By Carrie Feibel
Abortion is one of the more common procedures performed in the U.S., more common even than appendectomy. But as clinics in Texas close, finding a place in the state where medical residents training to be OB-GYNs can learn to do abortions is getting harder.
“There are places in Texas where there are OB-GYN residents who can’t get anywhere to be trained,” said a senior doctor at one Texas clinic who is also a medical school professor. The physician asked not to be named to avoid backlash from anti-abortion groups and politicians.
Clinics that used to perform abortions have closed recently in Lubbock, Odessa and other Texas cities. But the professor’s clinic, which still does abortions and trains some OB-GYN residents, can’t take up the slack.
“We’ve been approached by many different residency programs about the ability to train their residents,” she said. “Unfortunately, we just don’t have the capability to train everyone.”
The day we spoke, the doctor was spending the afternoon at the clinic, supervising a third-year resident. The resident agreed to be identified by her middle name, Jane.
During her four years of residency, Jane spent about a month doing rotations at this clinic. The experience improved her medical skills, she said, but also gave her a new political perspective on what it means to be a doctor.
“It makes it even more obvious how important it is for women to have access to abortions,” she said. The rotation made her more committed to providing abortions throughout her career, she added. “If I think a woman needs access and I have the skills to provide access, I should,” she said.
Jane listened as the senior doctor prepared her for the next patient: “She’s 21 years old, and this is her first pregnancy. She is at about eight weeks today. Do you have any questions about what we’re going to be doing or the procedure?”
Later, I asked the professor if it’s hard to teach abortion. She said it’s not difficult to teach the procedure.
“The technical procedure is the same, whether you are doing it for a miscarriage, or whether you’re doing it to terminate an ongoing pregnancy,” she said.
That procedure is known as a dilation and curettage, or “D and C.” The cervix is dilated, and then a suction instrument is inserted to remove tissue from the uterus.
D and Cs are also used to treat excessive bleeding, or to take a biopsy from inside the uterus.
“I like to say that a D and C, a suction D and C even, is bread and butter gynecology,” she explained.
OB-GYNs have always learned the D and C procedure. There’s nothing controversial about it, per se. But when it’s done because a woman chooses to end a pregnancy, it’s called an elective abortion, and to be able to perform the procedure in such a case, the doctor needs to have additional training.
Elective abortions are almost always done on an outpatient basis. To do them, doctors learn how to counsel the patients and manage their pain during the five-minute procedure. They also need to learn how to administer medical abortions — the ones that use pills.
In addition, many states like Texas require doctors to perform extra steps, such as reading out loud a state-mandated script to the woman or having her listen to the fetal heartbeat.
OB-GYN residents can’t learn all that’s required without spending time at an outpatient clinic, which is where most abortions in Texas take place.
But in Texas, there are only 18 of those clinics still in operation.
That worries Lori Freedman, a medical sociologist at the University of California, San Francisco. “How can you have abortion provision if you don’t have trained doctors?” Freedman said. “Especially the ones likely to stay in your state.”
Abortion training has become more common in the U.S. but only in some areas in the country. “We’ve trained a lot of people, but they’re staying in relatively liberal, urban areas,” Freedman said.
Texas has 18 OB-GYN residency programs. All of them undergo periodic reviews by the Accreditation Council for Graduate Medical Education, or ACGME, in Chicago.
One of the things the reviewers look for is whether residents have opportunities to learn about induced abortion, called that to distinguish it from a miscarriage.
All 18 residency programs in Texas are currently accredited, even though some of them are located in cities where outpatient abortion providers have closed.
Programs without abortion providers nearby have other options for fulfilling the training obligation, said Dr. John Potts, ACGME’s senior vice president for surgical accreditation.
He explained the residents don’t have to perform elective abortions. They can practice terminating pregnancies in the hospital, for other reasons.
“As long as they’re getting sufficient experience in some form of abortion, you know, where the mother’s life is in danger, where there’s significant neonatal abnormalities,” Potts said.
In other words, to become an OB-GYN, the resident must know how to safely empty a woman’s uterus if her pregnancy is experiencing a medical complication. For situations when it’s the woman choice to end pregnancy, residents can hear lectures about it, perform simulations or practice counseling skills on each other.
Some Texas professors maintain that minimal standard of experience is good enough — or, at least, the best they can do under the circumstances.
But I asked Dr. Bernard Rosenfeld, who has been providing abortions in Houston for decades, if he thought it really was enough to learn how to perform elective abortions.
“No, absolutely not,” he said.