On June 24, 2022, the U.S. Supreme Court ruled in Dobbs v. Jackson Women’s Health Organization that “the Constitution does not confer a right to abortion. Roe [v. Wade] and [Planned Parenthood of Southeastern Pennsylvania v.] Casey must be overruled, and the authority to regulate abortion must be returned to the people and their elected representatives.” No. 19-1392, slip op. at 69.
The Court’s decision sent shockwaves across the legal and political landscape. This was due, in part, to many states’ “trigger laws” that would outlaw abortion after some set period of time after Roe v. Wade was overturned, as well as states that might now pass new restrictions on abortions. In either case, the effects are also being felt in the realm of graduate medical education. In particular, the Dobbs decision has wrought consequences for residency training in gynecology and obstetrics (OBGYN) that are just now being addressed months after the majority’s opinion was issued, with more adjustments to be made in the coming months and years.
Until recently, the Accreditation Council for Graduate Medical Education (ACGME) required that the OBGYN residency programs it accredits to “provide training or access to training in the provision of abortions” as part of its planned curriculum, with the opportunity for residents to opt-out of that aspect of the training based on moral or religious objections (former Sections IV.A.6.d of the Program Requirements). Notwithstanding this requirement, according to news reports, even prior to Dobbs, some residency programs did not offer training for induced abortions to OBGYN residents. Indeed, just two weeks after the Supreme Court heard oral arguments in Dobbs, but before a decision was issued, the Texas Attorney General issued a formal opinion letter advising that the “Coats-Snowe Amendment, found in 42 U.S.C. § 238n, . . . requires the State of Texas to disregard Accreditation Council for Graduate Medical Education accreditation standards that compel the provision of induced abortion training on an opt-out basis, thereby allowing graduate medical education programs to provide induced abortion training on an elective, opt-in basis.”
Nonetheless, it appeared that the vast majority of OBGYN residents had access to abortion training. According to a 2020 survey, 92% of OBGYN residents reported having access to some level of abortion training.
However, trainers and practitioners have raised the concern that with many states outlawing abortion as a result of “trigger laws” or new legislation in the wake of Dobbs, the number of OBGYN residents with access to abortion training will fall dramatically. A recent commentary published in Obstetrics & Gynecology projected that the prior figure of 92% of OBGYN residents having access to abortion training “would plummet to at most 56%” with the overturn of Roe v. Wade. That same commentary noted that this likely undercounts the effect of the change in the law, in part, because it does not count family medicine residents who also would receive abortion training.
The ACGME has acted in response to the Dobbs decision. It began by notifying programs that the Obstetrics and Gynecology Review Committee would not cite any residency program for non-compliance with the abortion training requirement where abortion was prohibited by state law, and contemporaneously soliciting comment on revised Program Requirements concerning abortion training. In the ACGME’s “Impact Statement” to its interim revisions of the Program Requirements, it explained that revisions were needed in light of Dobbs making induced abortions illegal in some jurisdictions, but still ensuring that OBGYN residency programs provide “the knowledge, skills, and abilities necessary to practice comprehensive reproductive health care in the United States” in a way that prevents “any resident, physician educator, or residency program violating the law . . . .”
Among other things, the interim Requirements mandated that “Programs located in jurisdictions where there are legal restrictions on induced abortions will need to (1) make arrangements and provide support for this clinical experience to take place in another jurisdiction where induced abortions are legal, and (2) provide a comprehensive and legal curriculum on induced abortion for those residents who are unable to travel to another jurisdiction for clinical experience in induced abortion. The curriculum must include didactic activities, including simulation, and assessment on performing a uterine evacuation (surgical and medical) and communicating pregnancy options.” The new OBGYN Program Requirements resulting from the comment period, which were made effective on September 17, 2022, appear to carry over the same mandates without any substantive changes. Interestingly, though, the ACGME’s recent refresh of the Milestones for OBGYN training, which were revised in 2021, no longer include familiarity with abortion as a criterion of competency in medical knowledge.
The aforementioned concern about the effect of Dobbs on graduate medical education training has been registered by many of the leading medical authorities and specialty boards, including the Association of American Medical Colleges and the American College of Obstetricians and Gynecologists. Principal among the concerns are the loss of opportunities to learn life-saving abortions as well as to practice skills related to abortions, including miscarriage management, emergency procedures such as excessive uterine bleeding, and even biopsies. Others have voiced concerns about the influx of trainees from residency programs in jurisdictions where abortion is illegal seeking abortion training in programs that do provide that instruction.
How Dobbs affects residency training long-term remains to be seen, but there is no mistaking that the decision overturning Roe v. Wade is causing the ACGME and the programs it accredits to adapt rapidly to a new reality. There are still pathways to obtaining abortion training, but it will require a great deal of effort and extra cost to make it happen.
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