Patient care is a top priority for Jessica Mecklosky, a fourth-year medical student at Tulane University. “As a future physician,” she says, “my goal is to make sure my patients get to make their own choices regarding their health and their bodies. Understanding patient autonomy is an important part of being a doctor and caring for my patients.”
Clinical training in abortion and related services, Mecklosky says, is a critical part of her education to become a pediatrician with a specialization in adolescent health. “To care for my patients and to empower them,” she says, “I need to have a comprehensive understanding of reproductive health care. It affects every single patient I have in some way, regardless of their gender or whether they can get pregnant.”
But Tulane University is in Louisiana, a state that has gradually limited access to legal abortion over the past decade. Until recently, only three health clinics in the state provided abortions. They were also where Tulane medical students completed a rotation if they wanted to get hands-on experience with abortion and related procedures—training not provided as part of their medical school’s curriculum. However, by the time Mecklosky began clinical rotations in her third year of medical school in 2021, security threats at the clinics—including physical assaults, break-ins, and blockades—made it unsafe to do her rotation in Louisiana.
“I knew it was probable I could go through my entire medical training and never see an abortion procedure because I am in a state that doesn’t allow it to be part of the curriculum. That meant I had to find my own way of getting that training,” Mecklosky says. Ultimately, she traveled to the Montefiore Medical Center in New York to complete a reproductive health externship funded by Medical Students for Choice (MSFC), an organization that supports future providers of abortion and other reproductive health care.
Following the Supreme Court’s June 2022 ruling in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade and removed the federal constitutional right to abortion, the three clinics in Louisiana shut down. They currently plan to relocate to other states. The situation is similar in the other twenty-four states where abortion is now highly restricted or banned. Like Mecklosky, medical students and residents in these states seeking comprehensive education in reproductive health must find alternative ways to get the training they need. And like Mecklosky, they are likely to have limited options.
More than 930,000 abortions, both surgical and medicinal, are performed in the US each year, according to the Guttmacher Institute’s 2020 Abortion Provider Census. That number does not include the use of abortion pills obtained outside of clinical settings.
Despite the prevalence of the procedure, even before the Dobbs ruling, half of all medical schools offered either no formal abortion training or only a single lecture, according to a 2020 study by researchers at Stanford University. The Liaison Committee on Medical Education, which accredits medical school education programs in the United States, does not require medical schools to provide abortion training. “Abortion is one of the most common medical procedures, but abortion-related topics are glaringly absent from medical school curricula in the USA,” the Stanford researchers note. (Future OB-GYNs receive this training during their residency programs.)
Following Dobbs, medical students, faculty, and administrators around the United States have grappled with uncertainty and confusion about how the Court’s decision will ultimately affect medical education. Because of restrictive state laws put into place after Roe was overturned, some medical schools and residency programs are now unable to offer OB-GYN rotations that include abortion and related procedures. Many others are still determining what education they can and cannot offer in this unfamiliar legal environment.
“The first two months after the decision were incredibly chaotic, with a lot of anxiety from students,” says Pamela Merritt, executive director of MSFC. “Some medical schools told students that they would not be allowed to train out of state or receive credit for trainings they had already completed. This is all completely uncharted territory—I don’t know how we are going to navigate it.”
Faculty and students at the Warren Alpert Medical School at Brown University in Rhode Island expressed frustration after the Dobbs decision, says Benjamin Brown, an assistant professor of obstetrics and gynecology at Warren Alpert. Although abortion remains legal in Rhode Island, students were apprehensive about how the decision will affect medical professionals and patient treatment throughout the country. “Students had a lot of questions,” he says. “I heard many of them express a great deal of concern about how this would impact their ability to provide medical care.”
Local politics will now have a significant effect on the content of medical education, Brown explains. He is concerned that this will result in trainees in some parts of the country studying only a subset of standard, science-based care. “Some students will not have sufficient exposure to everything medical experts expect them to know in order to practice in a specialty,” Brown says.
Citing concerns over repercussions from administrators or the advice of lawyers, close to twenty medical faculty members and program directors in abortion-restrictive states declined to be interviewed by Liberal Education about their institutions’ response to the Dobbs decision.
The overall effect of Dobbs on medical education will be sweeping, explains AnnaMarie Connolly, chief of education and academic affairs for the American College of Obstetrics and Gynecology (ACOG). Eventually, the decision could even limit what medical educators are allowed to say in the classroom. Dobbs, Connolly notes, also affects teaching future physicians how to respond to a variety of medical situations besides elective abortion. For example, the procedure most often used to perform abortions, dilation and curettage (D&C), is also used in life-threatening emergencies such as when someone who is pregnant has a stroke, has a heart attack, or begins hemorrhaging. To prevent infection and sepsis, a D&C is also performed to vacate the uterus after an incomplete miscarriage—a situation in which a fetus is no longer viable but tissue from the pregnancy remains in the uterus. Genetic counseling, surgery for an ectopic pregnancy, early gestational ultrasonography, infertility treatments such as in vitro fertilization, cancer treatments, and morning-after contraception for sexual assault victims are all on the list of medical responses that could be restricted due to the Dobbs decision.
Providers, including medical students and residents, are often unsure whether the laws that ban abortion also prohibit these other types of treatments. Ian Peake, a fourth-year medical student in Oklahoma, reports hearing of care being delayed in medical emergencies because providers must run decisions by a legal team before they can help their patients. “In Oklahoma, we face both criminal and civil statutes,” he says. “We have a vigilante law under which an abortion provider can be sued by anyone who disagrees with their decision to provide a procedure. It’s relentless, the way the state keeps moving further and further to the extreme on this issue.”
Other medical students are also reporting feelings of moral distress when their ethical commitment to providing patient care clashes with the law and could lead to criminal prosecution. “As medical trainees,” Mecklosky says, “it is really difficult to have to look into the eyes of a patient who is trusting us with so much and tell them that we cannot help them due to rules being made by nonmedical professionals.”
Confusing legal statutes and a patchwork of laws that differ from state to state further complicate the situation for medical schools and teaching hospitals. “Abortion restrictions are intentionally broad and are intentionally written to be unclear,” Brown explains. “The more ambiguous laws are, the more doctors, residents, and medical students will have to pause to try to parse the law before providing care to a patient.”
Because the Dobbs decision sent the power to regulate abortion back to the states, each state can now have a different approach with varying interpretations of where to draw the line between when a procedure is medically appropriate and when it is a crime. “I’m concerned this will lead to different standards for education in different places,” says Eileen Fry-Bowers, dean of the School of Nursing and Health Professions at the University of San Francisco (USF). “Depending on the state, going forward, educational institutions may need to consider a variety of legal questions: Can the topic of abortion be discussed in the classroom? Is the instructor at risk if they discuss pharmacological abortion? Is the student at risk for participating in the discussion? What kind of clinical training can we offer at this time?”
Educational programs that reach across state lines have additional questions to answer. For instance, USF’s online nursing program is based in California, a state where abortion is still legal. The program must now find a way for remote students residing in states where the procedure is restricted to complete the required abortion-training practicums. “It’s a challenging time because we are tasked with trying to understand how to educate students about a topic that’s completely legal in one state and criminalized in another,” Fry-Bowers says. “We have to work out a way to do that that results in appropriately educated health care providers across the entire country.”
Educational content and quality may become overly dependent on geography, Brown explains. “When I work with a trainee, whether it’s in a classroom or a clinic, I want to teach them to understand a patient’s needs and values and then provide care that’s based in science. When politicians intrude on that process, in the end it means that patients don’t get the care they need.”
Approximately 45 percent of the United States’ 286 OB-GYN residency programs, together training around 2,600 of the nation’s 6,000 OB-GYN residents, are in states where abortion is either already or likely to be banned, according to a study published in Obstetrics & Gynecology, the journal of the ACOG. “In 2020, 92% of obstetrics and gynecology residents reported having access to some level of abortion training,” the authors of the study note. “We predict that, if Roe v. Wade is overturned, this would plummet to at most 56%.”
In September 2022, the Accreditation Council for Graduate Medical Education (ACGME) reaffirmed its long-standing requirement that OB-GYN residency programs include abortion training. Residents with religious or moral objections can opt out but must still learn to discuss the procedure with their patients and to treat complications. To sit for their medical boards, residents must complete an ACGME-accredited program.
“We’ve had this requirement for close to forty years. It is a core part of training for OB-GYN,” says John Combes, chief communications and public policy officer at ACGME. “Our only change since Dobbs is stating that if abortion is now illegal in a state, the program must provide the resident with the opportunity to train in a state where it is legal, and they must [financially] support that resident.”
Many OB-GYN medical residency programs now face a catch-22. If they offer abortion training, they could be prosecuted. If they do not offer it, they will lose their accreditation—negatively affecting their ability to recruit faculty and medical students and imperiling their Medicare funding. (Programs must take place in a working hospital or clinic and be accredited to receive Medicare funding.)
However, providing abortion training through out-of-state rotations can cause many practical challenges. The number of residents seeking such rotations will greatly exceed the current number of spots. Differing regulations from state to state for licensing and malpractice insurance also present significant obstacles. And while residents in private programs are unlikely to face funding issues, some state governments could instruct publicly funded programs to disregard ACGME rules about financially supporting residents—thus, making housing and travel expenses a problem for some participants.
Such cost burdens disproportionately harm residents from marginalized communities, who are more likely to attend publicly funded residency programs. “If a program does not pay for these residents’ travel and housing costs, they won’t be able to complete out-of-state rotations,” Merritt says. “It will make it that much harder for them to become physicians.”
Furthermore, as states such as Missouri and Texas seek to block citizens from getting abortions out of state, programs that establish out-of-state trainings could also face civil lawsuits or criminal prosecution. Even before the Supreme Court struck down the constitutional right to abortion, Texas Attorney General Ken Paxton issued an opinion in 2021 that residency programs in Texas do not need to follow ACGME rules and require abortion training. The Office of the Attorney General of Texas did not respond to Liberal Education’s request for a comment.
The overall situation is also affecting where medical students do their residencies. Initial research indicates that a significant number of all medical students are now less likely to apply to residency programs in abortion-restricted states. An ongoing research project led by Emory University recently surveyed third- and fourth-year medical students throughout the US. and across specialties about how access to abortion training will affect their residency application decisions. Sixty percent said they wouldn’t apply to residency programs in states with abortion restrictions. According to the Association of American Medical Colleges (AAMC), abortion-restricted states saw a 10.5 percent drop in applicants for OB-GYN residents from 2022 to 2023.
Most physicians end up practicing in the states where they complete their residency programs, according to the AAMC. If a significant number of students do not want to attend residency programs in states with abortion bans, existing OB-GYN shortages in several parts of the country could worsen. Medical residents may also have concerns about putting down roots in states where laws could affect their own family planning. “Residents are people,” Merritt says. “They also have to consider whether they want to do a residency in a state where, if they got pregnant, they would be subject to legal limitations.”
OB-GYN residents who do not support abortion have a different perspective on the Dobbs decision. According to the American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG), residency programs in states where abortion is banned are now more likely to offer accommodations to participants who oppose abortion. The AAPLOG website provides member recommendations for “residency programs that will not be hostile to [medical students’] Hippocratic conscience convictions against doing elective abortion.” AAPLOG asserts that students who oppose abortion will seek out residencies in abortion-restricted states.
More options are emerging for those who want an approach to medical education that excludes training in abortion and related procedures. For instance, Benedictine College, a private Catholic institution in Kansas, plans to open a medical school that will train students in an environment steeped in Catholic values about contraception, abortion, and end-of-life issues. In practice, this includes continuing to give nutrition and fluids to terminal patients as part of palliative care, not administering the morning-after pill, and counseling patients to carry pregnancy to term and to consider options such as adoption. Students will also learn Catholic doctrine about acceptable forms of contraception, such as the withdrawal method of birth control. “It is vital to train future doctors at a place like Benedictine College that understands the essential role of faith and morality in the sciences,” said Stephen D. Minnis, president of Benedictine college in a press release.
Some medical faculty who oppose abortion don’t think the Dobbs decision will have much of an effect on training future physicians. Dean Prentice, dean of the College of Health Sciences at Oral Roberts University, a Christian university in Oklahoma, says the ruling will not significantly change either medical education in the United States or how his institution trains future medical practitioners. “We will still prepare our students from a faith-based, spirit-empowered perspective,” Prentice says. “We believe that life is created by God, and it’s not our role to take it. That said, these are medical procedures—like any other medical procedure, we will continue to have open discussions about them.”
His faculty tell students that as future health care professionals, they will have choices about where to work. “If there are places that offer services that don’t align with their values,” he says, “they have the choice not to work there.”
More than two dozen colleges and universities, organizations, students, and faculty members who oppose abortion either declined or did not respond to interview requests from Liberal Education.
Advocates of abortion bans have also suggested that simulation modeling can replace hands-on experience and thus sidestep the issues posed by clinical training. In this approach, already a common precursor to direct care, residents watch videos and practice on low-tech uterine models, such as papayas. Many medical faculty and organizations disagree that such simulations can substitute for real-life experiences. “Simulation cannot replace the importance of caring for real patients in the process of educating a health care professional,” Brown says.
Almost a year after the Supreme Court decision, much remains unknown. “We won’t know for many years how this decision might impact clinicians’ decision about where to train and ultimately where to practice,” Connolly says. While she believes that the decision will make medical education more difficult and may have long-term negative implications on the profession and for patients, she also notes that many people remain dedicated to the practice of medicine in places where abortion care is now restricted.
In the aftermath of the Dobbs ruling, many medical students, residents, and faculty are expressing a renewed commitment to providing a full range of reproductive health services. “As a community of health care trainees and health care educators,” Brown says, “we need to continue to advocate for policies that will allow us to provide comprehensive care for our patients so we can continue to serve them in an evidence-based and patient-centered way. That’s why we are here, and that is why we are not going anywhere.”
Jessica Mecklosky will soon graduate from medical school. While she does not yet know where she will go for her residency or how her career will play out, she’s looking forward to the future. “I imagine my career occurring in the three spheres of advocacy, clinical work, and research—abortion and reproductive health will be a big part of that,” Mecklosky says. “I’m excited to become a doctor. I am determined to work for the good of my patients.”
Illustrations by Sébastien Thibault
Dobbs and Mental Health Education
How will abortion bans affect the training of future psychologists?
Mental health practitioners are grappling with unprecedented concerns following the Supreme Court’s Dobbs decision, including questions about how the ruling will affect the training of future psychologists. Practitioners have apprehensions about patient care, provider shortages, confidentiality, and the mental well-being of practitioners and trainees. In the following conversation with Liberal Education, Lynn Bufka, associate chief for practice transformation at the American Psychological Association (APA), reflects on how the overturning of Roe v. Wade could affect psychology education in the United States.
What are the implications of the Dobbs decision for educating the next generation of mental health providers?
When educating future therapists, you want to broadly train them in anything that might come up. Depression and anxiety can have many sources, including social issues such as not having access to necessary health care. Trainees need extensive experience in listening to difficult stories and helping patients navigate hard decisions.
At this early stage, I am not aware of specific legal restrictions that relate to educating trainees about reproductive health content knowledge—moreover, few programs offer extensive training about all aspects of reproductive health. That said, state legislatures are passing laws restricting educational content all around the country. If states legally limit psychology education related to reproductive health, mental health providers will have serious knowledge gaps in understanding their patients’ overall health and well-being. This becomes especially problematic if practitioners are unaware that they have these knowledge gaps, because they won’t realize that they need to either learn more or refer patients to someone who has the right expertise.
The Dobbs decision is also likely to change where students want to complete their training. This could lead to increased competition for some programs and an insufficient number of students for others. Also, people tend to practice where they train. We already have a mental health crisis in this country and a shortage of providers. Dobbs could make this situation worse.
How might the Dobbs decision affect the practice of psychotherapy and, by extension, training programs?
The top concern is how the decision could affect patient confidentiality—in February 2023, the APA reaffirmed that confidentiality is at the core of psychotherapy and what we do as psychologists. Therapists in abortion-restricted states are worried that protecting their patients’ privacy may ultimately result in legal complaints and criminal charges. Anything that impacts the practice of psychology impacts psychology education—so there are open questions about how different training programs will deal with this topic. It seems likely that programs in abortion-restricted states will only focus on what the law says about abortion and how to respond if a patient wants to speak with their therapist about abortion.
If therapists are concerned about legal repercussions, how will that affect patient care?
Right now, there’s a tension between what state laws say and what our professional ethics require. Ethics and best practices dictate that patients must be able to speak freely about what’s happening in their lives with the understanding that confidentiality is part of the psychotherapeutic process. Some psychologists will decide their obligation is to confidentiality and having a conversation is not the same as providing access to, or guidance on, how to obtain different kinds of reproductive care. Our job is to talk with people about the pros and cons of decisions they are trying to make about a personal dilemma. It’s not our job to tell people what to do.
How are therapists and trainees themselves affected when they need to consider political and legal issues in their medical practice?
It adds significant strain. The pop culture image of women easily deciding to have an abortion because they got pregnant as a result of casual sex is inaccurate. In reality, these are difficult decisions and difficult conversations. Psychologists want to focus on the work of helping and supporting their patients. In many states, there’s now the added burden of trying to figure out what’s safe and legally advisable when practicing psychotherapy.