Navigating Difficult Terrain One Year After Dobbs

From the July 14, 2023 issue of the Transformational Times

As Predicted, Things Have Gotten More Complex: Navigating Difficult Terrain One Year After Dobbs

Adina Kalet, MD, MPH and Elizabeth (Libby) Ellinas, MD, MS

It has been a year since the US Supreme Court ruled in Dobbs vs. Jackson Women’s Health Organization. As director of an institute dedicated to the transformation of medical education with character, caring, and competence and the leader of our institution’s Center for the Advancement of Women in Science and Medicine, we are monitoring the cascade of consequences these changes are having. We continue to believe that robust discussion, dialogue, and debate surrounding this complex issue is essential. In this spirit, we once again invited a range of authors to share their perspectives with the Transformational Times ...

In the June 24, 2022 issue of the Transformational Times, anticipating that the US Supreme Court would overturn federal protections of access to abortion, we predicted that the healthcare landscape would become more complex. We have not been disappointed. This ruling has already had significant nationwide impact. The intended and unintended consequences continue to evolve.  

The legislative pot continues to roil. Abortion is now illegal in thirteen states with a few going as far as criminalizing health professionals for offering abortion care. Sixteen states have voted to affirm some sort of abortion rights, with Michigan, California, and Vermont making abortion access part of their constitutions. As of June 13, 2023, nearly 700 abortion bills had been introduced, split evenly between those that would expand and those that would restrict access. This has significant implications for medical education and the health of the public. 

The Dobbs decision is affecting where physicians train and work

Physicians, as a group, are strongly committed to preserving professional autonomy. Independent of party and religious affiliation, data demonstrate that we suport ensuring patients receive the best individualized care possible. To the extent that physicians see abortion bans as interfering with the doctor-patient relationship—which is built on the trust that there will be absolute respect for privacy, confidentiality, and a commitment to shared decision making—physicians may choose to practice in places where they can share with their patients all available reproductive healthcare options.

In a recent survey of physicians (Vinekar, 2023), 82% of respondents reported that they preferred to work or train in states with preserved access to abortion. Seventy-five percent of both physician and trainee respondents report that they would not even apply for a job in a state that imposed legal consequences for providing abortion care. Early data from this last national residency match show fewer applications to residencies in the most restrictive states (across all specialties), although the residency program “fill rates” remain stable. There has been 5% drop in the number of students applying for OB/Gyn residencies. While it will take years to see how these trends manifest, they are especially worrisome for underserved rural states and urban areas already at risk.  

In states with strict abortion bans, access to healthcare was falling prior to the Dobbs decision. These are states with the fewest physicians per capita and places where rural hospitals have been closing at alarming rates over the past decade. Wyoming, Mississippi, West Virginia, and Kansas already lose more than 40% of college graduates to other states. This “brain drain” is predicted to worsen if young people perceive that their personal autonomy is threatened. 

One in four women in America will need a pregnancy-related procedure during her lifetime. As of August 2022, 44.8% of accredited OB/Gyn residency programs are in states moving to ban abortions. This means that a significant number of physicians who are committed to providing OB/Gyn care will need to travel to learn to do routine procedures. This has implications for medical education and health care nationwide. 

Medical education and physician organizations are advocates

In June 2022, the AAMC released a statement regarding the Dobbs decision, predicting that it would “significantly limit access for so many and increase health inequities across the country, ultimately putting women’s lives at risk, at the very time that we should be redoubling our commitment to patient-centered, evidence-based care that promotes better health for all individuals and communities.” In the ensuing year, the AAMC’s Group on Women in Medicine and Science (GWIMS) and Medical Education Senior Leaders (MESL) have create a joint Reproductive-Health Task Force which produced a white paper (look for it soon on the AAMC Reproductive Health web page), and a series of webinars to discuss those consequences to reproductive health. You can access a recording of the first webinar here and sign up for the second webinar, which looks at the Dobbs’ decision’s effect on education here.  

The AAMC is taking a data-driven approach to the effects of Dobbs on medical students, residents, and residency selection. The Task Force is considering adding two questions to the Graduate Questionnaire that is completed by all students as they finish medical school; those questions would assess whether and how the Dobbs decision influenced their choice of specialty and location. The AAMC sees reproductive health under Dobbs as “complex and challenging for patients, providers, and learners” and will continue to provide support to the academic medicine community as we continue to navigate that complexity.

Jesse Ehrenfeld, MD, MPH, the newly-installed President of the American Medical Association and a member of the MCW faculty, reiterated in his inaugural speech and in an interview, the AMA’s position. “Let me state unequivocally that we oppose strongly the interference of government in the practice of medicine. And we oppose strongly any law that prohibits a physician from providing evidence-based medical care that is in the best interest of their patients.” 

In our essay one year ago in the Transformational Times, we acknowledged that our salaries and status would allow us to travel out of state if we or our families ever needed restricted care, a privilege to which many others do not have access. Many, including the American Bar Association attest to this “exacerbation of wealth disparity.” In addition, not all insurance policies pay for contraception or abortion. These potential out-of-pocket expenses—plus travel, childcare, hotels, and meals—add up, and are prohibitive for many, especially when emotionally-fraught decisions must be made quickly, work issues managed, and resources gathered. In response to this need, some companies now offer abortion travel coverage for employees in states with restrictive laws, decreasing the costs for employees at those companies. 

Preparing our students to be adaptable and engaged 

Times like these—defined by rapid change and complexity—can lead us to be both weary and wary. To care for our patients and educate our students, we need to monitor rapid changes in law, practice, and local regulation. This can make us weary. When the issue is as controversial as abortion, many of us become wary of being drawn into contentious, difficult conversations. However, we know that if physicians do not engage, the public will be worse off.  

Abortion is only one of many controversial, increasingly politicized concerns that will impact the practice of medicine over the coming era. To support our future healthcare professionals to flourish and lead, we will need to help them (and us) learn to adapt to—rather than simply comply with—rapidly evolving and challenging situations. 

Learning adaptive behavior requires intellectual skills best built through facilitated civil discourse. Woodruff (2023) at the Pritzker School of Medicine at the University of Chicago, developed a Growth Oriented Pedagogy aimed at enhancing adaption and based on a rigorous form of civil discourse. The curriculum prepares trainees to face complex real-world problems (such as well-being, career choices, and diversity, equity, and inclusion), and engages them as individuals in grappling with and learning to adapt to complex challenges. The pedagogy they have developed is both highly conceptual and pragmatic. It guides students to maintain their strong connections with the meaning and purpose in their chosen work, especially as the environment around them is undergoing rapid change. 

The Kern Institute’s Philosophies of Medical Education Transformation Lab (PMETaL), building on the work of Woodruff, is working to develop frameworks for, and faculty development to, support implementing such a growth oriented, civil discourse-based pedagogy for our new school of medicine curriculum.  

As healthcare providers, our opinions matter and we must communicate effectively to both policy makers and the public. In order to do so, our immediate work must include preparing students and physicians to engage in respectful and intellectually rigorous conversations that effectively cover difficult terrain. By doing so, we will improve the health of our communities, care for ourselves, and preserve the autonomy of the profession for future generations.  

For further reading:

Mengesha B, Zite N, Steinauer J. Implications of the Dobbs Decision for Medical Education: Inadequate Training and Moral Distress. JAMA 2022;328(17):1697–1698. doi:10.1001/jama.2022.19544

Grover A. A Physician Crisis in the Rural US May Be About to Get Worse. JAMA 2023;330(1):21–22. doi:10.1001/jama.2023.7138

Verma N, Grossman D. Obstacles to Care Mount 1 Year After Dobbs Decision. JAMA. Published online June 23, 2023. doi:10.1001/jama.2023.10151 

Vinekar, Kavita MD, MPH; Karlapudi, Aishwarya BS; Nathan, Lauren MD; Turk, Jema K. PhD, MPA; Rible, Radhika MD, MSc; Steinauer, Jody MD, PhD. Projected Implications of Overturning Roe v Wade on Abortion Training in U.S. Obstetrics and Gynecology Residency Programs. Obstetrics & Gynecology (August) 2022; 140(2):146-149. | DOI: 10.1097/AOG.0000000000004832

Woodruff, James N. MD1; Lee, Wei Wei MD, MPH2; Vela, Monica MD3; Davidson, Arnold I. PhD4. Beyond Compliance: Growth as the Guiding Value in Undergraduate Medical Education. Academic Medicine (June) 2023; 98(6S):S39-S45. | DOI: 10.1097/ACM.0000000000005190

Adina Kalet, MD MPH, is the Director of the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education and holder of the Stephen and Shelagh Roell Endowed Chair at the Medical College of Wisconsin.

Libby Ellinas, MD, MS, is Professor of Anesthesiology, Associate Dean for Women’s Leadership, and Director of the Center for the Advancement of Women in Science and Medicine (AWSM) at the Medical College of Wisconsin.