (OHSU's) School of Medicine and director of the ob/gyn Ryan Residency Program at OHSU, estimated that 1000 ob/gyn residents per year will seek out-of-state abortion training. The estimate is based on the number of residents in programs in states with restrictions.

The Ryan Program, which began in 1999, helps ob/gyn residency programs provide training in abortion and contraception care (family planning) as a required rotation.

Connecting Programs

Ryan-affiliated residencies have been helping connect programs in states with abortion bans and restrictions to programs in states with more liberal laws.

Twelve of the 100 Ryan programs sent residents out of state in the past academic year, and 15 will follow this year. More are expected soon, said Kristin Simonson, MA, director of programs and operations at the Ryan Residency Program, headquartered at the Bixby Center for Global Reproductive Health at the University of California, San Francisco.

Before the Dobbs decision, very few programs considered next steps to train ob/gyn residents if abortions became illegal, Simonson said. "I think a lot of people just kind of were waiting and seeing...and hoping that they wouldn't have to make any drastic plans. It was hard to motivate people to have a plan B ready to go," she said.

"Almost all of us working in this field had a really bad feeling," said Courtney G. Forbis, MD, UNM assistant ob/gyn professor and Ryan Residency director. She and colleagues began planning for the future months ahead of the court decision. But the program wasn't able to begin accepting out-of-state residents until now, she said. "We are trying to use this experience to see what we can accommodate in the future."

OHSU also began planning for alternative training when it learned of the leaked Supreme Court decision, Colwill said. "We decided that we had the bandwidth and opportunity to train more individuals that were going to lose access to services and educational opportunities," she said.

The university ran a 4-week test rotation last fall. So far, six residents and one fellow have come from out of the state, said Colwill. OHSU hopes to have 10 more in the coming year. The out-of-state learners will join 32 ob/gyn residents and 12 fellows who were already in the program, she said.

To ease residents' integration into an away program, the Ryan Program ― along with the American College of Obstetricians and Gynecologists (ACOG), the Council on Resident Education in Obstetrics and Gynecology, and Innovating Education in Reproductive Health ― recently began offering a free, web-based patient-centered abortion education curriculum .

The course supplements in-person clinical training in abortion care and prepares residents traveling and transitioning into another program to begin learning new skills on their first day, AnnaMarie Connolly, MD, ACOG's chief of education and academic affairs, said in a prepared statement.

Training Costs

Residents and their institutions also face additional costs. The home institution that loses a resident for a few weeks to a month has to determine how to cover the care not provided while they are away, Simonson said. Residents may incur expenses for transportation, housing, food, and other things while out of state.

OHSU covers transportation and housing through its abortion care and training fund, but there are other factors to consider, Colwill said. For example, the home and host programs have to coordinate licensing, malpractice, and line up rotation dates, she said.

Among other complications, UNM wasn't able to set up an agreement so that its new resident could participate in a rotation at Planned Parenthood. "We have the clinical volume to accommodate another learner," Forbis said. But the program has to balance resources, such as "trying to make sure we don't have one faculty [member] assigned to too many learners at one time," she said.

Given the logistic and financial challenges, programs may not be able to ensure that all residents who need abortion training receive it, said Simonson.

The Ryan Program, for instance, can't help the more than 100 residency programs in states where abortions are currently illegal, she said.

UNM is trying to partner with specific programs, such as in the state of Texas, where abortion is banned, to train its residents each year, Forbis said.

OHSU also will look for opportunities to train as many residents as possible, Colwill said, "but I don't think we'll ever be able to fill that gap of 1000 residents that need this training."

Alicia Ault is a Saint Petersburg, Florida–based freelance journalist whose work has appeared in publications including JAMA and Smithsonian.com. You can find her on Twitter @aliciaault.

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How Ob/Gyn Programs Provide Abortion Training Post Dobbs

Connecting Programs

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