Learning and Not Learning Abortion

When fewer doctors possess a working comfort with the full spectrum of reproductive health to begin with, assaults on abortion may seem to many physicians like a lamentable thing happening to some distantly affiliated and dimly imagined professional cousin.

Everyday reproductive care is a skill that fewer and fewer US physicians now possess

Protestors and police stand outside a women’s clinic in Houston, 1988.
A women’s clinic in Houston, 1988.

I don’t know how to perform an in-clinic (also known as a surgical) abortion, nor how to counsel a person about one, nor provide follow-up care, nor identify and manage the rare complication that might occur—at least, no more of an idea than any ordinarily literate adult with access to the internet, an increasing number of whom are learning just these sorts of things every day. Trouble is, I am a physician of internal medicine, my theoretical purview being all the organs of the adult body. It’s true that my clinical job is what poet John Berryman would’ve called “thinky”: fewer hands-on procedures; more diagnosis, counseling, and prescription. But I still ought to know more than I do about a common procedure performed on an organ half the people on the planet possess. This lacuna in my knowledge—shared by most of my colleagues across all medical specialties, obstetrics and gynecology very much included—is one of the great scandals of contemporary medicine in the US. As the recent Dobbs decision accelerates the twenty-first 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 themselves come to learn and practice the procedure.

Currently only 24 percent of ob-gyns provide abortions. The American Medical Association 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. 89 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 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 to the broader public 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 and phrenology. Mustn’t incompetence signal an essential non-centrality, a certain dodginess?

The roots of this systemic and widespread incompetence are manifold, some old and deep, others new but frighteningly vigorous. From the start of America’s allopathic (M.D.-bearing, biochemically oriented) medical profession in the 19th century, US physicians took great pains to underscore two things: that they were every bit as scientific and professional as their European counterparts, and that they were in a completely different business than the assortment of healers, midwives, barber-surgeons, herbalists, and therapists of every stripe who also populated the American scene. When the American Medical Association (AMA) was formed in 1847 to delineate the borders of this guild, its members agreed that opposing the practice and legalization of abortion was an easy way to mark the profession’s difference from non-physician providers who offered these services—and came with the additional hope of driving some of those non-allopathic providers out of business. The AMA succeeded in its efforts to criminalize abortion in most states by the 1860s, kicking off the so-called “century of silence” until the Roe era. In the 1860s and ’70s, much of the lobbying of state legislatures was accomplished by physician organizations, who framed their efforts as a war against “quacks” and charlatans, buttressing and defining the boundaries of respectable medicine. By the late 19th century, physicians had changed their anti-abortion language to focus on abortion as “physiological sin,” cleverly dovetailing scientific credential with spiritual clout—though to their great inconvenience, American clergymen and religious groups were by and large not particularly interested in turning the issue into a cause.1 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.

Historians like Leslie Reagan, Kristin Luker, and James Mohr have shown how early American 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 with “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. “Some go so far as to say that the two terms ‘midwife’ and ‘abortionist’ are synonymous,” wrote one New York City official in 1907.2

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 Report3 gave dismal reviews to schools that pulled too much from alternative or non-allopathic healing traditions, that did not contain well-equipped laboratory spaces, that used local faculty rather than recruiting nationwide, or that admitted students with atypical credentials (often correlating with gender, race, and class). The report resulted in the rapid de-accreditation 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 1920.4

This was a catastrophe for the medical profession’s most inclusive entry points: five of the seven medical schools that then taught Black students closed, as did all but one of the extant women’s medical colleges, and within a generation the number of women doctors dropped by a third from pre-Flexner levels. One 2020 study estimated that over 35,000 additional Black physicians would have practiced medicine in the 20th century had those five schools not been shuttered by Flexner.  But for the AMA, the de-accreditations were a victory and a relief: with Flexner’s report defining the acceptable medical-school standard by negation, it became easier to convince the broader public that contemporary medical graduates at the schools left standing would possess a uniform competence worthy of general trust. Medical schools and physicians who had maintained cooperative relationships with midwives and colleges of midwifery rushed to dissolve these associations, additionally bankrupting several of the most prominent midwifery colleges in the process. At the same time, formal schools of nursing began to appear in the United States in 1873, providing a vocational outlet for women drawn to health care with declining options as either physicians or midwives. Nursing schools, however, 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 given hospital, but for subsequent pregnancies would have to look elsewhere beyond the official hospital system.5

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 rarified 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 past century’s explosion in biomedical knowledge and technologies, aspects of this shift have been 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 towards subspecialization has also 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, for example, 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.6 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 is skewed by the Hyde Amendment, which bans federal Medicaid contributions in paying health care providers for most abortions, but it is broadly true that abortion is on the low end of reimbursement among physician procedures—disincentivizing physicians, clinics, and hospitals from expanding the availability of such procedures, as well as trainees from focusing their work on mastering abortion skills.

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 another 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 paid substantially more to do their work, and enjoying significantly more prestige and personal safety.

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, of course, 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 curriculum and clinical practice in exchange for state or public funding for something else.7 (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 aspiring doctors how to provide abortions, trainees face additional barriers to learning this basic skill. 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. But in so doing, the US health care system pushed abortion out of sight and out of mind for most medical trainees—who spend the vast majority of their “clinical rotations” in medical school and residency at the hospital, rather than at outpatient community-based clinics. Though the tide is slowly turning to emphasize outpatient “ambulatory” care as a necessary facet of medical education, the step exams and boards 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. Yet these sites away from hospital and lab—safety-net clinics for uninsured 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.8

Every morning as I approach my workplace, I put on my ID lanyard, fill out the smartphone form that testifies to my credentials and my good health that day, and flash both as I walk past the two or three security guards, legs planted apart and arms akimbo, who block the corridor that leads towards my office. The entrances used by patients and visitors have the same, with the addition of metal detectors and cordoned queues. As many hospitals have become more like airports, sometimes even with armed security details, the sense of what constitutes a “safe-enough” workspace has slowly shifted in the minds of health care workers. Among ob-gyns surveyed who do not provide abortions, “safety concerns for staff” ranks among the top five reasons cited.9 This is not to say that armed guards at a hospital are a good thing, nor that the physical danger and constant psychological menace faced by some outpatient abortion providers in conservative states is acceptable, either: both are terrible dilemmas. But the contrast between the fortress-like apparatus of some hospitals and the relatively undefended environs in which community-based abortion providers practice is striking, and drives home a lopsidedness in how and when patients and health care workers are protected as they give and receive ordinary care. The consequences of this lopsidedness have sometimes been spectacular and lethal, as Eyal Press describes in his book Absolute Convictions. Recounting the murder of one outpatient abortion provider in Buffalo, Press traces how the murder rippled through a network of other abortion providers, with the understandable fear of being next driving several (though not the author’s father, who remained a gynecologist committed to the provision of abortion) out of practice.

Especially as abortion becomes further embattled in the coming post-Dobbs months and years, more abortions could, in states where they are not outright illegal, be brought back into the regular purview of hospital care, in addition to their availability at clinics. This is by no means a solution to the reprehensible criminalization of abortion around the country, but focusing some abortion access efforts here would have the salutary effect of bringing abortion in from the periphery of medical education—by meeting students and residents where they can be found, which is in hospitals—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. As Press writes, hospitals have been loath to make this shift for fear of overwhelming numbers of patients, unwanted publicity, and aggressive anti-abortion demonstrators. 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.

What can a doctor, or an aspiring doctor, do instead? Many medical students are agitating to have more of their education shifted away from the hospital and the lab and toward community clinics, where the majority of routine health care—including abortions—actually happens. Medical students, residents, and fellows motivated to learn abortion care are already finding each other, and the training they need, through organizations like Medical Students for Choice and the National Abortion Federation. 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.

But then I think about my own case: 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 couple of 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. But my grades and evaluations were good but not excellent, and it felt like a herculean effort just to continue meeting the everyday expectations of medical training—let alone to organize the time and travel required for a supplementary program of study for myself. Rightly or wrongly, it felt like too heavy a lift.

I’m glad, of course, that my friends disagreed. But doctors and health care workers-in-training shouldn’t have to be prodigies, nor especially altruistic, to become good abortion providers and allies. Making abortion an ordinary, mandatory, central part of onsite 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. Merely 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 non-physicians (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 well.

When fewer doctors possess a working comfort with the full spectrum of reproductive health to begin with, assaults on abortion may seem to many physicians like a lamentable thing happening to some distantly affiliated and dimly imagined professional cousin. Given the endemic overwork, the labyrinthine insurance and billing arcana, and the ever-expanding body of knowledge that is medicine itself, it would almost be forgivable for doctors not to notice how abortion is being erased from medical education under our very noses, creating a vicious cycle whereby most of us continue not to know or think about a skillset and body of knowledge being steadily withdrawn from view, in medical schools as in the law. But its withdrawal is systematic and engineered, and it’s a colossal affront to each and every one of us—and to physicians’ central duty to care knowledgeably and skillfully for the bodies of others.

  1. 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). 

  2. https://www.jstor.org/stable/44449049 

  3. http://archive.carnegiefoundation.org/publications/pdfs/elibrary/Carnegie_Flexner_Report.pdf 

  4. The urge to expose and extinguish the “social evil” of ordinary people continued to drive Flexner, and the opportunity to do so on American industrialists’ dime continued to present itself: after finishing his study on medical education, his next blockbuster report on “Prostitution in Europe” was published by the Rockefeller Bureau of Social Hygiene in 1914. It is a peculiar fact of American medical history that we continue to live in a world disproportionately shaped by one man and his funders’ particular abhorrence of sexual and gendered “vices.” 

  5. For an excellent overview of the rise of the modern American hospital, see Charles Rosenberg’s The Care of Strangers: The Rise of America’s Hospital System (1987). 

  6. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1754364 

  7. https://www.theatlantic.com/health/archive/2015/06/learning-abortion-in-medical-school/395075/ 

  8. In 1974, 51 percent of abortions done by physicians were performed in clinics, the remaining half in hospitals; by 2008 95 percent were done in clinics. 

  9. https://files.kff.org/attachment/Report-OBGYNs-and-the-Provision-of-Sexual-and-Reproductive-Health-Care-Key-Findings-from-a-National-Survey.pdf 

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