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.

Journeys to Parenthood

From the June 16, 2023 issue of the Transformational Times - Father's Day

Journeys to Parenthood  

 

 

Adina Kalet, MD, MPH 

 

 

As another holiday celebrating parents approaches, Dr. Kalet shares her very personal, circuitous, and challenging journey toward parenthood. Statistics suggest the challenges she and her husband faced are shared by many other physicians … 

 

 

I always assumed I would have at least two children. My husband and I wanted a family and cherish our close sibling relationships. At 32, after completing residency and fellowship, and having started my first clinical job, I got pregnant easily. The pregnancy was uneventful, even fun at times, although I eventually needed a Caesarean section after 30 hours of labor for “failure to progress.” Even though our first child had neonatal jaundice and needed to stay in the hospital for a few days, we all went home happy and healthy.   

  

When Zachai turned two, we were eager to have a second child. After an unsuccessful year trying the usual way, we sought the advice of a reproductive endocrinologist. Except for feeling a bit insulted when he called me “elderly” (I did know that advancing age was the most common cause of infertility, but didn’t think 34 was all that old), we were eager to get going. Time was of the essence. Thus began the five most challenging years of my life.  

 

We started with a series of increasingly invasive tests. After a few cycles of medication, I had two major surgeries and one life-threatening complication. Still no pregnancy. With each “failure,” there was a swift, pressured decision to escalate the technical interventions. Because of the remarkable scientific advances, the options of Artificial Reproductive Technologies (ART) were rapidly expanding; but success rates were poorly established and thought to be highly dependent on the skill of the physicians. Deciding which team was the best made a research project out of choosing where to get fertility care.  

 

I was getting increasingly desperate. I had full-time clinical and teaching schedules and was raising a toddler. It never occurred to me to take either time off work for these treatments (it would not have been supported) or ask anyone in leadership for special arrangements. For one week of every cycle of in vitro fertilization (IVF), I needed to have daily intravaginal ultrasounds. This meant rising at 4 a.m., getting to the physician’s office, and then going to work. One Saturday morning, after another negative pregnancy test, I accidentally turned our car the wrong way on a busy avenue. Luckily, the other 6 a.m. drivers were alert, and I quickly turned the car around.  I was exhausted and heartsick. I pulled over to the curb and cried. 

 

Seeking more options 

 

In that moment, I realized that while becoming pregnant again was unlikely, having a second child in our lives was not. That week, I attended the first in a series of workshops on adoption and joined a support group for people with “secondary infertility.” 

 

A month later, in what was to be our final cycle of IVF, the physician told us that I had an “inhospitable uterine environment” (really, he said it exactly that way!) and further attempts would be futile. He said our only option of having another biological child would be gestational surrogacy.  

 

I wasn't excited about surrogacy, but we explored it. A short while later, we had a conference call with a Surrogacy Agency in Colorado (gestational surrogacy was not legal in some states), where we discussed the procedural, legal, financial, and ethical challenges of having our embryos (which were in deep freeze in New Jersey) transferred to a wonderful Florida woman willing to carry this pregnancy as a surrogate.  

 

Soon, though, I made a very different phone call.    

 

A lawyer who specialized in international adoptions listened to my story carefully. She asked me nothing about body size, menstrual cycles, uterine environment, or sex life. She said nothing about lab tests, operating rooms, or anesthesia risk. She empathized with my sense of failure, sadness, and disappointment. After hearing that my husband and I had a combined age much less than 100 years, were employed and in good health, and were already raising a child, she reassured me that if we wanted another child—and were willing to complete reams of paperwork, be fingerprinted three different places, and welcome a social worker for an extensive home visit—we most likely would have a child as soon as the New Year.   

 

Three weeks later, we received a fuzzy faxed photograph of a beautiful newborn. It was the week before the Jewish New Year (I had thought she meant January 1!). We quickly arranged a trip abroad to meet the baby, but we needed to leave her in family foster care as the slow, rigorous legal adoption process proceeded. We were receiving weekly updates about our “to be” child, preparing our now 6-year-old for life as a big brother, and anxiously awaiting “the call.”  

 

We brought her home in January and the rest, as they say, “is history.”  

   

 

Physicians have more trouble getting pregnant than the general population  

 

One in four American physicians seek infertility treatment. The well-documented, progressive decline in fertility with aging occurs a decade earlier in women than men, making the choices and timing of childbearing for women physicians especially important to consider.  

While in retrospect, most (56.8%) women physicians have no regrets regarding childbearing, 28.6% say they would have attempted pregnancy earlier, 17.1% would have chosen a different career, and 7.0% would have chosen to cryopreserve their eggs (Stentz, et. al. 2016). Available  options are likely to become less invasive and more effective as the biology of ART evolves,  changing the decisions people make.  

 

Physicians who had babies during medical school and residency perceived less workplace support (68.2%) than those who had their first pregnancies following training (88.6%). Nearly half of physicians who eventually faced infertility were surprised, as I was (Stentz, et. al. 2016). 

 

Infertility, pregnancy complications, and miscarriages are associated with high rates of burnout (Casilla-Lennon M, et. al. 2021). 

 

Understanding of—and attitudes about—adoption and alternative ways to create a family are also rapidly evolving (more on that at another time). Involuntary childlessness is more common among physicians compared to the general population and may be preventable if we are willing to acknowledge and meaningfully address the problem. As women make up a significant proportion of all physicians, this issue impacts the health of the profession and the public.   

 

 

Like all women, physicians need support during this difficult experience 

 

In a recent article in our premier peer reviewed journal, Academic Medicine, three physicians with personal and professional experience with infertility made three relatively modest and achievable calls for change:  

 

1. Increase education and awareness about fertility. 

   
   

   Research has shown that nonfertility specialist physicians do not truly understand how rapidly fertility declines with age and overestimate the effectiveness and underestimate the cost of fertility treatments.  

   
   

   Addressing these knowledge gaps and providing individualized counseling is a simple strategy to help our future colleagues make the best choices for themselves. 

   After nearly 40 years as a physician and 30 years as a parent, I have very few regrets about the choices I have made. I would not trade the wisdom I have gained from having faced very hard things. I would not have made different choices. But if I had known more and had a trusted mentor to turn to for help in navigating the hard times, it would have saved me a great deal of personal suffering. 

   
   

   Combining a medical career with parenthood is challenging! Explicit and balanced  

   discussion of these issues during medical education only seems right.  

    

   Provide insurance coverage for and access to fertility assessment and management. 

   
   

   As I have discussed in my Mother’s Day Director’s Corner, insurance coverage for fertility treatments is not ubiquitous. Infertility treatments are very costly financially, physically, psychologically, and spiritually. Even with two incomes, my husband and I needed to borrow money to pay for the care we pursued.  

   
   

   Offer support for trainees and physicians undergoing fertility treatments. 

   
   

   I sought group therapy and needed care for anxiety and insomnia from a psychiatrist. I asked for and received the support of my faith community. I was on my own to work all this out. As institutional leaders and educators, we have an opportunity to improve the long-term resiliency and well-being of our physician workforce through increased awareness, empathy and understanding.  

   
   

   We can reduce the concern many have about being stigmatized by peers and leadership for taking time away from work to attend to personal needs by making it possible to schedule fertility-related care as part of routine health maintenance.  

    

Working with young physicians to ensure they can flourish in the profession in the long haul is fundamental to our work as medical educators. Helping others build healthy families is core to that mission. 

Given that prime childbearing years overlap with the most intense decade of a physician’s education and training, our systems must be structured so that every physician parent and medical family—no matter how that is defined—can thrive.   

Like many others before and since, we took a circuitous route to parenthood of our two wonderful children. I hope our story helps others talk more about these issues. As colleagues and friends—and as institution leaders—we must be mindful that becoming a family is one of the most important, frightening, and wonderful transitions life offers. 

For further reading: 

• Stentz NC, Griffith KA, Perkins E, Jones RD, Jagsi R. Fertility and Childbearing Among American Female Physicians. J Womens Health (Larchmt). 2016 Oct;25(10):1059-1065. doi: 10.1089/jwh.2015.5638. Epub 2016 Jun 27. PMID: 27347614. 
• Marshall, Ariela L. MD; Arora, Vineet M. MD, MAPP; Salles, Arghavan MD, PhD. Physician Fertility: A Call to Action. Academic Medicine 95(5):p 679-681, May 2020. | DOI: 10.1097/ACM.0000000000003079 
• Casilla-Lennon M, Hanchuk S, Zheng S, Kim DD, Press B, Nguyen JV, Grimshaw A, Leapman MS, Cavallo JA. Pregnancy in physicians: A scoping review. Am J Surg. 2022 Jan;223(1):36-46. doi: 10.1016/j.amjsurg.2021.07.011. Epub 2021 Jul 21. PMID: 34315575; PMCID: PMC8688196. 

Two resources I found extraordinarily helpful in my journey:  

• RESOLVE: A Blog of the National Infertility Association, Kitchen Table Conversations: The Impact of Infertility & Women Physicians. (link here) 
• National Council for Adoption blog: Adoption Medicine: Improving the Health and Wellbeing of Adopted Children. (link here) 

 

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.