Studying Medicine in a Post-Roe America

For years, aspiring ob-gyns at Louisiana State University's School of Medicine have driven four hours from the New Orleans institution to Shreveport for an intensive two-week training at the Hope Clinic, one of the only practices in the state where students can observe and gain hands-on experience with surgical abortion procedures.

But after the Supreme Court overturned Roe v. Wade last month, the Hope Clinic is likely in its final days of operation, awaiting the almost certain end of a temporary court injunction that’s currently preventing Louisiana’s trigger abortion ban from taking effect. Now, LSU must find new ways to give medical students the training they need—and with the legality of abortion-related medical education murkier than ever, they are exploring their options carefully.

“It’s going to be a big challenge to figure out how to train our residents, which I’m very worried about. But I’m also upset about the impact it’s going to have on all of our patients in our community,” said Nicole Freehill, director of the clinical residency program for ob-gyns at LSU’s Health Sciences Center in New Orleans. “The big question mark is, what do we do now?”

Freehill is far from alone in asking that question. From Louisiana to Texas, Ohio to Florida, medical schools and students are coping with the sudden implosion of their reproductive health-care training.

A study conducted in April by researchers at the University of California, San Francisco, and UCLA found that 45 percent of ob-gyn residency programs, and 44 percent of residents themselves, were located in states where abortion was likely to be banned outright if Roe v. Wade was overturned.

“In 2020, 92% of obstetrics and gynecology residents reported having access to some level of abortion training,” the researchers wrote in the study. “We predict that, if Roe v. Wade is overturned, this would plummet to at most 56%.”

With the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization now on the books, eight states have enacted bans on terminating a pregnancy under practically all circumstances, and many more are likely to do so in the near future.

The limited availability of abortion-related medical education was already an issue before Roe was overturned. More than 800,000 abortions, surgical and medicinal, are performed in the U.S. each year, making it one of the country’s most common surgical procedures performed on women. Yet according to a 2020 study by Stanford University researchers, half of all medical schools offered either no formal abortion training or only a single lecture—and that was before the Dobbs decision.

“Abortion is one of the most common medical procedures, yet abortion-related topics are glaringly absent from medical school curricula,” the researchers wrote.

Now, abortion training is almost certain to become even rarer—and, for the first time since 1973, much more legally risky.

“Medical schools and hospitals are incredibly risk averse,” said Pamela Merritt, executive director of Medical Students for Choice, an organization that advocates for access to abortion training and provides extracurricular resources to students. “As a result of not wanting to poke the hornet’s nest, only states that don’t have the ban are probably going to provide this kind of training and care.”

Jeannette Lager, director of the ob-gyn program at UC San Francisco, said that reality may lead to fewer applications to programs in states where abortion training is outlawed, including at some of the most well-regarded medical schools in the country: Washington University in St. Louis, for instance, or Emory University in Atlanta.

“[Students] have to make the difficult decision of whether they want to be trained at a program in a state that doesn’t provide abortion care,” Lager said. “Those programs are going to have fewer applicants, and the states that can provide abortion care will be inundated with even more applications.”

Training for abortion procedures won’t be the only thing affected by Dobbs. The laws triggered or enabled by the Supreme Court decision could limit medical schools’ ability to provide education in family planning, medical ethics and a range of treatment options that may be off the table thanks to the possibility of miscarriage as a side effect, such as lithium, which is used to treat acute depression and schizophrenia.

At Wright State University’s Boonshoft School of Medicine in Ohio, where the Dobbs decision triggered the implementation of a ban on abortions after six weeks of pregnancy, a family planning elective was canceled when the women’s health clinic that usually ran it shut down. Some students were left in the lurch, and institutions like Wright State are waiting on clarification from accreditors and state lawmakers.

“The overturning of Roe has impacted medical school academic programming not only in Ohio but across the Nation,” Seth Bauguess, a spokesperson for Wright State, wrote in an email to Inside Higher Ed. “Like other schools, the School of Medicine is looking to the Accreditation Council for Graduate Medical Education and Residency Review Committee for further guidance on how the recent decisions will ultimately impact the curriculum.”

Freehill said there are methods of simulated and virtual procedures that LSU is exploring to replace the in-person experience, but she added that “simulation can only take the place of patient care to a certain extent.”

Freehill said that she believes LSU’s medical program is good enough to withstand any decrease in enrollment that might result from the state’s post-Roe abortion laws. But she’s worried that the residency program for ob-gyns will suffer.

“If we don’t figure out a way to make sure that this portion of their training stays intact, then I am worried that good candidates that we want to recruit might not even look at us at all,” she said.

Merritt said that medical students across disciplines, not just ob-gyns in training, will also now have to understand the legal risks they assume when taking the Hippocratic oath.

“Everybody needs to understand abortion. Every physician is dealing with a population where one in three people who are capable of pregnancy will consider abortion,” Merritt said. “That means that there isn’t any area of medicine that doesn’t now require an evaluation of risk for future prosecution or the loss of your licensure if you give this important medical advice.”

“It’s going to have ripple effects across every single concentration,” Merritt added. “What we’re seeing is a slow-moving, man-made catastrophe that will impact the lives of all people in this country very quickly.”

Pressure on Accreditors

Some accreditors are looking for ways to keep abortion care in their standards without encouraging what is now a criminal activity in some states. The Accreditation Council for Graduate Medical Education, which sets the standards for residency programs, proposed new guidelines that would allow programs in states with abortion restrictions to remain accredited by helping ensure that students have access to required training in states where the practice is still legal. (This paragraph has been updated to reflect the ACGME's role in approving residencies, not in the match process itself).

“Access to experience with induced abortion must be part of the curriculum in order to ensure that physicians in training have the opportunity to gain the experience necessary to care for all of their patients’ needs,” the council wrote in a statement after the Dobbs decision.

For years, students, reproductive health-care advocates and caregivers have been calling on the primary medical school accreditor, the Liaison Committee on Medical Education, to make family planning education a universal standard for accredited institutions, just as providing abortion training is a universal requirement for residencies. Those calls have only grown louder since the Dobbs decision.

“Losing accreditation means you lose an incredible amount of money, and it is a black mark against your institution,” Merritt said. “That’s the only leverage we have.”

Veronica Catanese, the committee's senior director for accreditation services, told Inside Higher Ed that the committee “does not prescribe specific curricular content to be included in an M.D.-granting medical school’s curriculum,” and so accreditation standards will not be changed in light of Dobbs.

“Each individual medical school is responsible for developing a medical education program and curriculum that ensures medical students, upon graduation, have the professional competencies appropriate for entry into any residency program and for the subsequent contemporary practice of medicine,” she continued.

Merritt said she understands it’s a “long ask” to push accreditors and universities to draw a line in the sand around a practice that is now illegal in many states. But she said that when it comes to women’s reproductive health, she hopes more institutions see it as a risk worth taking.

“We should not be altering the basic standard of residency experience in training to fit a narrow and regressive legal analysis,” she said. “Unless we want to see people lose their fertility and lose the best quality of care and potentially their lives, we have to take on a huge level of risk.”

Exacerbating Regional Inequities

Freehill was born and raised in Louisiana, and she earned her medical degree there, at Tulane University. But in 2009 she went to Philadelphia for her residency, and she stayed in the Northeast as a practicing ob-gyn for 13 years before eventually taking a job back in her home state four years ago.

She was thrilled to return to Louisiana, but were she faced with the decision now, in the wake of Dobbs, she said the choice would be much harder.

“It would not have been easy,” she said. “I would have had to think twice.”

In red states, medical students, particularly ob-gyns, have been matching with residencies out of state for years—especially as the number of clinics providing abortions in those states has decreased. Now, physicians say, clinics in states that have promised to protect abortion rights will be even more swamped with patients than ever, cutting into the time and resources they can afford to spend training students.

Freehill said that before they partnered with the Hope Clinic, LSU often sent its ob-gyn students out of state for abortion training due to the scarcity of reputable clinics in Louisiana. She said the university is exploring the possibility of reviving that practice, but that with more and more programs looking to out-of-state residencies in the wake of Dobbs, it might be more difficult than before.

“We’re one of 24 states that are going to be looking into sending students out of state now,” Freehill said. “We’re not the only residency program trying to figure out what we’re going to do.”

Lager said that in the past UCSF has welcomed medical students from states where residencies that offered abortion training were few and far between. She said the university would continue to do so, though a major increase in demand will likely put a strain on its resources.

Lager does worry that if more students leave red states to complete their residencies, it will lead to a shortage of practicing ob-gyns in states where students lack access to abortion training.

The American College of Obstetricians and Gynecologists estimated that in 2020, there was a shortage of 8,800 practicing ob-gyns nationwide, and over half of all U.S. counties had no practicing ob-gyn. According to a 2021 study by the Association of American Medical Colleges, over half of all medical students who graduated between 2010 and 2019 practice in the state where they completed their training.

“I think that there will be this cascade effect where there’ll be even more of an issue in red states as current providers start to leave, and then as students, residents and other trainees decide to stay in places where they feel like they can still provide abortion care safely,” Lager said.

“It creates a horrible decision for doctors, but folks who are interested in providing good, patient-centered ob-gyn care are going to go where they can do it,” Merritt said.