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Abortion is one of the more common procedures performed in the U.S., more common even than appendectomies. But as clinics in Texas close, learning to do them is getting harder for the doctors training in obstetrics and gynecology, known as residents.
The first part of this series looks at how the battle over reproductive rights has penetrated academic medicine in Texas.
"There are places in Texas where there are ob-gyn residents who can't get anywhere to be trained," said a senior doctor at one Texas clinic where ob-gyns residents can still come to learn how to do abortions. The doctor asked not to be named to avoid backlash from anti-abortion groups and politicians.
Clinics have closed recently in Lubbock, Odessa, and other Texas cities. But the professor's clinic can't take up the slack.
"We've been approached by many different residency programs about the ability to train their residents," she said. "Unfortunately, we just don't have the capability to train everyone."
The doctor was spending the afternoon at the clinic, supervising a third-year resident. The resident agreed to be identified by her middle name, Jane.
During her four years of residency, Jane spent about a month doing rotations at this clinic. The experience improved her medical skills, she said, but also gave her a new political perspective on what it means to be a doctor.
"It makes it even more obvious how important it is for women to have access to abortions," she said.
The rotation made her more committed to providing abortions throughout her career.
"If I think a woman needs access and I have the skills to provide access, I should," she said.
Jane listened as the senior doctor prepared her for the next patient: "She's 21 years old and this is her first pregnancy. She is at about 8 weeks today. Do you have any questions about what we're going to be doing or the procedure?"
Later, I asked the professor if it's hard to teach abortion. She says a first-trimester abortion is not a complex procedure, and is actually the same thing as a dilation and curettage, or "D and C."
During a D and C, the doctor dilates the patient's cervix, inserts a suction instrument into the uterus, and uses that to remove tissue from inside the uterus.
"The technical procedure is the same, whether you are doing it for a miscarriage, or whether you're doing it to terminate an ongoing pregnancy," the doctor said.
D and Cs are also used to treat excessive bleeding, or to take a biopsy from inside the uterus.
"I like to say that a D and C, a suction D and C even, is bread and butter gynecology," she explained.
Ob-gyns have always learned the D and C. There's nothing controversial about it, per se. But when it's done because a woman chooses to end a pregnancy, it's called an elective abortion, and that requires additional training.
Elective abortions are almost always done on an outpatient basis. To do them, doctors must learn how to counsel the patients and manage their pain during the five-minute procedure. They also need to learn how to administer medical abortions, the ones that use pills.
In addition, many states like Texas require doctors to perform extra steps, such as reading out loud a state-mandated script to the woman, or having her listen to the fetal heartbeat.
Ob-gyn residents can't learn that process without spending time at an outpatient clinic, which is where most abortions take place in the state. And in Texas, there are only 18 of those clinics still in operation.
That worries Lori Freedman, a medical sociologist at the University of California, San Francisco.
"How can you have abortion provision if you don't have trained doctors? Especially the ones likely to stay in your state," Freedman said.
Abortion training has become more common overall in the U.S., but it also depends on what area of the country you're talking about, she said.
"We've trained a lot of people, but they're staying in relatively liberal, urban areas," Freedman said.
Texas has 18 ob-gyn residencies (see interactive map below). All of them undergo periodic reviews by the Accreditation Council for Graduate Medical Education, or ACGME, in Chicago. One of the things the reviewers look for is whether residents have opportunities to learn about induced abortion (so called to distinguish it from a miscarriage).
All 18 residencies in Texas are currently accredited, even though some of them are located in cities where outpatient abortion providers have closed. But those residencies do have other options for fulfilling the training obligation, according to Dr. John Potts, the ACGME's Senior Vice-President for Surgical Accreditations.
He explained the residents don't have to perform elective abortions. They can practice terminating pregnancies in the hospital, for other reasons.
"As long as they're getting sufficient experience in some form of abortion, you know, where the mother's life is in danger, where there are substantial fetal abnormalities — as long as they're getting sufficient experience in those areas, and didactic information about elective abortions, then they do meet our standards," Potts said.
In other words, the resident learns how to safely empty a woman's uterus, if her pregnancy is experiencing a medical complication. For situations when it's the woman’s choice to end a pregnancy, residents can hear lectures about it, perform simulations, or practice counseling skills on each other.
Some Texas professors maintain that's good enough, or, at least, the best they can do under the circumstances.
But do those residents know enough to become future providers of abortion in Texas? Many experts don't think so.
"No, absolutely not, it's so much different," said Dr. Bernard Rosenfeld, an ob-gyn who's been providing abortions in Houston for decades.
When residents are learning to do D and Cs, they usually do them in the hospital, and the patient is often asleep, Rosenfeld pointed out. But most abortions in this country take place in outpatient clinics.
At the clinics, patients get a local anesthetic or none at all. That actually makes the abortion safer for the patient, but it requires more skill on the part of the doctor, according to Rosenfeld and other experts.
"Time is a big factor, and causing as least pain as possible, and having a very gentle touch," Rosenfeld said. "But all that is learned."
Residents won't have competence in abortion until they perform dozens of outpatient abortions, Rosenfeld said.
"Lots of time you'll have uterine abnormalities and you're not going to know, unless you've done many procedures, what to do with a uterine abnormality," the doctor said.
There's another intangible, but critical, experience residents get from abortion training, though it has nothing to do with technique. Jane, the resident, summed it up this way: "Every woman has a different story and a different reason why she chooses to end her pregnancy."
Hearing those stories from patients is crucial to an ob-gyn's professional development, said Dr. Jody Steinauer, an ob-gyn professor and researcher at the Bixby Center for Global Reproductive Health at the University of California, San Francisco.
Counseling patients teaches doctors valuable bedside skills like compassion, empathy, and political awareness.
"When they spend time in a setting that provides abortion care, they have real epiphanies," Steinauer said. "They become more aware of their biases. They're surprised that more than half of women having abortion are already mothers, for example."
The experience can also motivate young doctors to continue providing the service. Steinauer's research shows that ob-gyns who have access to abortion training during residency are more likely to provide the procedure later in their careers.
But some doctors question the need for more training, saying if residents really want abortion skills they can leave Texas to acquire them, and then come back to the state to practice.
Other ob-gyns, like Dr. Donna Harrison, condemn the entire concept.
"It should not be part of any kind of medical training to do elective, induced abortions," said Harrison, executive director of the American Association of Pro-life Obstetricians & Gynecologists, in Michigan.
Residents have always been able to "opt out" of abortion training if they have moral or religious objections, and Harrison acknowledged that. But she said some residents might feel pressured to do the rotation, and could end up indoctrinated with the view that elective abortion is OK.
"If you do a procedure that you have moral qualms with, there's a kind of desensitization that goes on," Harrison said. "The attempt to force residents to participate in abortion is an attempt to desensitize those residents, so they will have less ability to think clearly about what that procedure is actually about."
But Lori Freedman, the medical sociologist, disagreed that abortion training amounts to indoctrination.
"If you look at medicine in general, how many things do we do to teach people empathy, sensitivity, compassion about a lot of things?" she asked.
Doctors will always have patients whose life decisions they privately disagree with, Freedman added. Some examples include obese patients, smokers or drug addicts. But it doesn't help when doctors judge those patients or withhold a treatment or procedure.
"Things happen to people that they don't want, health-wise, all the time," she said. "We just need doctors to know how to do this."
According to a national survey, 97 percent of ob-gyns have had a patient who wanted an abortion, but only 14 percent of them actually provide abortions.
Use the “+” sign above to zoom in and see how residency programs responded to the question: "How are ob-gyn residents trained in abortion?"
- Green dots indicate the residency is located in an area where clinics still offer elective abortion (12).
- Yellow dots indicate that a nearby clinic still provides abortion, but the clinic could close soon depending on the U.S. Supreme Court's interpretation of Texas law (2).
- Red dots indicate that none of the clinics left in the area provide abortion (4).