Learning and Not Learning Abortion
Most doctors don’t know how to do abortions. Why not?
I don’t know how to perform an in-clinic abortion (also known as a surgical abortion), or how to counsel a person about one; I also don’t know how to provide follow-up care, or how to identify and manage the rare complication that might arise—at least, no more than any other literate adult with access to the internet. The trouble is, I am a physician of internal medicine: my theoretical purview is all the organs of the adult body.
It’s true that my clinical job is what the poet John Berryman would’ve called “thinky”—fewer hands-on procedures; more diagnosis, counseling, and prescription—but I ought to know more than I do. Surgical abortion is a common procedure performed on an organ half the people on the planet possess. The fact that most doctors like me—and even my colleagues in obstetrics and gynecology—don’t know how to perform abortions is one of the great scandals of contemporary medicine in the US. As the recent Dobbs decision accelerates the 21st century’s steady dismantling of abortion rights in America, it’s worth examining how the medical profession has, for generations, systematically limited the extent to which doctors come to learn and practice the procedure.
Currently only 24 percent of ob-gyns nationally provide abortions. The American Medical Association (AMA) continues to refuse to make abortion education a curricular mandate across accredited schools, and half of all medical schools provide either zero or just one lecture on abortion. Even among specifically ob-gyn programs, only half provide routine abortion training to residents; there is currently no mandate that education or training on abortion be provided during students’ ob-gyn clinical rotations. Eighty-nine percent of US counties have no abortion providers in them at all. It is not by accident that the medical profession on the whole is bad at abortion and its accompanying care, counseling, and discourse.
With the end of the Roe era upon us, I share the general worry about a rise in unsafe abortions for people without other options, although I’m also heartened by the fact that the patients I know are often astonishingly creative at obtaining medications, procedures, and forms of care that their doctors can’t or won’t provide, often with great adaptability and courage. What worries me more is that given the moral authority still accorded to us doctors—the second most respected profession in the US for its ethics, after nurses, according to Gallup—our collective ineptitude around abortion might make it seem like maybe there is actually something wrong or untoward about abortion itself, that maybe the “safe, legal, and rare” Clintonism really is the decorous response. After all, there’s a reason why contemporary doctors are also inept at bloodletting, phrenology, and lobotomy. Mustn’t incompetence signal an essential noncentrality, a certain dodginess?
The roots of systemic incompetence in clinicians’ abortion training and practice are manifold, some old and deep, others new but frighteningly vigorous. From the start of America’s allopathic (MD-bearing, biochemically oriented) medical profession in the 19th century, US physicians took great pains to underscore two things: they were every bit as scientific and professional as their European counterparts, and they were in a completely different business from the assortment of healers, midwives, barber-surgeons, herbalists, and therapists of every stripe who also populated the American scene. When the AMA was formed, in 1847, to delineate the borders of this guild, its early membership—all male—agreed that opposing the practice and legalization of abortion was an easy way to mark the profession’s difference from nonphysician providers who offered these services (as well as a good way to drive them out of business).1 Physician organizations lobbied state legislatures against abortion, framing their crusade as a war against quacks and charlatans.
By the 1860s, the success of their efforts to criminalize abortion in most states kicked off what the sociologist Kristin Luker dubbed the country’s “century of silence,” during which abortion was still widely practiced and discussed but effectively wiped from public and political discourse. This silence had a lasting effect, as the original, historical silence of the time was doubled by a second, historiographical silence on the part of later scholars who treated reticence to speak publicly about abortion during the period as evidence of its absence. (The impact of these supposedly mute passages in the historical record is more than academic, since one of the tests of whether the abortion right is protected under the due process clause of the Fourteenth Amendment asks whether the liberty is “deeply rooted in this Nation’s history and tradition.”)
By the late 19th century, physicians’ anti-abortion language shifted to focus on abortion as “physiological sin,”2 cleverly dovetailing scientific credentials with spiritual clout—though to doctors’ great inconvenience, American clergymen and religious groups were by and large uninterested in turning the issue into a cause. Within the pages of their professional journals, physicians wrote editorials advising their colleagues on how to point out the immorality of abortion to their local clergymen, and complained about how various churches were sluggish in allying with doctors in this new moral crusade.
The everyday care of women’s bodies is a once-universal medical skill that fewer and fewer US physicians now possess.Tweet
Some of these guild professionals were economically self-interested players hoping to increase allopathic medicine’s market share, but plenty were true believers in a positivist view of medicine that held to an essentially monotheist schema substituting Nature, Order, or Reason where a deity used to be. Case reports abounded with pronouncements like that of David Humphreys Storer, who wrote that much perimenopausal and postmenopausal uterine disease and chronic illness could conceivably be the body’s retribution for earlier abortions, since nature’s law “cannot be broken with impunity” and the “Lawgiver is inexorable.”
Historians like Leslie Reagan, Carroll Smith-Rosenberg, and James Mohr have shown how early professional societies of physicians targeted, in particular, “the midwife problem”—a major source of lost revenue for doctors, since childbirth reliably happens in ample numbers every year—and worked to associate midwives with squalor, incompetence, and perhaps most successfully “criminal” activity like abortion. Professional manuals warned (male) doctors against “jealous midwives and ignorant doctor-women” who might both steal business and befoul the populace through their dubious practices. (In 1907, a New York City official wrote that one might “go so far as to say that the two terms ‘midwife’ and ‘abortionist’ are synonymous.”)
The physician societies’ next targets were medical schools that pulled too much from alternative or non-allopathic healing traditions, used local faculty instead of national recruits, admitted students with atypical credentials (often correlating with gender, race, and class), or lacked well-equipped laboratory spaces—including those that had maintained cooperative relationships with midwives and colleges of midwifery. In 1908, the high school teacher and amateur philosopher of pedagogy Abraham Flexner was hired by the Carnegie Foundation to assess the state of American medical schools with the aim of instilling “educational patriotism” and “medical patriotism”—that is, ensuring that a school “will not take up the work of medical education unless it can discharge its duty by it . . . or else it will drop the effort to do what it can only do badly.” His 1910 Flexner Report resulted in the rapid disaccreditation and closure of many institutions that were preparing fledgling clinicians for the real world as best they could. Of the 160 US medical schools that existed before 1910, only 85 were still extant by 1920.
While Flexner’s report was a victory and a relief for the AMA—defining the acceptable medical school standard by negation and convincing the public that graduates of the schools left standing possessed a uniform competence worthy of trust—the disaccreditations were a catastrophe for the medical profession’s few inclusive entry points. Five of the seven medical schools that taught Black students closed, as did all but one medical college for women. One 2020 study estimated that more than thirty-five thousand additional Black physicians would have practiced medicine in the 20th century had those five schools not been shuttered. Within a generation, the number of women doctors dropped by a third.
A rush among physicians and institutions to dissolve associations with midwives led to the bankruptcy of several of the country’s most prominent midwifery colleges. Formal schools of nursing, which had begun to appear in the United States in 1873, provided a vocational outlet for women drawn to health care with declining options as either physicians or midwives. But nursing schools specifically did not teach the delivery of babies, nor the provision of abortions, and advised nurses to defer to physician and hospital discretion regarding the treatment of unwed pregnant women—such as the so-called first-time loser policy, whereby a woman could deliver her first out-of-wedlock child at a hospital, but for subsequent pregnancies would have to look elsewhere.3
In the mid-20th century, reproductive and abortion care was further marginalized within American medicine by the rise of medical specialization and subspecialization. Encouraged by the growing centrality of the large hospital with its fleets of consultants—and by the rising number of physicians interested in blending clinical practice with grant-funded or industry-funded research into increasingly rarefied problems—the health-care industry fragmented. New professional pathways, certifications, and standards emerged whereby a doctor would be not “just” a doctor but a radiologist; not “just” a radiologist but an endovascular surgical neuroradiologist.
Given the explosion in biomedical knowledge and technologies between the mid-20th century and today, some aspects of this shift were inevitable: one person cannot possibly maintain a working knowledge of all of medicine, nor the dexterity and spatial memory needed to accomplish all surgeries. But the long movement toward subspecialization has been accompanied by shifts in pay and status (often mirroring the vicissitudes of the health-insurance market) that have, over time, equated rare diseases and high-tech solutions with intellectual and economic heft, while common conditions—along with the preventive and general care of the healthy public—are assumed to be the purview of doctors who couldn’t make the grade in, for example, craniofacial surgery. A famous study in 2013 found that a physician is reimbursed by Medicare and Medicaid 368 percent more for an hour of screening colonoscopies than for an hour of interviewing, examining, and diagnosing patients, and 486 percent more for an hour of extracting cataracts. Given those realities, clinics and hospitals often push physicians to spend less time on so-called cognitive services (communicating with patients about their conditions and therapeutic options) and more time on procedures.
Over time, this has led to fewer “cognitive service providers” and more proceduralists—and to a hierarchy of lucrative procedures. Reimbursement data for abortions are skewed by the Hyde Amendment, which prohibits Medicaid insurance plans from covering most abortions, but it is broadly known that abortion is on the low end of reimbursement among physician procedures, disincentivizing doctors, clinics, and hospitals from expanding the availability of such procedures, as well as trainees from focusing their work on mastering abortion skills.4 For people covered by Medicaid in any of the thirty-four states in which both state and federal governments refuse to pay for abortions, it is, of course, best that abortions be free or as low-cost as possible. But as long as earnings determine the labor supply of physicians with certain specialties, private insurance reimbursement schemes and policies like the Hyde Amendment will continue to fuel a multidecade race to the bottom, in which ever-fewer doctors provide abortion services.
Partly because talking to people about abortions, and in fact performing them, is not particularly lucrative, and partly because higher-paying and more highly technologized realms of health care accrue more intraprofessional cachet, the everyday care of women’s bodies is a once-universal medical skill that fewer and fewer US physicians now possess. Even primary care doctors often refer patients to the gynecologist when they’re due for a Pap smear, although Paps are still (perhaps wishfully) listed among the core competencies that all internists are supposed to have by the time they exit residency. And though the field of family-medicine—the generalist and consistently low-paying domain meant to attract physicians who still wish to practice whole-person care on adults and children—technically encompasses abortion care, today only 24 out of 461 family medicine residency programs provide abortion training. There are now more doctors in the US trained to provide brain surgery than there are abortion clinics in the US, with neurosurgeons enjoying substantially more pay and prestige for their work, as well as personal safety, than abortion providers.
The aim is not just to make abortions unavailable at publicly funded hospitals. It’s also to create fewer and fewer abortion-competent American physicians each year.Tweet
On a technical level, exactly how difficult it is to do a surgical abortion, compared with other things that doctors and health-care workers do, is complicated to quantify. As with other activities that are both physical and attentive (is it harder to fly-fish or bake a croissant? to breastfeed an infant or bathe a paralyzed person?), there may be no one objective answer. At the same time, there’s no reason to think that what insurance companies are willing to pay for a procedure is a valid proxy for its intrinsic complexity. A friend of mine trained in surgical abortions says that because the procedure involves technical finesse and takes place near structures with numerous, highly sensitive, and important nerve endings and can require empathic and trauma-informed response to a patient’s experience and might provide an opportunity for the astute clinician to deduce and respond to other unmet health needs their patient might have, the total level of expertise required is high. It doesn’t take a genius, though, or even an MD or DO degree. Mostly it takes time, care, and attention—the parts of medical practice most threatened by revenue-driven models of health care.
Sometimes, at work in the hospital, I find myself reciting bits of the doctor’s speech in Denis Johnson’s story “Emergency,” when a patient shows up to the hospital with a knife “buried to the hilt” in the corner of his eye:
Here’s the situation. We’ve got to get a team here, an entire team. I want a good eye man. A great eye man. The best eye man. I want a brain surgeon. And I want a really good gas man, get me a genius. I’m not touching that head. I’m just going to watch this one. I know my limits. We’ll just get him prepped and sit tight.
It’s a comic scene because sitting tight, of course, is definitely not the advisable move here. But this is the kind of speech my colleagues and I make all the time. Not my job. Wait for the subsubspecialists.
Specialization starts in medical schools. So does the teaching or not teaching of reproductive care. Medical schools are subject to the whims of state legislatures and private philanthropists, and many states have now passed laws that prohibit public funds of any kind to institutions that teach or provide abortions. Thus it’s impossible for many state medical schools—and challenging for many private ones receiving partial state support in the form of grants and tax breaks—to remain open and still offer abortion teaching and practice. As the family medicine doctor Mara Gordon has reported, some medical schools and affiliated university hospitals have banned abortion from curricula and clinical practice in exchange for public funding for something else. (In probably the crassest example, a quid pro quo arrangement in the Arizona state legislature’s budgetary negotiations meant that the University of Arizona Medical Center stopped teaching and performing abortions in order to obtain a new football stadium.) The aim is not just to make abortions unavailable at publicly funded hospitals and medical establishments. It’s also to create fewer and fewer abortion-competent American physicians each year—a gap in knowledge that follows physicians for the rest of their clinical lives.
Even in states that haven’t threatened to roll back funding for medical schools that teach abortion, aspiring doctors face additional barriers to learning. In the years following the 1973 Roe decision, well-intentioned efforts to make abortion more accessible and less onerous to patients drove the procedure out of the hospital and into ordinary clinics and doctors’ offices: in 1974, 51 percent of abortions done by physicians were performed in clinics, the remaining half in hospitals; by 2000, 95 percent were done in clinics. As a consequence, abortion was pushed further out of sight and out of mind for most medical trainees, who spend the majority of their clinical rotations in medical school and residency at the hospital.
The tide is slowly turning to emphasize outpatient ambulatory care as a necessary facet of medical education, but the step exams and board exams that shape trainees’ career prospects, the quest for letters of recommendation from academically prestigious referees, and the pressure to attain excellence in the research lab and hospital all relegate community-based learning to an afterthought for many doctors-in-training. In most medical schools and residencies a distinct minority of one’s time is spent doing outpatient care—sometimes a half-day per week, or a week or two every couple of months.5 Yet these sites away from hospital and lab—safety-net clinics for un- or underinsured people as well as the middle-class and tony “concierge” clinics where the more privileged get their care—are precisely where abortions generally happen.
What can a doctor or an aspiring doctor do to combat these structural problems? Many medical students are agitating to have more of their education shifted away from the hospital and the lab and toward community clinics, but they’ll also need help from federal legislators, since one perverse incentive anchoring trainees to hospitals is the means by which Medicare pays for the training of future doctors. Under its current funding structure Medicare pays hospitals and health systems—not training programs directly—a per-resident sum meant to subsidize the resident’s salary as well as other costs incurred in their education. Even when a particular residency program commits to a serious overhaul, it has only so much control over how those dollars are allocated.
Doctors and health-care workers-in-training shouldn’t have to be prodigies or especially altruistic to become good abortion providers and allies.Tweet
In the meantime, the number of medical student-run “free clinics” offered pro bono during students’ own discretionary time has more than doubled since 2005, pointing to an otherwise unmet hunger to provide high-impact community care outside the confines of the inpatient wards. The AMA’s caucus of medical students routinely advances resolutions to improve students’ outpatient training. Medical students, residents, and fellows motivated to learn abortion care are already finding one another. They are traveling to achieve the necessary training at workshops, conferences, and external clinics when training isn’t available at the clinics affiliated with their medical schools. Funding these efforts is an important way to ensure the expansion of the number of abortion-competent health-care workers in the coming decades. Currently, students often do this on their own dime or seek financial assistance from organizations like Medical Students for Choice and the National Abortion Federation, which funds externships for trainees wanting abortion education beyond what their home institution offers. The post-Dobbs flurry of crowdfunding efforts to connect pregnant people with Plan B pills, medical abortion pills, travel, lodging, and coverage for the out-of-pocket costs of surgical abortions is of course a critical present-tense stopgap to prevent forced births. What would have a more profound multiplier effect is organized aid for medical trainees, such that a first-gen student in rural Texas, pursuing medical school through a combination of student loans and financial aid, could get excellent abortion training out of state during breaks from her mandatory school curriculum.
Furthermore, medical professionals can advocate to bring more abortions into the regular purview of hospital care while also pushing for increased access in the clinics where abortions are taking place. Doing so would have the salutary effect of bringing abortion in from the periphery of medical education (meeting students and residents where they can be found) and would also make hospitals share resources and risk with outpatient abortion providers, who currently take on little of the former and nearly all of the latter. Hospitals—including formally “nonprofit” hospitals, some of which are more profitable than their taxpaying counterparts—compete for patients, skilled employees, premier trainees, national and regional rankings, grants, and various perks. Organized groups of current and prospective health-care workers, physicians in particular, might be capable of applying critical pressure on several of these factors, compelling hospitals to vaunt their newly expansive abortion access policies if they want to attract and retain their hefty student tuitions, their per capita Medicare subsidies for resident training, and the prominent clinicians and researchers that bring patients of all kinds through the door. US hospitals have been loath to make this shift for fear of overwhelming numbers of patients, unwanted publicity, and aggressive anti-abortion demonstrators.6 At this late date, though, it seems unconscionable that any of us in health care permit ourselves to opt out of abortion care’s inconveniences.
When I think of my own case, I ask myself: Why didn’t I learn more about discussing, providing, and giving aftercare for abortion during my years of medical school and residency? I attended the few lectures offered and looked at the pamphlets, zines, and cell phone shots of PowerPoint slides in hotel ballrooms brought back by my friends who made elaborate travel arrangements to attend trainings around the country. Though my grades were good they were not excellent, and it felt like a herculean effort just to meet the everyday expectations of medical training, let alone to organize the time and travel required for a supplementary program of study. Unlike almost any other topic in medicine (except other socially charged ones, such as addiction medicine), abortion training is currently treated in most institutions as a community service experience or a personally enriching extracurricular at best. At worst, it’s treated as taboo.
I’m glad that some of my friends disagreed—that they schlepped to abortion trainings on weekends and school breaks, applied for independent studies and self-directed elective time, and even followed through in their post-residency careers and continue to provide abortions today. But doctors and health-care workers-in-training shouldn’t have to be prodigies or especially altruistic to become good abortion providers and allies. Making abortion a central part of on-site education and training for medical students in states where this is still possible—and making discussion, referral, and aftercare an ordinary and mandatory competency of all physicians regardless of specialty—seems like a good place to start.
Bringing hospitals back into the elective abortion business would do a great deal to improve the comfort and expertise of doctors-in-training around abortion. Curricular mandates by the major medical professional societies would do the rest. Doctors will need to give credit where it’s due to nonphysicians (never something we’ve been great at as a profession, and especially not since the formation of the AMA): several studies demonstrate, unsurprisingly, that “mid-level” providers such as nurses and midwives perform first-trimester surgical abortions just as well as MDs. Research is underway comparing outcomes by provider type in second-trimester abortions. As more data show how skilled nonphysicians are at providing various forms of abortion, the medical establishment will have to resist the age-old temptation to stifle or control this upwelling of potentially autonomous or semiautonomous talent. Indeed, given the current dismal ratio of abortion-providing physicians to the total number of medical students and residents today, much of the abortion training of future doctors will likely need to be led by nurses, nurse practitioners, physician assistants, midwives, and others. This inversion of the conventional hierarchies of health care is good medicine for us all.
The AMA did not admit women until 1876 and had no female board members until 1989. ↩
The legal scholar Reva Siegel provides an exhaustive review of the 19th-century campaign of physician organizations against abortions, midwives, and non-allopathic practice in the excellent “Reasoning from the Body” (1992). ↩
For an excellent overview of the rise of the modern American hospital, see Charles E. Rosenberg’s The Care of Strangers: The Rise of America’s Hospital System (1987). ↩
Federal Medicaid funds cover abortion fees only in case of rape, incest, or life endangerment of the mother, although sixteen states pull from their own budgets to make up the difference for Medicaid users who seek abortion for other reasons. ↩
In 2001, the ACGME, the accrediting body of medical schools, mandated that at least one third of medical students’ clinical training take place outside of hospitals in outpatient clinics. This rather meager fraction, meant to be taken as a floor, often becomes the ceiling: by some estimates medical students still receive only about 20 percent of their clinical training in the outpatient setting, despite whatever numbers medical schools may be reporting to the ACGME. ↩
For a detailed history of this tendency, see Eyal Press’s excellent book Absolute Convictions. ↩