Impact of Dobbs ‘immediate and profound’ on OB/GYN residents in Wisconsin

Key takeaways:

• Wisconsin OB/GYN residents participated in an out-of-state training partnership after Dobbs led to the cessation of abortion services statewide.
• The partnership came with administrative and financial burdens.

When the Supreme Court ruled on Dobbs v. Jackson Women’s Health Organization in 2022, abortion clinics in Wisconsin closed the same day, upending how OB/GYN residents in the state would receive abortion training.

In the wake of the ruling, which upheld a Mississippi law limiting abortion access and overturned the precedent set by Roe v. Wade, many OB/GYN residents living in Wisconsin questioned where they would obtain the abortion training required by the Accreditation Council for Graduate Medical Education (ACGME), according to Abigail Cutler, MD, an OB/GYN at UW Health and assistant professor in the department of obstetrics and gynecology at the University of Wisconsin School of Medicine and Public Health. Administrators at the University of Wisconsin School of Medicine and Public Health worked with a neighboring institution in Illinois to create a partnership in just 6 months, sending residents across state lines to obtain abortion training. But the partnership did not come about without many administrative, financial and even emotional hurdles, Cutler said, including requiring residents to move to a temporary apartment, secure new licenses and malpractice insurance.

“Residents have seen firsthand what happens to patients when they cannot access comprehensive reproductive health care, including abortion care,” Cutler told Healio. “They will not stand for it. Our residents are willing to go extra lengths to receive this training out of state.”

Healio spoke with Cutler about how the Dobbs decision has impacted OB/GYN trainee education, the efforts to create an out-of-state partnership with an Illinois institution so residents could continue training, and the lessons learned. Cutler and Ellen Hartenbach, MD, the Ben Miller Peckham, MD, PhD, chair in obstetrics and gynecology at the University of Wisconsin School of Medicine and Public Health, recently co-authored a perspective article on their experiences with trainees for The New England Journal of Medicine.

Healio: What led you to write this perspective now?

Cutler: Like all residency programs, we conduct internal program evaluations on an ongoing basis to make sure we are meeting all the requirements of the ACGME.

Routine training in abortion care has been a core educational requirement of ACGME for OB/GYN programs since 1996. Prior to that training requirement, the proportion of programs that reported routine abortion training for residents was low — as low as 12% in 1992. That was a big problem given how common abortion care is: One in four people who are capable of pregnancy will have an abortion before age 45 years.

ACGME now states that induced abortion, not just procedural management for miscarriage, must be integrated into the OB/GYN residency curriculum. Following the fall of Roe, when a significant number of residency programs like ours found ourselves in states with abortion bans or severe abortion restrictions, ACGME updated their requirement to stipulate that programs in restrictive states must plan for residents to receive abortion training at another institution.

The inspiration for this piece came from a recent meeting, where I presented our procedural numbers for abortion to members of our program evaluation committee. The numbers showed how the timeline of events since Dobbs had impacted our residents’ procedural volume and education. It was striking to see how quickly our program took a hit after Dobbs and how integral our out-of-state partnership was in helping us to recover that lost training.

Importantly, the numbers also demonstrated that it was not until we were able to return to providing abortion in our own state that our educational experience fully recovered. That underscores the main point of our piece: While training partnerships are invaluable in so many ways, they cannot be the sole solution. Educators and leaders in places with abortion bans or other restrictions must work tirelessly to reverse those restrictions in their own health care settings.

Healio: What were some of the concerns residents shared with you after Dobbs?

Cutler: The impact on all of us, but particularly on our residents, was immediate and profound. The day of the Dobbs decision, abortion provision essentially ceased across Wisconsin. This threw into immediate question how we, in the hospital setting, would provide care for patients facing pregnancy complications. Residents are on the front lines of that care, so that was a concern right away. We were also concerned with how we were going to meet ACGME abortion education requirements without being able to send our residents to Planned Parenthood, where our residents had long received the bulk of their routine abortion training.

Residents worried about how they were going to acquire the necessary skills in uterine evacuation — the same skills needed whether one is inducing an abortion or managing a miscarriage, or certain complications of pregnancy. Residents also expressed distress about how the legal environment was shaping the way they were learning to provide obstetric care. One resident told us, “It is terrifying to think that a generation of OB/GYNs are only learning how to practice in a post-Dobbs world.”

For about a year and a half after Dobbs, residents found themselves caring for patients who wanted or needed abortion care but unable to provide it because of the restrictions and the legal uncertainty. That led to a lot of moral distress.

Healio: To help residents receive their training, your institution set up a partnership with an academic medical center in Illinois. Can you walk us through some of the hurdles in setting up that arrangement, for residents in particular?

Cutler: We took the first steps of establishing a partnership on the day Dobbs came down. It was a complicated, time-consuming process. It required securing commitments from a lot of people — stakeholders at both hospitals, GME administrators and residents of both programs, program leadership, faculty at both places. Anytime you set up a program like this, there is a letter of agreement that has to be created and signed by both institutions. There was money required to rent an apartment so residents had a place to stay when rotating out of state. We had to ensure residents had malpractice coverage and Illinois licenses. Because of state-specific rules that dictated eligibility for the required training licenses necessary, we decided to send our third-year residents to participate in the partnership. This meant that they were not going to get abortion training during their intern year, which was always instrumental in fostering foundational gynecologic skills early in residency.

We managed to pull this off in 6 months, but 6 months is also a long time for an OB/GYN resident to be missing out on training and education.

Healio: You mention all the buy-in involved across two institutions to make this happen. How important is administrative support for an arrangement like this?

Cutler: First, we were lucky to have a willing partner. We don’t get into the burdens for the host programs, but they are not small. Paperwork is burdensome. They must also secure buy-in from their residents, faculty and institutional leadership. Training an entire cohort of residents from outside your own program is a big lift, often uncompensated work in terms of time and money. There is also concern about diluted educational experiences for their own residents. It is a lot of work for unrestricted states to shoulder. This is on top of facing huge influxes of patients from states with restricted abortion access who are seeking clinical care.

Second, support from our own institution was crucial. Our efforts would not have been successful without people at the top of our health system, who prioritized abortion provision and training in our clinical and educational missions. We write about all the efforts over the years our leaders have made to ensure this training remains available to our residents. That is not easy to do, either. The costs can be high. There is pressure from state legislatures, pressure from other sources. It is clear that advocacy for abortion education access must be a priority for all hospitals, clinics and health systems, regardless of ZIP codes. Sitting on our hands is not an option.

Healio: What are the lessons coming out of this experience that you most want to convey to readers?

Cutler: One, our future OB/GYN workforce really want this training. They know how important it is because they are the ones on the front line caring for patients and their families who need this care. Residents in restricted settings know the moral injury that comes from having their hands tied — from wanting to help the patient in front of them and feeling the professional and ethical responsibility to do so but being told that they cannot.

We also learned that their counterparts, the residents living in protected states, are also willing to make sacrifices, to share their own educational experiences and their procedural volume.

Second, setting up these partnerships is not an easy task, even with leadership that is willing to put in the work. Training partnerships are invaluable in so many ways, and I am so grateful for and proud of the one we built. But these partnerships cannot be the sole solution to our nation’s challenge, which is: How do we train a future generation of OB/GYNs and physicians in comprehensive reproductive health care when our ability to do so is contingent on political winds and election outcomes?

Relying on programs in protected states to ensure we are training our future workforce is not a fair or workable solution for the long-term. Especially when we know that nearly half of OB/GYN residency programs in states with legal abortion do not even provide routine abortion training, probably because of institutional policies that have nothing to do with state laws. It is incumbent upon institutions everywhere to assume responsibility for removing barriers and restrictions to abortion care and training.

Finally, we learned that amidst the huge challenges, our profession is full of incredible clinicians and advocates who are going to work incredibly hard to make sure we are doing right by our trainees and our patients.

Reference:

• Cutler AS, et al. N Engl J Med. 2024;doi:10.1056/NEJMp2407390.
• Steinauer JE, et al. Am J Obstet Gynecol. 2018;doi:10.1016/j.ajob.2018.04.011.
• Vinekar K, et al. Contraception. 2024;doi:10.1016/j.contraception.2023.110291.

For more information:

Abigail Cutler, MD, can be reached at ascutler@wisc.edu.