Every year, more than 100 new obstetrician-gynecologists graduate from a residency program in Texas and enter the medical workforce. Theoretically, all of them have had the opportunity during the four years of residency to learn about "induced abortion" – so called to distinguish it from a miscarriage.
The second part of this series explores what Texas residencies are teaching instead of elective abortion, and why some doctors say that has to change.
But the closure of abortion clinics in Texas following the passage of the strict abortion regulation law HB2 – more than 20 since 2013 — has made that training increasingly difficult.
Texas has 18 residency programs in ob-gyn, but only one allowed me to observe how abortion is taught. Because of the political pressures facing abortion providers, I agreed not to reveal the doctors' full names or the clinic's location. (The resident agreed to be identified by her middle name, Jane.)
Although residents can opt out of abortion training for religious or moral reasons, Jane felt a professional obligation to learn the procedure.
"This is part of ob-gyn, it's not an optional part, per se," Jane said. "Women can choose if they want an abortion or not, but you as their doctor need to be able to provide them with all the choices available."
Jane spent that morning performing ultrasounds on pregnant women, working alongside a senior doctor who supervised. Together, the two women examined a printout from a fetal ultrasound, and the senior doctor offered some feedback.
"On this image here, you want it more of a plane, as if you were opening it like this, so that you have the hypothalamus in your picture," the doctor advised Jane. "That's going to give you a better measurement."
Doctors do ultrasounds before abortions in order to date the pregnancy, which helps determine which technique will be used to terminate the pregnancy. In some states, like Texas, an ultrasound is also mandated by state law.
Jane spent about a month at this family planning clinic during the third year of her residency. Abortion is just one of the skills she learned. She counseled patients about abortion, contraception and sexually-transmitted diseases. She also learned techniques for pain management and dilation of the cervix.
A History of Abortion Training
Roe v. Wade legalizes abortion
Congress passes the Church Amendment: federally-funded entities can't be required to perform abortion
Congress passes the Hyde amendment: Federal funds can't be used to pay for abortion except in cases of rape, incest, or to save the mother's life
Abortion training declines to a low point. Only 12 percent of obstetrics and gynecology residencies offer routine training in first-trimester abortion
Founding of Medical Students for Choice, which advocates for abortion education during medical school
Accreditation Council for Graduate Medical Education (ACGME) mandates ob-gyn residency programs offer experience with training in induced abortion. Religious hospitals can comply by sending residents elsewhere
Congress weakens the ACGME mandate by passing the Coats Amendment: federal, state and local governments can't withhold funds (or licensing) from an ob-gyn residency that fails to provide abortion training
Founding of the Kenneth J. Ryan Residency Program to support better training of ob-gyn residents in abortion and contraception
New York City requires abortion training for ob-gyn residents at city hospitals
California requires ob-gyn residencies to provide access to abortion training
Studies show uptick in residents getting training
Texas passes HB2, a bill that requires all abortions to be performed in ambulatory surgical centers, by doctors with admitting privileges within 30 miles of the center. The law is under review by the U.S. Supreme Court
Many of those skills will be useful in other practice areas, Jane said. For instance, ob-gyns use ultrasounds for many different reasons.
"Before in residency, we were doing ultrasounds maybe once during a clinic afternoon, or a few ultrasounds in the o-b triage area," Jane said. "But here we do 30 ultrasounds in a morning, so it's a lot of good learning about how to do ultrasounds."
It may be good learning, but in Texas this training happens quietly, almost in secret.
"Doctors working in these institutions are walking a very delicate line," said Carol Joffe, a medical sociologist at the University of California, San Francisco who studies doctors who do abortions.
"Some of them want very much to be able to train residents,"Joffe said. "But they are fearful of the other sectors of the university coming down on them and saying ‘You're threatening our funding.'"
Academic medical centers in Texas receive tens of millions of dollars a year in state funding. Many of those centers sponsor residencies, which are the training programs that come after medical school. They last four or more years and allow doctors to focus on a specialty.
It's understandable why an ob-gyn resident in Texas might think twice about providing abortions. Doctors who provide the service must think about security issues, for themselves and their staff. They also have to deal with the scrutiny of state inspectors and the disruption of anti-abortion protesters.
Last summer, hundreds demonstrated outside the Planned Parenthood affiliate in Houston after an anti-abortion group released a series of undercover videos purporting to shed light on problems with fetal tissue research. (Planned Parenthood maintains the videos are deceptively edited and denies wrongdoing.)
"Aren't you glad you're from Texas, a pro-life state?" a man shouted into a microphone. "We've got great, pro-life leaders, like Sen. Ted Cruz," he added as the crowd burst into cheers. Later, the protesters prayed and sang "Glory, Hallelujah."
Surveys and research show that doctors who do abortions may have fewer job opportunities. That's because many hospitals and group practices refuse to employ doctors who do abortions, even if it's during evenings or weekends, on their own time.
A few years ago, 48 doctors in Texas did abortions, but a recent study shows it's now down to 28. Some of the remaining doctors are getting older.
Dr. Bernard Rosenfeld, 73, hasn't been able to line up a successor.
"They've picketed my house where I live," he said. "They put bullets in our parking lot."
Rosenfeld has two medical offices, but provides abortions at only one, a modest brick building in the Museum District. He bought the abortion clinic from other doctors in 1982, but now he can't find anyone to buy it from him.
"I've talked to some doctors, but none of them are interested in the political consequences of providing abortions," Rosenfeld said.
As the number of doctors in Texas dwindles, medical educators have raised the alarm about the need to train the next generation.
To find out how much abortion training was going on, News 88.7 contact all 18 ob-gyn residencies in Texas. Although abortion is legal, and residencies are expected to provide some access to abortion training, the queries were frequently met with fear, evasion, or even outright hostility.
One ob-gyn professor in Dallas hung up. Another prominent professor agreed to an interview, then cancelled.
Six of the programs — a third of the total — simply refused to answer questions about how the training takes place.
"UT Health does not want to participate in that story," said a spokeswoman for the University of Texas Health Science Center in Houston. "It's not a story that benefits us."
UT Health sponsors two ob-gyn residencies, one at Memorial Hermann in the medical center and one at LBJ Hospital.
In the end, it was found that only three out of 18 programs in Texas have made arrangements for residents to spend time learning at an outpatient family-planning clinic. Those types of clinics are where most abortions in Texas take place.
It's unclear how some of the other residencies are handling the training requirement. Some directors point to the difficult fact that the nearest abortion clinic is now closed. Other directors may be providing some options for training, but won't talk about it publicly.
"As of now, there's really nothing in a close radius to us," Casanova said. "Our patients will go to Albuquerque, they'll go to Dallas, they'll go to Denver."
Casanova was left in a similar bind, with no local clinic where the ob-gyn residents could learn.
"The limited choices for our patients pretty much parallels the limited choices for our residents to get training, to where they feel comfortable doing something along those lines," he said.
To compensate, Casanova created special seminars about abortion. He even arranged for guest speakers to fly down from Denver.
Since 1996, all ob-gyn programs in the U.S. must offer the residents at least the option to learn abortion, even if the training happens elsewhere. If the programs don't, it can affect their accreditation.
In Texas, all 18 programs are currently accredited — even in places like Lubbock, where there are no more clinics.
Given the political climate in Texas, and the dwindling number of clinics, residency directors have had to scramble to find other ways to fulfill the curricular requirement.
Dr. Tony Wen, the residency director at UTMB in Galveston, the residency director at UTMB in Galveston, said it's one of the thorniest logistical problems he's encountered. His ob-gyn residency is a large one, with slots for 32 residents.
"We cannot teach them the procedure itself," Wen said. "Can we teach them the concept, and describe the procedure and that sort of thing? Yes, we can do all that."
Wen explained he is hampered by three factors:
- Like most hospitals in Texas, UTMB does not allow elective abortions. Doctors must obtain special approval to do abortions for other reasons, such as severe fetal abnormalities or a threat to the mother's life.
- Galveston does not have an outpatient abortion clinic. Wen has arranged for his residents to travel to a clinic in Houston, an hour's drive away, but almost none have gone, probably because it's inconvenient.
- The faculty physicians at UTMB accept reimbursement from a state-funded program for low-income patients, the Texas Women's Health Program. The doctors cannot be paid if they perform elective abortions or affiliate with an organization that does. The upshot is that Wen and his colleagues cannot teach the procedure, even at an off-site clinic.
Most of his residents don't seem bothered by the situation.
"If this part of the training is very important to them, more likely they will probably rank and choose another residency program to go to, instead of come to Texas," Wen said.
That's not to say the politics haven't affected the curriculum in other ways, Wen explained. Because getting an abortion has become harder in Texas, more patients may be purchasing abortion drugs on the black market to try to induce a miscarriage.
"Here in Texas, they could easily cross the border and get that medication. A lot of people's thinking process is ‘If five tablets (is) good, ten must be better!'" Wen said.
So the director has started teaching the residents how to diagnose a woman who has overdosed on abortion drugs, and what to do to save her life.
*Editor’s Note: This story was originally published on June 13, 2016.