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Medical Education

Abortion And OB-GYN Residency: Training In Jeopardy

20% of OB-GYN residents receive their training in states that outright ban abortion. An additional 14% train in states that severely restrict abortion. As a result, one-third of OB-GYN residents face barriers to get adequate training in performing abortion. Unless these residents make special training arrangements, they will be unprepared to safely perform abortions as practicing physicians, even in cases of rape or medical threat to the mother’s life.

ACGME training requirements in OB-GYN

The Accreditation Council for Graduate Medical Education (ACGME) is the organization that sets training requirements for all specialties, including residencies and fellowships. If a residency program fails to meet ACGME requirements, that residency risks losing its accreditation, which can have implication for funding and physician recruitment. Residency programs that are not accredited by the ACGME cannot receive Medicare funding from CMS for Direct Graduate Medical Education (DGME) and Indirect Medical Education (IME). For physicians to obtain board certification, they must train at an ACGME-accredited residency program. Training programs that lose their ACGME accreditation must assist residents to transfer to another residency program and cannot participate in the Match Program. The work that these residents had done must then be performed by attending physicians, at significant cost to the hospital.

The ACGME publishes the requirements for every specialty, including the requirements for OB-GYN residencies. One of these requirements is that OB-GYN residents must be trained to perform abortions; however, residents can opt-out of abortion training if they have religious or moral objections. The converse is not true – residency programs cannot “opt-out” of providing residents training in abortion procedures. In states where abortion is illegal, to be compliant with ACGME requirements, OB-GYN residency programs and their sponsoring hospitals must make arrangements and provide financial support for its residents to get abortion training in another state. The specific wording of these ACGME requirements are:

IV.C.7.a).(2) Residents must be involved in educating patients on the surgical and medical therapeutic methods related to the provision of abortions.

IV.C.7.a).(3) Residents must participate in the management of complications of abortions.

IV.C.7.a).(4) Programs must provide clinical experience or access to clinical experience in the provision of abortions as part of the planned curriculum. If a program is in a jurisdiction where resident access to this clinical experience is unlawful, the program must provide access to this clinical experience in a different jurisdiction where it is lawful.

IV.C.7.a).(4).(a) Residents who have a religious or moral objection may opt out and must not be required to participate in training in or performing induced abortions.

IV.C.7.a).(4).(b) For programs that must provide residents with this clinical experience in a different jurisdiction due to induced abortion being unlawful in the jurisdiction of the program, support must be provided for this experience by the program, in partnership with the Sponsoring Institution.

 

This year, there were 1,557 first-year residency (PGY-1) positions in OB-GYN offered in the 2024 Match. OB-GYN residency lasts for 4 years and thus there are about 6,230 OB-GYN residents in training at any given time in the United States. About 1,260 of these residents are in states where abortion is completely illegal. Unless these residents attest that they have moral or religious objection to abortion, their hospitals must arrange and provide financial support for them to get this training in another state. An additional 848 OB-GYN residents are in states that severely restrict abortion and many of these residents are unable to obtain adequate experience in first and second trimester abortions, as required by the ACGME.

As an example, the University of Texas Southwestern Medical Center in Dallas has the country’s largest OB-GYN residency – 1 out of every 80 OB-GYN physicians in the U.S. did their residency at UT Southwestern. In Texas, abortion is illegal and a physician who performs an abortion is subject to first or second degree felony prosecution. The OB-GYN residency program at UT Southwestern states on its residency website regarding its 4-week family planning rotation: “During this rotation, fourth-year residents have the ability to travel out of state to receive induced abortion training.

What states ban or restrict abortion?

Since the U.S. Supreme Court overturned Roe v. Wade, it is now up to each state to make its own laws regarding abortion. As a result, these state-specific laws now range from outright bans to restriction based on the number of weeks of gestation to no restrictions on abortion.

In 14 states, abortion is illegal: Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, and West Virginia. In an additional 7 states, abortion is severely restricted to less than 6 weeks (Georgia and Alabama), less than 12 weeks (Nebraska and North Carolina), less than 15 weeks (Arizona and Florida), or less than 18 weeks (Utah). In the remaining 29 states, as well as in Puerto Rico and the District of Columbia, abortion is legal with either no gestational limit or a gestational limit sometime in the second trimester of pregnancy.

Implications for the future

In most states, abortion training is a regular component of family planning rotations for OB-GYN residents. Any OB-GYN resident can opt out of this training for religious or moral reasons. OB-GYN residencies in states that prohibit abortion must still provide abortion training as the default option for residents. In the words of the ACGME: “Programs must be structured such that residents may “opt out” rather than needing to “opt in” to this experience.” Nonetheless, there are obstacles that residents in these states face in order to get training in abortion procedures. They have to travel to another state for a month or more of their residency, they have to find and pay for housing in that state, they have to obtain hospital credentialing where they will get the additional training, they have to obtain a state medical license in that state, and they have to be separated from their families for a month or more. There are also burdens on the residency programs. The residency program must still pay the resident’s salary when that resident is out of state getting additional training. Also, when a resident is out of state, that resident has to be taken off of the call schedule and as a result, the rest of the residents must pick up additional nights on-call.

So far, OB-GYN residencies in states that ban or severely restrict abortion have not had their recruitment significantly impacted. In the 2024 residency match, there was no difference in the percent of available PGY-1 resident positions filled in states with an outright ban (99.0%), states with severe restrictions (99.5%), and states with no or minimal restrictions (99.2%). Similarly, there was no difference in the percent of available positions filled by U.S. senior medical (MD) students in states where abortion is illegal (70.5%), states with severe restrictions (73.6%), and states with minimal or no restrictions (71.1%).

But the 527 OB-GYN residents currently training in states that ban or severely restrict abortion face challenges in arranging and paying for out-of-state abortion training during their residency. For many of them, the obstacles attendant to out-of-state training will be too great and they will elect to opt-out of abortion training. As a result, in the future, it may be difficult for them to get jobs in states where abortion is legal. If they do not get training in abortion procedures and post-procedure patient management, then they cannot get hospital privileges to do abortions. This means that even if a woman has a life-threatening complication of her pregnancy, an obstetrician without hospital privileges for abortion procedures must find someone else to perform a life-saving procedure. In states where abortion is legal, given two otherwise equally qualified applicants, the obstetrician applying for a job who is able to perform an abortion will have an advantage over the obstetrician who is not trained in abortion.

Obstetric residents who are not trained in abortion can always get a job in a state where abortion is illegal. However, even in these states, there is usually a provision allowing an obstetrician to perform an abortion if the mother’s life is imminently threatened. An abortion in these women is generally much more complicated and much higher risk than an abortion in an otherwise healthy woman. But if none of the obstetricians in town were trained in performing abortions and in the management of abortion complications, there will not be anyone who can safely do an abortion in a women dying from a complication of pregnancy. You can’t learn how to do any medical or surgical procedure competently by just watching a YouTube video five minutes before you perform your first one. Competently performing an abortion in a high-risk patient is no different.

There are also legal uncertainties in the future for OB-GYN residency programs in states that are dominated by politicians with extreme social conservative stances. For example, will these states withdraw state government funding from hospitals that send their trainees out of state for abortion training? Will they require state-supported hospitals to publicize the names of OB-GYN residents who do out-of-state family planning rotations that include abortion training? Will they revoke the state medical licenses of OB-GYN residents who participate in abortion procedures in other states?

Idaho has one of the most restrictive abortion laws in the country. Since that law went into effect, 22% of its total obstetricians and 55% of its high-risk obstetricians left the state. Idaho is one of six states without an OB-GYN residency program so Idaho’s abortion law has not affected residency training. But medical students are not stupid – if they see that obstetricians are leaving states that ban abortion, they will be a lot less likely to rank OB-GYN residency programs in those states very high on their match rank list.

What can we do now?

It is in our country’s best interest to have our obstetricians trained in the safe performance of abortions and the management of complications of abortions. Otherwise, where will the 12-year-old pregnant rape victim go? Or the woman with an anencephalic fetus? Or the woman with a 15-week pregnancy needing to start chemotherapy for newly diagnosed acute leukemia? Fortunately, there are some specific tactics we can take today.

  1. Create training opportunities in OB-GYN residencies in states where abortion is legal. As a general rule, residency training programs do not like to accept visiting residents for a 1 or 2 month rotation. There is a lot of paperwork, there is uncertainty about the skill and ability of visiting residents, and the visiting residents can encroach on the training opportunities of the regular residents. Residency programs and hospitals need to create formal pathways for these OB-GYN residents and take down barriers for these guest residents coming from states where abortion is illegal or severely restricted.
  2. Hospitals need to have expedited pathways for credentialing “visiting” OB-GYN residents and should assist them in obtaining state medical licenses for the state that they will be doing their additional training. This could include partnering with residency programs in states with abortion bans in order to streamline the credentialing and licensure process.
  3. Not-for-profit organizations need to create funding to assist OB-GYN residents in states where abortion is illegal or severely restricted in order to obtain additional training. This could create grants to help pay for the cost of travel, housing, childcare, medical licensure, etc. Most residents owe money on educational loans with the average amount of those loans about $200,000. Without such grants, many debt-burdened residents simply cannot afford to travel out of state to get abortion training.
  4. Medical schools should advise students applying to OB-GYN residencies about the implications of attending residencies in states that ban abortion. This includes how training in these states could potentially affect job prospects in other states where abortion is legal.
  5. OB-GYN residency programs in states where abortion is legal can promote to applicants the advantages of training in their program versus programs where abortion is banned. This is a particularly good tactic when the applicants are on-site for their residency interviews and can give the residency program a competitive advantage over residency programs in states where abortion is illegal.
  6. OB-GYN residency programs should offer virtual interviews, especially for students applying from out-of-state medical schools. It could be cost-prohibitive for a medical student in Texas to fly to Ohio to interview for an OB-GYN residency position. But by allowing that student to interview virtually from Texas, the OB-GYN residency program in Ohio can open itself up to a larger pool of applicants and potentially end up with a higher quality group of students matching to the residency program. OB-GYN residency programs in states where abortion is legal should now be able to recruit the best student applicants from medical schools in states where abortion is illegal.
  7. Hospitals in all states need to review credentialing procedures for obstetricians applying for hospital privileges to perform abortion, even if abortion is only permitted when a pregnant woman’s life is in immediate jeopardy. With one-third of OB-GYN residents training in states where abortion is banned or severely restricted, is is less certain than ever before that an obstetrician who did residency in those states can competently perform an abortion or manage complications of an abortion. This may require hospital credentials committees to remove abortion procedures from the “core privileges” list for OB-GYN and moving them to the “optional privileges” list. Documentation of training should be required.

It’s a new era in OB-GYN

One of the most important (and most frequently forgotten) rules of law-making is that there is always unintended consequences. For example, let’s say that the anti-necktie lobby group got the state legislatures in 21 states to pass a law making it illegal for men to wear a necktie except for Leap Year Day. That would mean that a man could only wear a necktie on one day every 4 years in those states. Eventually, no man in those states is going to remember how to competently tie a necktie and no boys are ever going to learn how to tie a necktie. Men in the 29 states where neckties are legal would have a competitive advantage when it comes to dressing in formalwear. The same thing happens in states with abortion bans – it will not be too long until no one in those states knows how to competently perform an abortion even in the event of rape or the mother’s life being in danger. OB-GYN residency programs in the states (plus Puerto Rico and the District of Columbia) where abortion is legal now have the opportunity to take a competitive advantage in recruitment.

April 8, 2024

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital