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http://www.salon.com/mwt/feature/2009/06/15/abortion_providers/index.html
Is there a next generation of abortion providers?  *As if the threat of
violence and divisive politics weren't enough, getting trained is almost
impossible*

*By Kate Harding*

Jun. 15, 2009 |

"I vividly remember our abortion training in medical school -- kind of like
some people remember experiencing a bad car accident, or a train derailing,"
says Carolyn, a 28-year-old New England OB-GYN who provides abortions (and
asked me not to include her last name or specifics of where she lives and
practices). It was 2005, and Carolyn was working nights at an abortion
clinic in Oakland, Calif. After ending a shift at 2 a.m., she dragged
herself out of bed for a 9 a.m. lecture "because this was going to be the *one
hour* of education we received on elective abortions in two years of
didactics."

The professor for that one hour, a family practice doctor, "was very
strongly anti-choice. Which would not necessarily have to be an issue if she
had been able to present the information honestly and without
editorializing." Instead, the doctor gave false information about California
state laws regarding abortion -- "she pulled [laws] from other states and
acted as though they were nationally valid" -- and promoted
long-debunked<http://www.cancer.gov/cancertopics/factsheet/Risk/abortion-miscarriage>anti-choice
myths like "abortions cause breast cancer" to a roomful of
medical students. She then told the class stories about how she'd counseled
some of her own patients against abortion, including one woman who sought an
abortion elsewhere and didn't return to this doctor, her primary care
physician, for over five years. "I don't think she understood what she was
saying -- that she had alienated and effectively failed her patient," says
Carolyn. "That was in March of '05, and I'm still angry."

Carolyn is part of the next generation of abortion providers many people are
wondering and worrying about in the aftermath of Dr. George Tiller's murder
by an anti-choice zealot and the subsequent closing of Tiller's Women's
Health Care Center. Already, 87 percent of counties in the U.S., and 98
percent of rural counties, have no abortion services. Nearly
two-thirds<http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T5P-4TC8J52-3&_user=10&_coverDate=12/31/2008&_rdoc=11&_fmt=high&_orig=browse&_srch=doc-info%28%23toc%235008%232008%23999219993%23703123%23FLA%23display%23Volume%29&_cdi=5008&_sort=d&_docanchor=&_ct=16&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=aabff88e8107cc4bc716bbd417d4446d>of
second-trimester abortion providers are over 50 years old and bound to
retire sooner rather than later. And, as a recent PBS NOW
special<http://www.pbs.org/now/shows/524/index.html>highlighted, the
number of overall abortion providers has dropped by
one-third in recent years: From 2,680 in 1985 to 1,787 in 2005. Is terrorism
working to drive young doctors away from providing legal medical care? Do
doctors who were born after the 1973 Roe v. Wade decision take abortion for
granted, not having seen firsthand the devastating effects of botched
illegal abortions? Yes and yes, probably. But another factor keeping young
doctors away from providing abortions is lack of comprehensive family
planning training in medical schools. Apart from that outrageous hour of
"abortion education," says Carolyn, "I got none in the subsequent two years
of school-sanctioned rotations."

Lois Backus, executive director of Medical Students for Choice (MSFC), an
organization devoted to improving reproductive health education for aspiring
doctors, says, "Medical school is a fairly closed world, and many, many
medical students do very little education in family planning or abortion.
The majority of medical schools have a small curriculum exposure to oral
contraceptives, but family planning as a broader issue is not covered in a
comprehensive way." A survey of MSFC student members published in the
current issue of
Contraception<http://www.contraceptionjournal.org/article/S0010-7824%2809%2900049-3/abstract>found
that at schools across the U.S. and Canada, 33 percent of the students
"reported no coverage of elective abortion-related topics." And as Carolyn
learned the hard way, the education that's available, in both abortion care
and family planning in general, is often patchy and rife with
misinformation.

How can medical schools justify glossing over aspects of healthcare that
affect half the population and, in the case of abortion specifically, close
to 40 percent of women? "To be fair, we can't teach everything to medical
students," says Dr. Mitchell Creinin, president of the Society for Family
Planning <http://www.societyfp.org/default.asp>, who also serves as director
of family planning at the University of Pittsburgh. "Every specialist wants
the students in their first couple of years to get everything. If I'm a
kidney doctor, I think they should be learning everything about renal
disease." So the question becomes, "Is teaching about abortion so important
that it must be put into the first couple of years?" Potentially, says
Creinin, the answer is yes. "You could argue that there's no excuse for not
being exposed to abortion, because it's the second most common outpatient
procedure in the U.S." However, given that many students won't pursue
specialties that would involve providing abortions, and even those who go
into family practice or obstetrics and gynecology might choose not to offer
abortions, you could also argue that it's a waste of time in an already
overburdened curriculum. "I can understand, even if I don't agree, why the
training may be relatively limited. In all fairness, they're trying to
balance everybody's competing needs and competing interests."

Still, the reasons why schools don't provide comprehensive family planning
education go beyond simple time-management issues. For one thing, the same
relentless pressure from the anti-choice movement that plagues practicing
abortion providers is also directed at medical schools. Susan
Wicklund<http://www.salon.com/mwt/feature/2008/01/22/abortion_doctor/>,
a Montana OB-GYN and author of "This Common Secret: My Journey as an
Abortion Doctor," says, "I've witnessed pressure by antiabortion groups on
administrators and professors in medical schools not to discuss abortion.
There's the threat of being picketed or boycotted at the school itself if
they do any teaching of abortion." Says Creinin, "For anything that creates
controversy, it's easy for a med school to say, 'Look, it's not worth it.'"
Furthermore, Backus points out, "Part of it also is that largely in
medicine, being equally focused on the full range of women's healthcare
needs is still a struggle. What I still hear from medical students is, they
get two to three hours on Viagra and half an hour on every contraceptive
method combined. That's the reality in American medical education."

That's even more troubling in light of
research<http://www.ncbi.nlm.nih.gov/pubmed/17981252?ordinalpos=9&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum>that
shows exposure to comprehensive family planning education, including
abortion, is a strong predictor of whether a medical student will go on to
become a provider. Says Creinin, "Some residents that come in conflicted,
most of them get an idea of what it really is. They realize it's an
important part of learning how to be a complete physician." Carolyn's
experience bears this out. "I wasn't sure how I'd feel when I saw [an
abortion], or if I really wanted to polarize my life that way," she says.
But after "meeting the women who came to that clinic, hearing about their
lives, counseling them through the procedures -- I can't imagine *not* doing
abortions." That decisive experience, it's important to note, did not come
from her school's medical program. "All of my abortion training prior to
residency was through elective extracurricular work."

At least Carolyn got exposure to abortion care during her residency.
According to Medical Students for Choice, fewer than 50 institutions in the
U.S., out of 130 accredited medical schools, offer abortion training as part
of their residency programs -- and that, Creinin says, is the point at which
the lack of such training can no longer be dismissed as an understandable
concession to competing interests. "If somebody is going to provide women's
healthcare as an OB-GYN, there's no reason that a program shouldn't expose
them to all the procedures and medical issues that women need for their
reproductive lifespan and beyond. Somebody has to be putting their head in
the sand to say abortion's not part of that." Even if a doctor never intends
to perform abortions, Creinin says, the skills gained from a comprehensive
education in reproductive health are worthwhile. Most doctors don't use
everything they learned during their residencies -- Creinin himself hasn't
practiced obstetrics in 15 years -- but having a broad knowledge base helps
physicians provide the best possible care to a wide range of patients. As it
is, "General OB-GYNs know about how to treat cancer when they never do that,
but many don't know how to treat women who have an unintended pregnancy,
which is way more common."

"Close to 40 percent of women will have an abortion, and where do they go?"
says Susan Wicklund. The lack of access to abortion itself isn't the only
problem with the provider shortage -- it also means that women who
travel elsewhere to terminate pregnancies can't get adequate follow-up
care at their local hospitals."They travel back to their tiny towns,
and they're seen by a physician who doesn't have a clue what they're seeing.
They don't understand anything about abortion or what the possible
complications may be, or how simple it is to treat the very minor and rare
complications." That ignorance often leads to overreaction on the part of
doctors and expensive, unnecessary hospital stays for women who may not have
insurance. "If these physicians had gotten proper training, this kind of
overtreatment and mistreatment wouldn't happen. Not having adequate training
has a major trickle-down effect on half the population. It's inexcusable."