Making Choice Real

The 25th anniversary of Roe v. Wade in January of
1998 was a bittersweet celebration. While pro-choice organizations were publicly
paying tribute to a quarter-century of legal abortion, they were privately
worried that the alarming decline in the number of abortion providers would soon
strip reproductive rights of their meaning. After all, what good is the right to
an abortion if there are no doctors left to perform the procedure? Abortion
clinics, like other medical facilities, tend to cluster in urban areas; yet in
1996, one-third of American cities had no abortion services. Women in rural areas
who choose to terminate their pregnancy often have to travel hundreds of miles or
cross state lines to find a doctor willing to perform a perfectly legal operation.

The New York Times Magazine commemorated Roe's birthday in
1998 with a cover story on North Dakota's only remaining abortion doctor, a
60-year-old physician who also commuted to clinics in Minnesota, Wisconsin, and
Indiana in his six-seat plane. A majority of the nation's abortion doctors are
more than 65 years old, and access to abortion is getting scarcer with every
retirement. Between 1992 and 1996, the number of active abortion providers fell
in every state but two--North Dakota and South Dakota, which each had a single
provider in both of those years. As of 1996, only 14 percent of U.S. counties had
one (compared with 48 percent with a practicing obstetrician gynecologist).

Now, the situation is slowly beginning to change--after nearly a decade of
activism centered in medical schools and hospital residency programs. Consider
the typical student who entered medical school in 1990. By his or her third year,
the first chapter of Medical Students for Choice (MSFC), which now boasts
7,000 members on more than 100 campuses, had been formed. Since then, MSFC
has been instrumental in reintroducing abortion as a medical procedure and a
matter of public health into the curricula of the nation's medical schools. And
by early 1996, when our newly minted M.D. might have been starting a residency in
obstetrics and gynecology, the Accreditation Council for Graduate Medical
Education (ACGME) had adopted new guidelines requiring that all OB-GYN
programs offer instruction in abortion procedures.

Anti-Anti-Abortion

The National Abortion Federation (NAF) first called attention to the
crisis in abortion access in 1990, when it organized a conference (co-sponsored
by the American College of Obstetricians and Gynecologists) entitled, simply,
"Who Will Provide Abortions?" One of the biggest concerns at the symposium was
how to change attitudes toward abortion in the medical profession. Doctors who
practiced in the late 1970s and early 1980s still carried with them vivid
memories of treating the victims of back-alley abortions gone wrong; they were
committed to the idea that offering safe abortions in a clinic or hospital
setting helped to save women's lives. But by 1990, the right to an abortion had
been a reality for almost two decades, and new physicians felt little motivation
to provide a service that carried with it personal and political risks.

Young doctors now completing their residencies constitute a third generation
of potential providers. While they are even further removed from the history of
coat-hanger abortions, they are witness to another form of violence: clinic
killings. In 1993 the murder of Dr. Michael Gunn, an abortion provider in
Florida, set off an escalating campaign of harassment at facilities around the
country. The number of reported death threats on clinic workers shot up from
eight in 1992 to 78 in 1993.

That year, the anti-abortion movement not only targeted clinics and doctors
but also peppered medical schools with mass mailings. The gruesome pictures and
inflammatory rhetoric was intended to turn future doctors' stomachs and thus
discourage them from performing abortions. A particularly egregious pamphlet
headlined "Bottom Feeder," which among other affronts compared abortion doctors
to Hitler, was sent to students at the University of California at San Francisco
School of Medicine--and had precisely the opposite effect. Incensed by what she
saw as a personal attack, second-year student Jody Steinauer called the National
Abortion Federation and asked what she could do to fight back. A few months later,
Steinauer became an intern in NAF's office in Washington, D.C., and started
contacting medical students around the country to gauge their interest in
abortion issues. "It quickly became clear to me that a movement was erupting,"
she now recalls. While the first post-Roe generation of abortion providers was
staunchly pro-choice and the second was more or less indifferent, this third
wave--newly energized by the violence and propaganda of the anti-abortion
movement--could be called anti-anti-abortion. They didn't want moralists or
religious zealots determining what they could or couldn't learn in medical
school, and they started questioning the silence on their campuses and in their
curricula. During the phone calls she made as an intern, Steinauer identified a
few fellow activists and they soon founded Medical Students for Choice.

The first members of MSFC had their work cut out for them.
Despite the fact that surgical abortion is the most common outpatient procedure
for women in the United States, it was hardly mentioned in medical-school
classrooms in 1993. Nor was it a regular part of third- or fourth-year clinical
rotations in gynecology. Even more surprising, a majority of OB-GYN residency
programs did not require basic instruction on how to provide abortions or
counsel women with unintended pregnancies.

Since Roe, there has been a steady decline in the number of
OB-GYN programs that teach resident physicians how to perform abortions. In
1976, 93 percent offered residents instruction in first-trimester abortions; by
1991, only 70 percent did. And these figures massively overstate the percentage of
residents who are actually being trained: An increasing majority of the training
takes place during "opt-in" elective rotations, while the number of programs that
consider abortion a routine part of the curriculum continues to drop. As of 1991,
only 12 percent of OB-GYN programs required instruction in abortion. (Of
course, residents with religious or moral objections have always been allowed to
opt out of this cycle.)

Relegating abortion to the status of an elective is effectively not to teach
it at all. Resident doctors in hospitals often work more than 80 hours a week.
Only the most devoted pro-choicers are likely to add an abortion class or
rotation to their already packed schedule voluntarily. Logistics pose another
problem: OB-GYNs are trained in hospitals, whereas by the early 1990s, 70
percent of abortions were performed in freestanding clinics. Hospitals are more
likely to provide difficult second-trimester abortions for women with a severe
medical condition, and then only rarely. "Residents typically train in hospitals,
but hospitals do few abortions," says Susan Yanow, the executive director of the
Abortion Access Project in Cambridge, Massachusetts. "Say a program has six
residents. Each resident would have to perform 50 to 60 procedures in order to be
fully trained, but the average hospital only does 30 abortions a year. Add it up:
That's not training."

As its first national action, Medical Students for Choice collected more than
3,000 signatures to petition the Accreditation Council for Graduate Medical
Education to reconsider its residency requirements for OB-GYN programs. In
February 1995, the ACGME issued a new set of carefully worded curriculum
guidelines that, for the first time, explicitly required training in abortion
procedures. "Access to experience with induced abortion," the document read,
"must be part of residency education." The rules included an exception for
individual residents or residency programs with religious or moral objections.
"We knew that using the A-word would be a red flag," a doctor who was involved in
issuing the new guidelines explained, "so we led with the exception."

The "A-word" did indeed raise a red flag--in the U.S. Congress. Indiana's
conservative Republican Senator Dan Coats (a fundamentalist who has since
retired) countered the ACGME's requirements with the deceptively titled
Medical Training Nondiscrimination Act. Wrapping his bill in the rhetoric of
conscientious objection, Coats vilified the new rules by implying that they would
coerce residents with personal objections into performing abortions. Congress
does not have the power to overturn guidelines issued by private
medical-licensing bodies like the ACGME, but it does have substantial
leverage over medical schools in the form of federal research grants. Coats's
legislation, which passed in 1996, ensures that any residency program that loses
its accreditation over its abortion policy will continue to receive federal
funding.

Yet despite Coats's best efforts, recent evidence suggests that the new rules
have been relatively successful in reintroducing abortion into OB-GYN
training schedules. A survey by the National Abortion Federation published last
year in the peer-reviewed journal Family Planning Perspectives found that 81
percent of OB-GYN residency programs now offer some form of training in
first-trimester abortions (up from 70 percent in 1991). Even more significant is
the fact that 46 percent of programs include routine training--a threefold jump
in less than a decade.

The survey's authors were cautious in interpreting the results and noted that
the response rate was a low 69 percent (compared with 87 percent in earlier
studies). Perhaps, they speculated, uncooperative programs were wary of being
caught ignoring the new ACGME standards. And some activists, like Yanow of
the Abortion Access Project, are skeptical of the study's methodology. "If you
call the residency program you get one set of answers, and if you ask residents
themselves you get another," she claims, adding that a bit of subterfuge is
necessary in such politically sensitive research. In her group's surveys of
Massachusetts hospitals, she says, "we have women call and ask for information on
abortions, saying that they are pregnant, and see how the hospitals respond."

Even if the numbers are a bit rough, there are other signs that
residency-training opportunities are increasing. Vicki Saporta, the executive
director of the National Abortion Federation, believes that the "ACGME
training requirements have made a difference" in spite of Congress's threats.
"We've been getting calls regularly from programs that need help implementing a
new reproductive-health curriculum," she notes. NAF has since developed a
textbook (A Clinician's Guide to Medical and Surgical Abortion) and a
training packet on medical abortion, complete with computer-graphics
presentations and a study guide on CD-ROM. The organization recently helped
to coordinate eight partnerships between hospital-based residency programs and
local clinics and, according to Saporta, plans to establish eight more over the
next few years.

Basic Training

Dr. Maureen Paul, a professor at the University of Massachusetts School
of Medicine and the staff physician for the Planned Parenthood League of
Massachusetts, is one of the leaders in the effort to create institutional
partnerships between hospitals and local clinics. In the past few years, she
helped design a 10-week rotation for residents at Baystate Medical Center in
western Massachusetts to work at the Planned Parenthood clinic in Springfield. A
similar association between the University of Massachusetts School of Medicine in
Worcester and a nearby Planned Parenthood clinic will start in 2002.

But Paul is quick to point out that discussion of abortion--one of the
nation's most common medical procedures--shouldn't be left up to specialists.
All medical students learn about cancer, whether or not they are planning to be
an oncologist. Similarly, she says, "not every M.D. will end up providing
abortions, but it's important for any doctor who works in women's health care to
be able to counsel women with unintended pregnancies, to tell women who choose
abortion about the different methods out there, and then to make the appropriate
referrals." Basic training, Paul believes, should begin in medical school, before
prospective doctors branch off into their isolated specialties. "Medical students
should hear about the public-health aspects of abortion," she says. "They should
learn how to take a good patient history, to counsel women who are considering
their options, and, of course, to consider the ethical questions and think about
how their own opinions might affect their professional role as future
physicians."

Medical schools vary widely in how they present information on abortion--if
they mention the procedure at all. Harvard Medical School is known as a leader in
reproductive health, but even there training can be hit-or-miss. According to
Debbie Stulberg, a fourth-year student at Harvard who is currently the New
England regional coordinator of Medical Students for Choice, abortion is included
in first-year classes on reproductive biology and pharmacology entirely because of
student efforts. "Six years ago, students went to the professor of the
reproductive-biology class and expressed their interest in learning something
about abortion," she says. The professor responded by offering an optional
lecture. Today, after another round of student activism, the lecture is a
required part of the course.

Students usually spend the third and fourth years of medical school completing
hospital clerkships that allow them to observe working physicians in action. At
Harvard, says Stulberg, getting clinical exposure to abortion depends on which of
the four area teaching hospitals a student is assigned to for rotation duty. "If
you do your OB-GYN rotation at a hospital like Brigham and Women's, where the
procedure is fairly common, it is easy to observe an abortion. But even then, it
is not required. It has to take place during elective time, on a day when you're
not expected to be on the floor somewhere else." Students who train at a hospital
that doesn't offer abortions, says Stulberg, "would have to ask specifically and
make a special arrangement to observe at a clinic."

Tony Charuvastra, a fourth-year student at Brown University's Medical School,
observes in an e-mail response to my inquiry that opportunities for training are
available--but are certainly not required. "Students can go down the street to
the Planned Parenthood to watch first- and second-trimester abortions if they so
choose," he says. "Probably 25 percent of the class does this. But no one talks
about it, at least not openly. The problem at Brown," he adds, "is that students
aren't interested. Particularly, male students are unaware of how prevalent
abortion is, ... [and] it's seen as a problem that happens to 'other people.'"

As patchy as the training may be at places like Harvard and Brown,
instruction is nearly nonexistent at southern and midwestern medical schools.
According to e-mailed comments from Binit Shah, a student at Northeastern Ohio
Universities College of Medicine (NEOUCOM) near Akron, the NEOUCOM
curriculum has a "paucity of information about reproductive procedures." So far,
the only mention of abortion has been three short sentences on RU-486 (the
abortion pill known generically as mifepristone) in his pharmacology course
materials. "At best," he says,"it could give us name recognition of such an
option, but not nearly enough knowledge to answer questions or advise our
patients about it." Noting that "43 percent of women will receive an abortion in
their lives," Shah wonders how this omission can "possibly do justice to medical
training," and adds: "Much less than 43 percent of the population will have heart
attacks, but we have been forced to learn about cardiac disease ad nauseam."

As Medical Students for Choice continues to grow, chapters are
forming in unlikely schools around the country--including NEOUCOM, where Shah is
the school's coordinator. There are now five chapters in Texas and one in Indiana,
Dan Coats's home state. Catherine Direen, the executive director of the
organization's national headquarters in Berkeley, California, estimates that
group members "have made substantial changes in at least one-third of the medical
schools in the country." The extent of the changes, of course, depends on the
school's location and institutional affiliation; Catholic schools and schools in
conservative areas are much less likely to introduce information about abortion
in the classroom. On one end of the spectrum, Direen points to the Stanford
University School of Medicine, where MSFC members designed and implemented a
10-week class on reproductive health with information on medical and surgical
abortions, contraception, and adoption. Last year, 50 students took the class.
"In schools that aren't as supportive," she says, "the main work is just finding a
neutral faculty member who is willing to introduce some mention of abortion into
a class on anything from pharmacology to family medicine or, of course, in an
OB-GYN course." At some conservative schools, the MSFC chapters don't dare to use
"Choice" in their name but instead call themselves Medical Students for
Reproductive Health.

Even in a supportive environment, curriculum reform can be held hostage
by recalcitrant professors or slowed down by multiple layers of bureaucracy.
Loren Roth, a first-year student at the Tufts University School of Medicine,
recalls that when her biochemistry professor introduced the class to
methotrexate, a drug used in chemotherapy, he neglected to mention that it is now
being prescribed for medical abortions. "It was a glaring omission," she says.
"At this point, I associate methotrexate very explicitly with abortions. So I
approached him after class and asked him why he didn't mention methotrexate's
other use. He balked and gave me excuses, saying that he doesn't have time to
bring it up." Eventually, Roth adds, after a five-minute exchange, her professor
conceded her point.

Vicki Saporta of NAF is optimistic that MSFC's efforts to reform
curricula at medical schools and residency programs will eventually solve the
shortage in abortion providers. "If only half of the students in MSFC add
abortion to the services they provide when they graduate," she says, "that could
almost double the number of providers in the United States." Indeed, half of the
students I spoke with who are active in MSFC plan to provide abortions.
("Whatever specialty I go into," says one third-year student at Tufts who
requested anonymity for fear of being personally targeted by anti-abortion
extremists, "it's important that I provide because so few doctors will actually
do it.") The other half are preparing for careers in fields like psychiatry and
pediatrics, but they emphasize their commitment to ending abortion's confinement
to the margins of medicine.

Because the vast majority of abortions in this country are performed in
freestanding clinics, many doctors now think of the procedure as something done
by "other people." The word abortionist still has a pre-Roe taint of
clandestine greed and incompetence. And the more that mainstream physicians shy
away from abortion, the more the procedure is shunted to the fringe of the
profession. Ultimately, MSFC's most important legacy may not be members who
one day actually provide abortions but its work to rehabilitate abortion's image
so that it's no longer seen as an act of political defiance but as a basic medical
procedure that should be readily available to all women.

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