Ignorance is no excuse

Few doctors learn how to perform abortions, and women pay for their lack of training. New York City is taking steps to reverse the trend.

By Fran Smith

Published July 25, 2002 7:10PM (EDT)

Back in the '80s, before I was ready to settle down with husband or child, I got pregnant. I went to my OB-GYN to talk about abortion.

I'd known and trusted this doctor for years. He'd always listened attentively and answered my questions with kindness and respect. That's what I expected now. Instead, he looked stricken. "Abortion?" he asked, almost choking on the word. "But you'd make such a great pregnant lady!"

Considering the hassle and outrageous harassment that women often confront when they seek abortions, a dumb, hurtful comment from a doctor should seem like no big deal. But that moment sticks in my mind more vividly than the memory of the vacuum aspiration that eventually ended the pregnancy. The message was unmistakable: Yes, abortion is legal; yes, it is one of the most common surgeries performed on women. But it is a procedure beyond the bounds, interest and dignity of the medical establishment.

Two decades later, medical schools and doctor training programs are finally taking important steps to bring abortion into the mainstream of medicine -- where it belongs. After years of simply ignoring the procedure and conveniently sidestepping controversy, a growing number of training programs are now requiring obstetrician-gynecologists to learn how to do abortions. This slow, steady, quiet shift got a dramatic boost this spring, when New York became the first city to mandate abortion training for OB-GYN residents at its public hospitals.

The move to incorporate abortion into standard medical education is one of the most significant developments in decades in the debate over a woman's right to choose. By teaching medical students about abortions, and by requiring newly minted M.D.'s to get hands-on experience, educators are giving the procedure the same legitimacy as any other medical treatment -- for the first time since Roe vs. Wade.

"If abortion is part of a clerkship, it's not going to be seen as a dirty procedure that has no educational value for students," said Mindy Sobota, a fourth-year student at the New York University School of Medicine.

Abortion-rights groups such as Medical Students for Choice and the National Abortion and Reproductive Rights Action League have pressed educators for years to add abortion to the medical-school curriculum. The effort has gained urgency as abortion providers -- actively stalked and threatened with death -- have packed up and abortion clinics have shut. Eighty-six percent of U.S. counties, and one-third of U.S. cities -- Sioux City, Iowa; Grand Forks, N.D.; Erie, Penn.; and Joplin, Mo., among them -- had no identifiable abortion provider in 1996, according to the most recent survey by the Alan Guttmacher Institute in New York.

While it is possible to blame antiabortion violence for the diminishing access to abortion, the medical establishment bears some responsibility. When medical schools and training programs fail to teach medical students how to do abortions, very few doctors perform them.

Though it was never part of most OB-GYN curricula, abortion training began to surge after 1973, when women suddenly flocked to hospitals for a newly legal procedure that almost no M.D. had been taught to perform. But by the late 1970s -- despite the demand -- only about one-quarter of OB-GYN residency programs routinely included abortion training. The number of programs to carry the training diminished further when abortions were less frequently performed in hospitals, the doctor's traditional training ground.

By the mid-1990s, a mere 7 percent of abortions were performed in hospitals, down from 81 percent in 1973. Women were going to clinics, like those operated by Planned Parenthood, for the procedure. The shift made sense medically and economically -- at least in the years before 1982, when clinics largely operated in peace. Early abortions are technically simple and patients tend to be healthy. Hospital operating rooms are set up and staffed for complicated surgery on the desperately ill. Outpatient abortions proved to be safer, quicker and cheaper -- so successful, in fact, that they precipitated the wholesale shift of elective surgery to outpatient centers.

But the rise of abortion clinics had an unintended consequence: It eroded abortion education. As abortions slipped off the hospital operating-room schedule, they also were dropped as a training requirement for young physicians. "They get trained to do things that happen in hospitals," said Felicia Stewart, co-director of the Center for Reproductive Health Research and Policy at the University of California, San Francisco. "It's not easy to get trained to do things that don't happen in hospitals."

By the early '90s, only 12 percent of OB-GYN training programs routinely included abortion. A resident determined to master abortion techniques could volunteer at a clinic in her spare time -- after putting in 100 hours a week in the hospital. Not surprisingly, few bothered.

The paucity of training had a logical effect: Most OB-GYNs in practice today completed their education without so much as a half-hour lecture on terminating a pregnancy. As a practical matter, the omission is staggering, considering that roughly half the women in the U.S. will undergo an abortion in their lifetime. The corresponding political impact is palpable: The lapse has effectively and insidiously pushed abortion to the margins of healthcare.

"The message was, at best, that [abortion] isn't worthy of your time. At worst, it's that [abortion] is bad," said David Toub, a board-certified OB-GYN in Pennsylvania. "Ultimately that really harms women."

With a majority of doctors unable to terminate a pregnancy, women eventually lost all choice in abortion providers. These days, it's a big clinic or nothing. The scarcity of these clinics means that women typically must wait to get a clinic appointment, a serious problem given that the risk of complications doubles with every two weeks an abortion is delayed. Moreover, women outside big cities, especially in the South, the Midwest and the Rockies, must travel far to find a clinic where doctors perform abortions. And those clinics are no longer able to operate peacefully, as they did through the '70s. Patients must often dodge hostile protesters -- a cruel warm-up to a procedure that is rarely easy, regardless of the circumstances.

"The unspoken message is very powerful that abortion is so completely out of the norm that you have to drive 500 miles and bring cash," Stewart said. "The reality is, we're making women feel like they're on the run. They have to be ashamed and hide what they're doing. It undermines women's self-worth, I think, to feel like they have to go through a clandestine experience."

As abortion has been relegated to the periphery of medicine, the right to choose abortion has come under threat. Abortion clinics are not only highly visible targets for antiabortion groups but also outposts of controversy easily -- or conveniently -- ignored by anyone who isn't a patient, a provider or a protester. Certainly the medical profession hasn't provoked the violence against abortion doctors and their patients. But would the attacks have gotten so vicious if abortions were performed under the same roof as tonsillectomies or cardiac stress tests? Polls show that Americans largely support legal abortion. Might they have become fed up with antiabortion harassment long ago if the protests took place outside community hospitals or popular HMOs?

For a while, some medical experts predicted that abortion drugs such as mifepristone would at last shift early abortion from clinics into doctors' offices. But so far few doctors prescribe the drugs -- nearly all prescriptions are written at abortion clinics. The oft-cited explanation is that the Food and Drug Administration imposed conditions on the use of mifepristone that many private doctors cannot meet. But it was unrealistic to expect that OB-GYNs who had never learned the first thing about abortion would rush to try the latest technique for ending a pregnancy.

"What was very disheartening to me as a physician wasn't so much the potential threat from the general public opposed to [abortion], who are very militant in some cases," said Toub, who has worked in abortion clinics and performed the procedure in his private practice. "What bothered me more was the attitude of my own colleagues. They couldn't even use the word 'abortion.' They'd use all sort of euphemisms: VIP -- voluntary interruption of pregnancy. TAB -- therapeutic abortion."

Such attitudes and ignorance have infuriated abortion-rights and women's health groups. But it was the dwindling supply of abortion doctors that triggered efforts to require training. Activists lobbied on several fronts -- individual hospitals, accreditation bodies, medical school administrators. Many medical educators, too, recognized that abortion care -- once the model for minor surgery -- had been shoved, dangerously, to the fringe.

"Abortion is as common as a hernia repair," said Carolyn Westhoff, professor of public health and obstetrics and gynecology at Columbia University. "What are we going to do -- have one hernia surgeon in each state that does repairs? It's absurd. Abortion is an everyday piece of women's health. [Doctors] should have a clue about something so common."

In January 1996, the Accreditation Council for Graduate Medical Education, the private body that establishes educational standards for thousands of residency programs in all specialties, called on OB-GYN programs to require abortion training. The decision capped an enormous controversy -- letters, debates, articles in the professional literature, all flowed freely -- with pro-choice activists, women's health groups and some educators on one side, and antiabortion organizations and Catholic and other religiously affiliated hospitals on the other. The council stopped short of imposing a blanket mandate. "No program or resident with a religious or moral objection will be required to provide training in, or to perform, induced abortions," the council said.

By granting individual physicians and training centers the right to opt out, the accreditation council recognized that choice lay at the heart of the abortion issue -- and subtly reinforced the marginality of abortion. Nowhere else in medical training may doctors decline to serve a patient because they don't personally approve of the necessary treatment.

"I did not get much pleasure doing a below-the-knee amputation when I was an intern," Toub said. "Its not a procedure you feel good about afterward. But I'm very glad I had the opportunity to receive the training. It adds to your pool of knowledge."

Law students, even those heading for careers in patents or divorces, must study criminal procedure whether or not they "object" to crime. Imagine if a group of hospitals refused to teach residents how to do C-sections because some influential donors considered them largely unnecessary.

Even with this important loophole, the accreditation council's abortion-training standard had a dramatic effect. Reliable statistics are hard to come by, but according to various estimates, 35 percent to 40 percent of OB-GYN residency programs now include abortion training -- roughly triple the percentage in 1992. The University of California at San Francisco, which continued to rotate OB-GYN residents through its outpatient abortion service even at the national low point of training, launched a program three years ago to promote abortion education around the country. The Kenneth J. Ryan Residency Training Program helps teaching hospitals set up abortion clinics where residents do five- to 10-week stints. Fifteen clinics have opened under the program, and 20 more are in the works, said Uta Landy, the program's director.

But until this summer, the expansion of medical training to include abortion happened one hospital at a time, without much public notice. The new training mandate at New York City hospitals, issued by Mayor Michael Bloomberg, was a breakthrough. It was the first time a city government required abortion training in publicly funded hospitals. And its installation has already sparked talk among proponents of abortion training for medical students in California of promoting legislation to require abortion training at public teaching hospitals throughout that state.

New York is also one of the largest training grounds for doctors -- one in seven U.S. doctors does a residency in a city-owned hospital there. This year, more than 150 OB-GYN residents will work in eight New York public hospitals. If any training program can help to replenish the ranks of abortion providers, it is New York's.

Finally, the city is a media nerve center, so the announcement got a lot of press. Unfortunately, the crush of publicity created the impression that New York's abortion-training mandate was novel-- instead of a new twist in a longtime trend. There were other distortions in the coverage, the most dangerous being the idea that doctors would now be forced to perform abortions no matter what their moral or religious objections. That is not the case. Nonetheless, a headline in the conservative Washington Times blared: "N.Y. hospitals to deny choice on abortion training."

Choice, of course, is what's at stake -- a doctor's choice to learn how to perform abortions, and a woman's choice to have one. Certainly, it makes no sense to force doctors to end pregnancies, just as it makes no sense to force women to carry pregnancies to term. But is it asking too much to expect all OB-GYNs to understand the basics of such a common procedure? Is it asking too much to require them to know how to handle post-abortion complications?

More than 1 million women in the U.S. will seek abortions this year. Many will turn first to an OB-GYN. It is not too much to hope that these doctors will offer options and wise counsel, instead of conjuring some rosy image of a great pregnant lady and then dishing out guilt. Patients, no matter what ails them, want professionalism, not patronization.

Fran Smith

Fran Smith is a freelance writer and editor who frequently covers health issues.

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