"I vividly remember our abortion training in medical school -- kind of like some people remember experiencing a bad car accident, or a train derailing," says Carolyn, a 28-year-old New England OB-GYN who provides abortions (and asked me not to include her last name or specifics of where she lives and practices). It was 2005, and Carolyn was working nights at an abortion clinic in Oakland, Calif. After ending a shift at 2 a.m., she dragged herself out of bed for a 9 a.m. lecture "because this was going to be the one hour of education we received on elective abortions in two years of didactics."
The professor for that one hour, a family practice doctor, "was very strongly anti-choice. Which would not necessarily have to be an issue if she had been able to present the information honestly and without editorializing." Instead, the doctor gave false information about California state laws regarding abortion -- "she pulled [laws] from other states and acted as though they were nationally valid" -- and promoted long-debunked anti-choice myths like "abortions cause breast cancer" to a roomful of medical students. She then told the class stories about how she'd counseled some of her own patients against abortion, including one woman who sought an abortion elsewhere and didn't return to this doctor, her primary care physician, for over five years. "I don't think she understood what she was saying -- that she had alienated and effectively failed her patient," says Carolyn. "That was in March of '05, and I'm still angry."
Carolyn is part of the next generation of abortion providers many people are wondering and worrying about in the aftermath of Dr. George Tiller's murder by an anti-choice zealot and the subsequent closing of Tiller's Women's Health Care Center. Already, 87 percent of counties in the U.S., and 98 percent of rural counties, have no abortion services. Nearly two-thirds of second-trimester abortion providers are over 50 years old and bound to retire sooner rather than later. And, as a recent PBS NOW special highlighted, the number of overall abortion providers has dropped by one-third in recent years: From 2,680 in 1985 to 1,787 in 2005. Is terrorism working to drive young doctors away from providing legal medical care? Do doctors who were born after the 1973 Roe v. Wade decision take abortion for granted, not having seen firsthand the devastating effects of botched illegal abortions? Yes and yes, probably. But another factor keeping young doctors away from providing abortions is lack of comprehensive family planning training in medical schools. Apart from that outrageous hour of "abortion education," says Carolyn, "I got none in the subsequent two years of school-sanctioned rotations."
Lois Backus, executive director of Medical Students for Choice (MSFC), an organization devoted to improving reproductive health education for aspiring doctors, says, "Medical school is a fairly closed world, and many, many medical students do very little education in family planning or abortion. The majority of medical schools have a small curriculum exposure to oral contraceptives, but family planning as a broader issue is not covered in a comprehensive way." A survey of MSFC student members published in the current issue of Contraception found that at schools across the U.S. and Canada, 33 percent of the students "reported no coverage of elective abortion-related topics." And as Carolyn learned the hard way, the education that's available, in both abortion care and family planning in general, is often patchy and rife with misinformation.
How can medical schools justify glossing over aspects of healthcare that affect half the population and, in the case of abortion specifically, close to 40 percent of women? "To be fair, we can't teach everything to medical students," says Dr. Mitchell Creinin, president of the Society for Family Planning, who also serves as director of family planning at the University of Pittsburgh. "Every specialist wants the students in their first couple of years to get everything. If I'm a kidney doctor, I think they should be learning everything about renal disease." So the question becomes, "Is teaching about abortion so important that it must be put into the first couple of years?" Potentially, says Creinin, the answer is yes. "You could argue that there's no excuse for not being exposed to abortion, because it's the second most common outpatient procedure in the U.S." However, given that many students won't pursue specialties that would involve providing abortions, and even those who go into family practice or obstetrics and gynecology might choose not to offer abortions, you could also argue that it's a waste of time in an already overburdened curriculum. "I can understand, even if I don't agree, why the training may be relatively limited. In all fairness, they're trying to balance everybody's competing needs and competing interests."
Still, the reasons why schools don't provide comprehensive family planning education go beyond simple time-management issues. For one thing, the same relentless pressure from the anti-choice movement that plagues practicing abortion providers is also directed at medical schools. Susan Wicklund, a Montana OB-GYN and author of "This Common Secret: My Journey as an Abortion Doctor," says, "I've witnessed pressure by antiabortion groups on administrators and professors in medical schools not to discuss abortion. There's the threat of being picketed or boycotted at the school itself if they do any teaching of abortion." Says Creinin, "For anything that creates controversy, it's easy for a med school to say, 'Look, it's not worth it.'" Furthermore, Backus points out, "Part of it also is that largely in medicine, being equally focused on the full range of women's healthcare needs is still a struggle. What I still hear from medical students is, they get two to three hours on Viagra and half an hour on every contraceptive method combined. That's the reality in American medical education."
That's even more troubling in light of research that shows exposure to comprehensive family planning education, including abortion, is a strong predictor of whether a medical student will go on to become a provider. Says Creinin, "Some residents that come in conflicted, most of them get an idea of what it really is. They realize it's an important part of learning how to be a complete physician." Carolyn's experience bears this out. "I wasn't sure how I'd feel when I saw [an abortion], or if I really wanted to polarize my life that way," she says. But after "meeting the women who came to that clinic, hearing about their lives, counseling them through the procedures -- I can't imagine not doing abortions." That decisive experience, it's important to note, did not come from her school's medical program. "All of my abortion training prior to residency was through elective extracurricular work."
At least Carolyn got exposure to abortion care during her residency. According to Medical Students for Choice, fewer than 50 institutions in the U.S., out of 130 accredited medical schools, offer abortion training as part of their residency programs -- and that, Creinin says, is the point at which the lack of such training can no longer be dismissed as an understandable concession to competing interests. "If somebody is going to provide women's healthcare as an OB-GYN, there's no reason that a program shouldn't expose them to all the procedures and medical issues that women need for their reproductive lifespan and beyond. Somebody has to be putting their head in the sand to say abortion's not part of that." Even if a doctor never intends to perform abortions, Creinin says, the skills gained from a comprehensive education in reproductive health are worthwhile. Most doctors don't use everything they learned during their residencies -- Creinin himself hasn't practiced obstetrics in 15 years -- but having a broad knowledge base helps physicians provide the best possible care to a wide range of patients. As it is, "General OB-GYNs know about how to treat cancer when they never do that, but many don't know how to treat women who have an unintended pregnancy, which is way more common."
"Close to 40 percent of women will have an abortion, and where do they go?" says Susan Wicklund. The lack of access to abortion itself isn't the only problem with the provider shortage -- it also means that women who travel elsewhere to terminate pregnancies can't get adequate follow-up care at their local hospitals."They travel back to their tiny towns, and they're seen by a physician who doesn't have a clue what they're seeing. They don't understand anything about abortion or what the possible complications may be, or how simple it is to treat the very minor and rare complications." That ignorance often leads to overreaction on the part of doctors and expensive, unnecessary hospital stays for women who may not have insurance. "If these physicians had gotten proper training, this kind of overtreatment and mistreatment wouldn't happen. Not having adequate training has a major trickle-down effect on half the population. It's inexcusable."