Training Shortages Post-Roe: Medical Careers, Accreditation, and Patient Safety at Risk
The short-term disruptions faced by many medical professionals in the wake of the Dobbs decision, which overturned Roe v. Wade, have partially obscured a looming crisis in access to training. Roughly half of OB/GYN residents risk losing access to some aspects of training required to complete their programs. Further, with many longstanding treatment practices now banned in some states, some training institutions risk losing their accreditation.
During a discussion convened by The Doctors Company, three prominent OB/GYNs considered the implications of the Dobbs decision for their specialty: Sheila Dejbakhsh, MD, MPH, of Orange Coast Women’s Medical Group; Daniel Grossman, MD, Professor at the University of California, San Francisco, and Director of Advancing New Standards in Reproductive Health (ANSIRH); and Ghazaleh Moayedi, DO, MPH, Founder and Chief Medical Officer of Pegasus Health Justice Center.
These experts expressed serious concerns regarding the long-term impacts of the Dobbs decision on training for medical professionals, as well as safety for patients.
A Critical Shortage of Training Venues
For medical residents, as for patients, location matters. “I work at a training institution,” Dr. Grossman says, speaking from California, “and I’m really concerned about, particularly, the OB/GYN residents, for whom abortion training is mandatory.” Dr. Grossman referenced an estimate that 44 percent of OB/GYN residents “are training in a state that is likely to ban abortion. And what’s going to happen to them?” he asked.
Solutions for space will no doubt include state-to-state student exchange arrangements between teaching institutions. However, with thousands of training seats potentially lost from states with bans—and with student exchanges themselves shadowed by legal risks—student exchanges likely won’t be enough for OB/GYN residents alone, much less for residents in family medicine or other specialties seeking abortion training. Further, some currently practicing professionals in primary care and general surgery are seeking training so that they can help fill the gaps in access to care—but again, there currently aren’t enough seats for OB/GYN residents alone, panelists said.
Fortunately, small solutions pursued over a large scale could make a dent: Dr. Grossman proposed that more private practices, as opposed to large teaching institutions, could open their doors to trainees via partnering with a local residency program, if they're located in a state where abortion is still legal. “Because really,” he says, “all of us are going to have to step up to meet the needs for training.”
The Potential for Expanding Maternity Care Deserts
Dr. Moayedi spoke to the additional pressures now on OB/GYNs to carefully consider where they live and practice, and how these pressures can collide with love of place. Many early-career medical professionals fear committing to a location where they won’t have access to required training, and/or to a program whose accreditation is threatened. They may also fear being criminalized for providing care, especially since patients and/or providers can face criminal prosecution for a miscarriage, not an abortion. Still, “At least for my state,” Dr. Moayedi says, “I can say that Texans are very proud. We love our communities. Many of the physicians I've talked to…want to remain. But who else we're going to be able to bring in is a huge question for us. We've definitely seen a drop in applications for fellowships and residency spots here in our state.”
In states like Texas, where patients already face long travel times to care, and where every kind of OB/GYN care access is already so limited, the consequences of OB/GYNs feeling forced to depart, or of OB/GYNs not being willing to begin their careers in the state, could be devastating: “I'm definitely concerned,” Dr. Moayedi says. She emphasizes that the loss of an abortion provider also means loss of access to many kinds of care: “We have real ripple effects in education and the care culture in our communities, as well.”
Dr. Moayedi expressed concerns about not only medical residents’ professional futures, but their personal futures, as well. “Many of our trainees are starting their own families,” she says, and because abortion bans spill over into care for pregnancy complications, “our ability to care for them safely and to keep them in a safe learning environment is being challenged over and over and over again.”
Patient Safety and Patient Relationships
All panelists agreed that institutions should plan ahead to prevent delays in care. For instance, “There should never be any delay in treating a tubal ectopic pregnancy,” said Dr. Grossman. Generally, widespread physician training is part of preventing delays in care.
In this case, training is impactful on a broad scale because the evacuation of the uterus, a.k.a. dilation and curettage (D&C), is performed in a variety of situations beyond elective abortion. These include miscarriages or other complications, such as ectopic pregnancies, as referenced by Dr. Grossman. D&C may also be performed for the diagnosis of cancer or other conditions not related to pregnancy.
Among patient presentations where a D&C has long been included in the standard of care, some complications could be life-threatening to the mother if not swiftly addressed. “It’s so upsetting to read these stories,” said Dr. Grossman, describing narratives, submitted in response to a call from ANSIRH, by emergency medicine clinicians describing what they felt was poor-quality care post-Dobbs.
Beyond technical skill and beyond the immediate technical requirements to create patient safety, Dr. Dejbakhsh considered training for abortion care within a wider frame. She spoke broadly about assisting patients with family planning, and about providing abortion care, as being crucial to her formation as a medical professional whose care is based in strong patient relationships. Dr. Dejbakhsh says, “I think that family planning training is at the pinnacle of OB/GYN training. It's huge. It's something that you really don't get exposed to otherwise. And unless you're actually there, looking the patients in the eyes, it's hard to kind of see the effects that this care has on a patient, and her family, and her future kids, and just an entire ripple effect. It made me a more, I think, capable provider.”
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.