By John Palmer
A recent study shows that medical students coming into professional practice aren’t being taught appropriate ways to discuss abortion with patients. This is an issue that at best reflects biases and social stigmas toward abortion, and at worst could lead to patients not getting medically necessary procedures done.
In the October 2018 issue of Elsevier journal Social Science and Medicine, Benjamin E.Y. Smith, MD, from the Fort Collins (Colorado) Family Medicine Residency at Poudre Valley Hospital, and several colleagues from Brigham and Women’s Hospital in Boston presented their findings after interviewing 74 OB-GYN medical students. Smith and his colleagues found that more than half of the students used the term “elective” to differentiate some abortions from others.
“This piqued our interest because ‘elective’ has a very specific—and confusing—medical meaning,” Smith wrote. “Within medicine, ‘elective’ describes procedures that can be scheduled in the future, and differentiates them from procedures that must be performed immediately.”
The term “elective” implies nothing about the value or importance of the procedure, he said. Unless an abortion is an emergency procedure to save the life of the baby or mother, it can generally (up to a certain point) be put off to another time—and therefore can be correctly called elective. However, Smith argues that outside of the medical arena, “elective” usually means voluntary or optional—and for some, medically unnecessary.
According to the research, Smith said most students used the term “elective” when describing abortions that they considered to be sought for so-called “social” or “convenience reasons.”
The question his research asks is whether medical students are being taught bias toward different types of abortion situations.
“The few who mentioned abortion after rape and incest were careful to clarify that those were unique social situations where abortions were not to be considered elective,” he wrote. “In our interviews, students used ‘elective’ to mark abortions sought for what they considered less-acceptable reasons or by what they considered less-acceptable people. Many students conveyed this bias by expressing that they would likely refuse to provide ‘elective’ abortions in their future practice despite being willing to provide others.”
What exactly does this mean for students coming into the field? It’s possible that they are learning from a biased group of older teachers who, despite working against standards set by the American College of Obstetricians and Gynecologists and other specialist associations, still try to gloss over the subject of abortion, the report suggests.
Smith told Stat that in his opinion, categorization of any abortion is unnecessary and unacceptable, especially when referred to with imprecise medical jargon, and places patients at risk of inferior treatment.
“One student related a story of seeing a patient transferred to an academic center from a freestanding abortion clinic for medical complications of pregnancy, but then having the patient be unable to receive care because no available faculty members would participate in an abortion that was considered elective,” Smith wrote.
In the Social Science and Medicine report, Smith wrote that students interviewed saw medical and psychosocial indications of abortions as “mutually exclusive, and became confused when interrelated factors influenced patients’ abortion decisions.”
“They ignored the voluntary nature of abortion in the setting of medical illness, sexual violence, or fetal complications, and accepted discrimination against women seeking abortion for psychosocial indications as normal and ethical,” he wrote.
Medical students can’t find training
Times are apparently slow to change. In a June 2015 article in The Atlantic, Maya Gordon, a resident in family medicine at the University of Pennsylvania, wrote about her various experiences in medical school. These ranged from a seminar for pro-choice medical students like herself where she met doctors who discussed abortion openly with their students, to situations where students had to hide the fact that they were attending such seminars.
“One woman attending medical school in the Midwest told me she had lied to her friends about where she was that weekend,” Gordon wrote. “There was a man from the South who said his anti-abortion classmates celebrated when his obstetrician-gynecologist father—one of his town’s only abortion providers—unexpectedly passed away. A student from another East Coast medical school just a few hours away from mine described how one of his classmates had been written up for ‘professionalism concerns’ for referring a patient to Planned Parenthood.”
There seems to be no real oversight on what kind of abortion training medical students should get; in fact, individual medical schools appear to decide what to include in their curriculum.
Gordon pointed out that as recently as 2014, the American College of Obstetricians and Gynecologists recommended that all medical schools offer opt-out abortion training.
“The University of Arizona College of Medicine, for example, banned abortions at its facilities in the 1970s (except those performed to save the life of the mother) as part of an agreement with the state legislature that authorized $5.5 million to renovate the university’s football stadium,” she wrote.
“The state Supreme Court upheld the decision in 1976, and elective abortions in public university-affiliated hospitals are still illegal in Arizona. (Several other states, including Kansas, Kentucky, Louisiana, Mississippi, Missouri, North Dakota, Oklahoma, Pennsylvania, and Texas, also have laws in place that restrict or ban abortions in publicly funded institutions, including state universities.) How can future physicians decide they want to provide abortions if they’ve never seen one?”
Stephanie Ho, director of primary care for Planned Parenthood Great Plains, which covers the states of Arkansas, Kansas, Missouri, and Oklahoma, wrote in a January op-ed piece in the Washington Post about how her medical school, the University of Arkansas, limited her exposure to abortion education to a half-hour guest lecture over a four-year period. It was mostly because of politics, she said, which carried over to her residency at a nearby hospital.
“Second-year residents gave presentations on a topic of their choice—and mine, on abortion, was the most highly attended and contentious that year,” she wrote. “A senior faculty member vocally disagreed with my description of abortion as a common medical service, interrupting every few sentences and quoting the Bible at me. Someone dubbed me the ‘abortion chick,’ and the nickname stuck. Whenever a patient at the clinic wanted to learn more about terminating a pregnancy, the staff would call me in to talk her through her options, even when I wasn’t scheduled on a shift. My fellow physicians didn’t feel comfortable sharing information about abortions.”
Ho left full-time practice as a hospital physician, but even as a high-level representative at Planned Parenthood, Arkansas’ strict laws against abortion hamper her work.
She says that clinics in the state can’t provide surgical abortions, because Arkansas requires facilities be outfitted comparably to a hospital surgical center. Moreover, the clinics are required by law to hand out pamphlets “filled with falsehoods about how the mifepristone pill, which ends a pregnancy, can be ‘reversed.’ ”
In addition, patients are required to submit to 48-hour waiting periods and mandatory follow-up visits, imposing costs that many patients can’t afford.
A June 2016 report from NPR says there are some places where OB-GYN residents have nowhere to be trained in abortions. A state like Texas, for example, has just a handful of clinics where residents can receive the training they need, according to the report.
“How can you have abortion provision if you don’t have trained doctors?” said Lori Freedman, PhD, an associate professor for the Bixby Center for Global Reproductive Health at the University of California, San Francisco, in the NPR piece.
Texas also has very strict laws that require doctors to read aloud to their patients a state-mandated script and listen to the fetal heartbeat before performing an abortion.
Freedman points out that in places like Texas, many OB-GYN residency programs undergo reviews from the Accreditation Council for Graduate Medical Education (ACGME), located in Chicago. These programs are reviewed to make sure residents have opportunities to learn about what the ACGME calls “induced abortion,” as opposed to miscarriage, she told NPR.
In other words, medical students learn how to “safely empty a woman’s uterus if her pregnancy is experiencing a medical complication. For situations when it’s the woman’s choice to end pregnancy, residents can hear lectures about it, perform simulations, or practice counseling skills on each other,” the NPR article noted.
The question is whether that training is enough. It’s one thing to learn to perform an emergency abortion to save a woman’s or baby’s life, but quite another to perform a scheduled abortion in a clinic, said Bernard Rosenfeld, MD, PhD, head physician at Houston Women’s Clinic, in the NPR report—and doctors should be trained to do both.
In a hospital, he said, the procedures can be performed with full anesthetic and many more skilled physicians around, but most abortions are done in clinics. If there’s a complication or if something goes really wrong, students should be educated and practiced at performing a safe abortion.
“Time is a big factor, and causing as least pain as possible, and having a very gentle touch, but all that is learned,” said Rosenfeld. “Nobody would ever say that about a cesarean delivery or a regular delivery: ‘Well, OK, you just saw one or two, so you can just do them.’ Lots of times, you’ll have uterine abnormalities and you’re not going to know unless you’ve done many procedures what to do with a uterine abnormality.”
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at email@example.com.