How the Dobbs decision shapes the ObGyn workforce and training landscape

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Six months after the Supreme Court decision that overturned the constitutional right to abortion, trainees across the United States are asking a critical question in the current resident recruitment season: How will the restrictions on abortion access affect my training as an obstetrician-gynecologist, and will they impact my ability to be the kind of provider I want to be in the future?

Among the myriad of downstream effects to patient care, the Dobbs decision will indisputably impact the scope of residency training for those that provide reproductive health services. Almost half of ObGyn residents train in states that have abortion restrictions in place.¹ New educational milestones for abortion training, which are a requirement by the Accreditation Council for Graduate Medical Education (ACGME), were proposed quickly after Dobbs, guiding programs to offer opportunities for training in nonrestricted areas or the “combination of didactic activities, including simulation” to meet the training requirement in abortion care.²

Like many providers, residents already are grappling with precarious and risky circumstances, balancing patient safety and patient-driven care amidst pre-existing and newly enforced abortion restrictions. Whether managing a patient with an undesired pregnancy, severe medical comorbidities, unexpected pregnancy complications such as preterm premature rupture of membranes, or bleeding, or substantial fetal anomalies, ObGyn residents cannot gain the experience of providing the full scope of reproductive health care without the ability to offer all possible management options. While some enacted abortion restrictions have exceptions for the health of or life-saving measures for the mother, there is no standard guidance for timing of interventions, leaving providers confused and in fear of legal retribution. At a time when trainees should be learning to provide patient-centered, evidence-based care, they are instead paralyzed by the legal or professional consequences they may face for offering their best medical judgements.

Furthermore, the lack of exposure to dilation and evacuation procedures for residents in restricted practice areas will undoubtably decrease their confidence in managing acute complications, which is one of the critical facets of residency training. In a surgical field where repetition is crucial for technical competence, highlighted by ACGME minimum case requirements, the decreased volume of abortion procedures is a disadvantage for trainees and a disservice for patients. While anti-choice promoters may argue that involvement in surgical management of early pregnancy loss should suffice for ObGyn training in family planning, this piecemeal approach will leave gaps in technical skills.

The fear of legal ramifications, moral injury, and inadequate surgical training may lead to the siphoning of talented trainees to areas in the country with fewer restrictions.³ Dobbs already has demonstrated how limiting abortion access will deepen inequities in reproductive health care service delivery. Approximately 55% of ObGyn trainees and nearly two-thirds of maternal-fetal medicine graduates join the workforce in the state where they received their training.⁴ Medical students will seek opportunities for high-quality ObGyn training in areas that will help them to be well-prepared, competent physicians—and more often than not, stay in the area or region that they trained in. This will lead to provider shortages in areas where access to reproductive health care and subspecialist providers already is limited, further exacerbating existing health disparities.

During this recruitment season, trainees and residency programs alike will need to reckon with how the ramifications of Dobbs will alter both the immediate and long-term training in comprehensive reproductive health care for the ObGyn workforce. ObGyn trainees have taken a stand in response to the Dobbs decision, and nearly 750 current residents signed onto the statement below as a commitment to high-quality training and patient-centered care. Clinical experience in performing abortions is essential to the provision of comprehensive evidence-based reproductive health care, and access to these procedures is as important for physicians-in-training as it is for patients.

Actions to take to ensure high-quality abortion training in ObGyn residencies include the following:

• Connect with and stay involved with organizations such as the American College of Obstetricians and Gynecologists (ACOG), Physicians for Reproductive Health (PRH), and Medical Students for Choice (MSFC) for initiatives, toolkits, and resources for training at your institutions.
• Seek specific abortion training opportunities through the Leadership Training Academy (offered through PRH) or the Abortion Training Institute (offered through MSFC).
• Ensure that your residency program meets the ACGME criteria of providing opportunities for clinical experiences for abortion care and work with program leadership at a program, state, or regional level to enforce these competencies.
• Reach out to your local American Civil Liberties Union or other local reproductive legal rights organizations if you want to be involved with advocacy around abortion access and training but have concerns about legal protections.
• Have a voice at the table for empowering training opportunities by seeking leadership positions through ACOG, ACGME, Council on Resident Education in Obstetrics and Gynecology and the Association of Professors of Gynecology and Obstetrics, American Medical Association, Student National Medical Association, and subspecialty organizations.
• Vote in every election and promote voting registration and access to your patients, colleagues, and communities. ●

Continue to: The implications of the Dobbs v Jackson Women’s Health Organization decision on the health care and wellbeing of our patients...