How Will Doctors Train For A Post-Roe World?

IRA FLATOW: This is Science Friday. I’m Ira Flatow. In the week since the Supreme Court removed federal protection for abortions, many people are still wrapping their heads around what this means for their states and themselves now that abortions are governed state by state. For physicians and medical professionals, there’s fear and confusion about what practicing in a world without federal protection means.

For example, will training for OB/GYNs change? How will abortion care be taught in medical school? Joining me today to talk about how the Roe overturning could impact training of medical professionals is Dr. Maria Isabel Rodriguez, associate professor of Obstetrics and Gynecology at Oregon Health and Science University in Portland. Welcome to Science Friday.

MARIA ISABEL RODRIGUEZ: Thanks so much. It’s great to be here with you.

IRA FLATOW: Nice to have you. Tell me what kind of concerns are you hearing from fellow OB/GYNs after the fall of Roe?

MARIA ISABEL RODRIGUEZ: Gosh, it’s hard to know where to start. All of us are incredibly concerned about what this is going to mean, most importantly, for the care of the women that we see every day. How are we able to provide care for them when it’s being legislated by laws that are written vaguely and aren’t always clear as to the impact?

Abortion is an essential part of healthcare. We can’t just silo one area of reproductive healthcare without there being far-reaching implications. And this is something that we’re all trying to sort through and figure out how to best still provide evidence-based care for the women we see.

IRA FLATOW: Mm-hmm, and for years, if you look at a map of the US, you see a shortage of OB/GYNs in many states. Why is that?

MARIA ISABEL RODRIGUEZ: Well, exactly. I think there’s multiple things to reflect on there. And part of it, it might have to do with hospitals closing in rural areas, simply because of the costs of maintaining a labor and delivery, and then that leading to fewer OB/GYNs in the area.

But there’s also been a shortage of abortion providers for years. Even though OB/GYN residencies, since 1995, have said that it’s a requirement to teach abortion, we know from recent surveys that about 80% of them have had challenges doing so, either from institutional reasons of not allowing abortion training or for state policies. And that’s led to a shortage of abortion providers across the country, particularly those that are trained in providing second trimester care.

I chose to train at OHSU specifically so I would have comprehensive training and reproductive healthcare. And I’ll never forget a call I got one night as a chief resident from a woman who’d presented to a different ER in our city with a highly desired pregnancy, 19 weeks along, but had gone in because she was hemorrhaging, bleeding heavily from a placenta previa. Even though there was no heartbeat and the pregnancy was clearly not viable, there was nobody in that hospital that was trained to perform a D&E. And they were considering performing a hysterectomy. That was their only option.

IRA FLATOW: Wow.

MARIA ISABEL RODRIGUEZ: You know?

IRA FLATOW: Wow.

MARIA ISABEL RODRIGUEZ: Yes, she would have lost her fertility and ability to have any more kids. And it was a complicated call where we were trying to figure out, could we stabilize her enough with transfusions, get a helicopter, and get her to our hospital, where we’d be able to treat her with a D&E and save her, not just her life, but also her ability to have more kids.

IRA FLATOW: And that’s because the physicians in that hospital were not trained well enough?

MARIA ISABEL RODRIGUEZ: Either because of training or, sometimes, people will get a limited amount of training in their residency. But if they practice in a Catholic hospital or a religious affiliated hospital where they’re not allowed to provide that care, they’re not going to maintain ongoing competency in that skill. And we’ve really allowed abortion to become kind of siloed to either outside clinics or just a few sites. And that has significant repercussions for how we take care of people who are pregnant.

IRA FLATOW: Quickly tell us what a D&E is.

MARIA ISABEL RODRIGUEZ: A D&E is just emptying a pregnant uterus.

IRA FLATOW: Let’s talk about this problem of what is currently taught in medical schools about abortion. When do med students learn about abortion?

MARIA ISABEL RODRIGUEZ: Well, in some cases, it’s not even taught in medical school. In some medical schools, it’s mentioned as part of their kind of core curriculum in women’s health. Or they learn about it on their OB/GYN rotation, which most students have to go through. But it’s typically a fairly short amount, if it’s presented at all. But in many places, it’s only in OB/GYN residencies where it’s mandated.

And that’s problematic because half of the people all doctors are going to see are female. And it affects not just OB/GYN residents, but family medicine residents, ER residents. A variety of specialties are going to care for pregnant women. And since nearly a quarter of all American women will have an abortion at some point in their lifetime, this is a really common procedure that all physicians and healthcare workers need to be educated in.

IRA FLATOW: Yes, for example, shouldn’t we be teaching how to save the life of a mother, like in an ectopic pregnancy?

MARIA ISABEL RODRIGUEZ: Absolutely And it’s not just ectopic pregnancies, which is a life threatening emergency– it’s never going to be viable– and swift operative treatment is needed, but it’s just regular pregnancies. We have had a patient that’s been flying into us from a restricted setting five times over the last six weeks because she’s pregnant.

She has a common mental health problem, the same anxiety that’s crippling a lot of people right now. But it became worse for her during pregnancy. And she could not find anybody in her home state that was willing to take care of her out of fear that the drugs they would prescribe for anxiety might harm the fetus and that they would be liable for criminal charges.

So she kept flying to us. And her anxiety had gotten to the point where she felt like she couldn’t continue the pregnancy. Fortunately, she was able to come to us. We were able to get her the mental health treatment she needed so that her care could be stabilized. And she’s been able to continue the pregnancy.

IRA FLATOW: Yes, this seems like it’s a case where, being an OB/GYN, you’re providing very time sensitive care. Could this overturn, delay these kinds of treatments?

MARIA ISABEL RODRIGUEZ: Absolutely. We’re currently passing legislation that’s devoid of not just science, but common sense. Some of the laws are written in such a vague way that it’s incredibly hard to know how to interpret them. And they could apply to not just treatment of induced abortion, but treatment of ectopic. They could affect IVF treatment. The same skills that we use for abortion procedures are used throughout gynecology– heavy or life threatening uterine bleeding, miscarriage management, uterine biopsies.

And volume really matters in training. The more procedures and counseling you do, the better you are at efficiently providing high quality care. And with a lot of these conditions, minutes matter. People’s lives are really on the line. You can lose a significant amount of blood quite quickly. And you need to be able to intervene timely. You don’t want to be either on the phone, consulting with a lawyer, to figure out how long you have to wait before you can provide treatment. Or you want to be skilled and competent to recognize complications, and to be able to intervene quickly.

IRA FLATOW: So do you think that med schools now are going to avoid teaching OB/GYN techniques that they used to?

MARIA ISABEL RODRIGUEZ: I hope not. I hope that we’re going to see a resurgence the opposite way, where there’s going to be a recognition of how important this training is, and that we see it not just in OB/GYN residencies, but in medical schools and family medicine residencies and for ER physicians, too.

I’m afraid that we’re going to have to turn back the clock to going back to some of the complications we used to routinely see for people to understand the importance of this care, that it doesn’t just affect women seeking to end a pregnancy. This legislation is really going to affect all of us. I mean, we only have to look to countries around the world where abortion is restricted to know what’s going to happen in the United States.

Globally, unsafe abortion is a major killer of women. About every 8 minutes, there’s a woman who dies from an unsafe abortion globally. And there’s significant morbidity that goes along with that, too, whether it’s hemorrhage or infection, uterine perforations. These are all complications that have been largely eliminated since the passage of Roe in the United States.

And I think we need to expect to see not just an increase in maternal mortality rates from people having either unsafe abortion care or complications, but also women who are critically ill that are having an increase in unplanned births. And this is going to affect the people that are already suffering from the highest rates of maternal mortality in the United States– people of color and people who are lower income who can’t afford to fly out of state or can’t afford to travel even a few hundred miles to seek care elsewhere.

IRA FLATOW: Is the fact that some med schools won’t be teaching OB/GYN techniques anymore, is it out of fear of the law? Or is it because they don’t think future physicians will need these skills in many states?

MARIA ISABEL RODRIGUEZ: I think in most cases, it’s political. This is such a common integral part of women’s healthcare. I interviewed for residencies back in 2003, and I specifically sought out programs where abortion was a normal integrated part of the curriculum. And I can tell you, at multiple sites, silly reasons were present for abortion not being trained. Like, for example, a donor had made a huge gift of a new football stadium with the understanding that abortion would not be part of the top curriculum.

So it doesn’t have anything to do with evidence or reason. We all know that these are skills that all physicians need to have, as well as other allied healthcare professionals. I think it’s really important to note that while we need physicians trained in abortion skills, sometimes one of the biggest challenges, for me in being able to do an emergent case, has to do with getting nurses that are willing to participate and be part of the care as well.

As a resident, we rotated through Catholic hospitals, where there’s significantly more restrictions on the care that you can provide. And in many cases, as a physician, even though I have the recommended course of action, I had a patient I saw one night that was having heavy bleeding, again, from a miscarriage. And it was clear she needed a D&C, a simple three-minute procedure I could have done in the ER room.

But I needed to convince the nurses to allow me to do it there, to have a nurse that was willing to provide the medication for anesthesia so the woman wouldn’t be in pain. And that all takes time. And there’s a lot of misunderstanding about legality, what this means, and what’s allowed for us to do. And that’s going to Institute delays across the healthcare system in providing the life saving care that women need.

IRA FLATOW: As we know, the effects of Roe v Wade overturn are going to vary state by state. Do you think this overturn is going to change where OB/GYNs go after medical school?

MARIA ISABEL RODRIGUEZ: I think it will. We all became experts in women’s health because we deeply care about women, and we see ourselves as advocates for women’s health. And to be told that you need to practice in such a way that flies in the face of evidence and science and your patient’s best interests is incredibly hard to handle as a physician.

And while I know there will be many dedicated individuals that stay in those locations to try to fight the good fight, it’s also going to drive people out. And I think we’re going to see even further increases in maternal morbidity and mortality in those areas.

IRA FLATOW: Wow. Dr. Rodriguez, thank you so much for talking about this, this very needed conversation we have to have.

MARIA ISABEL RODRIGUEZ: Thank you so much for highlighting it.

IRA FLATOW: Dr. Maria Isabel Rodriguez, associate professor of Obstetrics and Gynecology at Oregon Health and Science University in Portland.

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