The Impact of Changing Abortion Legislation on Emergency Medicine Residents in a State With Protected Abortion Rights

The US Supreme Court’s 2022 ruling in Dobbs v Jackson Women’s Health Organization overturned Roe v Wade and allowed individual states to determine abortion restrictions.¹  Twenty-one states now ban or restrict abortion.² Dobbs has created a new era of legal and ethical challenges for the health care system that particularly impact graduate medical education (GME).³  Although these changes most directly impact obstetricians and gynecologists, emergency medicine (EM) physicians, who must provide stabilizing treatment under the Emergency Medical Treatment and Active Labor Act, may face criminal liability for providing the standard of care in cases requiring pregnancy termination, such as ectopic pregnancy.^4,5  Professional organizations and leaders in GME underscore the need for training adaptations to navigate this evolving legal landscape effectively.^6,7  Despite these calls for action, we still lack a comprehensive understanding of how these legal shifts affect residency training. The emergency department’s (ED) unique position at the intersection of many medical specialties and its role as the health care system’s safety net makes EM an ideal lens for identifying these impacts on education and patient care.

While the focus has predominantly been on states enacting abortion restrictions and their direct implications for clinical practice and training, the repercussions in states where abortion rights are safeguarded are equally important to explore.⁴  Following the Dobbs decision, many patients now travel to states where abortion is protected for abortion services or complications of pregnancy, presenting unique ethical and legal considerations for management.⁶  Many residents may eventually practice in abortion-restricted states without a clear understanding of what clinical actions learned in residency may now be illegal.^4,6  These challenges may impact decisions about where residents practice after graduation, a phenomenon observed among medical students following the Dobbs decision.^4,6,8  Despite the potential impact on clinical practice and career decisions, the effects of Dobbs on graduating EM residents have not been explored.

Understanding the nuanced, indirect effects of the Dobbs decision on residents in states where abortion rights remain protected can provide a more complete understanding of how these significant legal changes impact the educational environment nationwide. Insights from residents at a critical juncture in evaluating their future practice locations and grappling with the prospect of soon taking sole responsibility for patient care may offer valuable insights into the preparedness needed to navigate these challenges. Therefore, this qualitative investigation sought to explore the experiences and perspectives of residents in California around changing abortion legislation.

We adopted a transcendental phenomenological approach within a constructivist paradigm to understand residents’ experiences and perspectives regarding changing abortion legislation.⁹  This approach allowed us to focus on both the essence of the participants’ experiences and the context in which these experiences occurred, providing a comprehensive understanding of their impact.^9,10 

We focused our study on postgraduate year (PGY) 4 residents at a single large university-based program in California because of its experience with reproductive health care initiatives.¹¹  Selecting a single residency site allowed us to conduct a comprehensive and integrated examination of the residents’ experiences, ensuring uniformity in the educational, institutional, and legal backdrop shaping these experiences. Furthermore, a focused approach at a site with support for reproductive health care initiatives would allow subsequent comparative analyses with experiences from different residency programs nationwide. We approached all 15 PGY-4 residents at the institution for participation, and 13 agreed to participate. Thematic sufficiency was reached before the final 2 interviews were scheduled, and no incentive was offered.

We selected interviews for data collection to offer participants a direct, personal avenue to articulate their experiences, thoughts, and feelings in their own words.^9,12  The interview guide explored understandings and perceptions regarding changes in the EM practice environment nationally, as well as personal experiences and perceptions, and included hypothetical scenarios that could be encountered by an EM physician in states with and without abortion restrictions (see online supplementary data). We developed the interview questions through a synthesis of issues relevant to EM residents identified in the literature and the study team’s experiences as emergency physicians and abortion care providers.^4,6,13 

Between February and March 2023, a single author (C.P.) conducted semistructured interviews, each lasting 30 to 60 minutes, via Zoom. We chose virtual interviews for their convenience, despite potential limitations of the format. We made efforts to ensure privacy and build rapport online to counteract these limitations. All interviewees provided informed consent before the interview, and each session was audio-recorded, transcribed, and deidentified for analysis.

We used NVivo v.1.7.1 (QSR International) for data management and analysis. Applying the phenomenology framework, we conducted a thematic analysis with an interpretive analytic approach to identify the unique experiences and interpretations of residents.¹⁴  Initially, the research team engaged in open coding of the first few transcripts, forming an initial codebook. This process involved iterative discussions and reflections among the team members to identify and refine codes, ensuring they accurately represented the participants’ experiences.

Following initial coding, all 3 researchers independently coded each transcript to enhance reliability and validity.¹⁵  The team resolved coding discrepancies through discussion until reaching consensus. This collaborative approach refined codes and eliminated redundancy, ensuring a coherent and comprehensive coding scheme.

Throughout data collection and analysis, we adopted an iterative approach, allowing for continuous refinement of the interview guide and coding scheme based on emerging insights. We continued interviewing and coding until reaching thematic sufficiency, where no new themes or codes were identified in the data.¹⁶  To maintain transparency and rigor, we kept and reviewed an audit trail detailing the analytic process, coding decisions, and team discussions during regular team meetings. These sessions served as a platform for critical reflection and consensus-building, enhancing the confirmability of our findings. After analyzing all transcripts, the team synthesized the codes into major themes and subthemes. Group consensus selected representative quotations to depict the core ideas of each subtheme.

Throughout the analysis, the team engaged in continuous discussion and reflection to ensure our perspectives enriched rather than biased our interpretations. Our interdisciplinary team comprised C.P., a clinical instructor in EM with a background in medical education research and formal training in qualitative methods; M.S., a clinical assistant professor of EM and civil rights attorney with expertise in social EM and reproductive health care research; and A.H., a clinical assistant professor of obstetrics and gynecology with specialization in complex family planning and formal training in clinical research.

The Stanford Institutional Review Board approved this study (68915). We adhered to the Standards for Reporting Qualitative Research.¹⁷ 

We interviewed 13 residents, 6 identified as male and 7 as female. Furthermore, 7 pursued fellowship training, while 6 secured positions in community-based EM practices. The majority, 10, chose to remain in California. We identified 4 main themes: (1) impact of changing abortion legislation on practice; (2) personal and professional decisions influenced by legislation; (3) navigating legal uncertainties in practice; and (4) advocacy and engagement beyond clinical practice (Table).

Residents exhibited varied levels of understanding regarding the implications of shifting abortion laws on EM practice. Some were well-informed, stating, “I feel educated to a degree because I read a lot…” (Resident [R]1), while others possessed only a cursory understanding, “I haven’t looked into it much apart from just knowing that it’s going to be much harder to get an abortion.” (R6) Participants anticipated encountering a range of patient presentations due to limited abortion access, including “more home abortions, and people presenting to the [ED], not really having gotten any physician education on what to expect after taking abortion medications or…coming in with complications.” (R7) Concerns also included patients traveling from different states and the associated medicolegal implications (R13).

Participants noted an expected increase in patients seeking abortion-related care in the ED, with one resident observing, “a lot more people [are] coming in who are pregnant who don’t necessarily want to be…” (R7) They highlighted the impact of new laws limiting access and requiring travel to states permitting abortion services: “…an influx of patients going from their state to surrounding states to perform these procedures. And the harm is…that additional burden of…travel and resources.” (R1) Despite California’s protective stance on abortion providing a sense of security, some residents observed increased patient confusion and an influx of patients from restrictive states: “Patients [are] coming from Arizona or even as far as Texas with certain complications for which they could not get their issues taken care of within their state borders.” (R12) The rise in telemedicine or mail-order medication abortions also led to increased presentations due to inadequate post-abortion counseling (R2).

Participants frequently noted an educational deficit regarding evolving abortion laws and their implications for EM practice. One resident remarked, “having these discussions is important, and it’s definitely a huge deficit in our curriculum.” (R11) Knowledge gaps included documentation, caring for out-of-state patients, and understanding legal responsibilities. Residents suggested compiling a resource list or “a platform for quick reference to state-specific laws.” (R2) They stressed the need for a nuanced understanding of legal challenges and their implications on future career planning: “you need to know at what point you are no longer able to provide that medical service without having legal ramifications. That’s extremely important.” (R8) There was a consensus that while some issues might not be immediately relevant in California, physicians should engage in legislative processes due to the protections they enjoy and advocate for those in less favorable circumstances, as one resident expressed: “And maybe it’s even more important for the people who do live in California to be much more involved in the legislative process because we are much more protected [to] stand up for the people who aren’t in our circumstances.” (R6)

Legal changes affected many participants’ decisions regarding their future practice environments. Many expressed apprehension about practicing in states with stringent abortion laws: “I would feel very uncomfortable practicing in a state where you had to ask a lawyer before you provided care to your patient.” (R2) Others firmly avoided working in restrictive states: “I didn’t even consider working in those states.” (R13) Personal considerations also played a role, with one resident expressing, “I don’t think we would ever move our daughter someplace where she wouldn’t have all the rights that everyone should have.” (R7) Another participant also pointed to the personal implications of such laws: “If I was actively trying to have children, it would definitely factor into where we choose to live and work.” (R5) However, not all participants perceived these considerations as pivotal, with one resident suggesting a possible awareness gap: “This is the first time I’m really hearing about it.” (R6)

Residents discussed the ethical and moral considerations of changing abortion legislation. As one resident stated, “I would feel confident enough in my belief of what’s right medically and ethically where I would find a gray area in the law and…just do what I feel needs to be done.” (R10) Others emphasized the need to be cautious, ensuring not to impose personal morality on patients: “In some cases, you have to think about ethics and morality more clearly. But…you have to be careful as a provider not to assert your sense of morality on someone else.” (R8) The duty to connect patients with appropriate care was also discussed: “if something can’t be done at your hospital, then it’s your job to connect them to a place that can.” (R6) These decisions were integral to establishing their professional identities: “it’s a question of who is the type of person I want to be, and which side of history do I want to be on? It feels like a bigger thing that I sleep with knowing that I am the person who would provide care for something I believe is life threatening despite what the current law is.” (R1) Furthermore, providing care for pregnant patients was seen as a fundamental part of the emergency physician’s role: “we value being the safety net for our patients, and I think abortion care…is part of our job and part of that safety net.” (R5)

Many respondents underscored the difficulties arising when legislation interfaces with patient care. Navigating exceptions to these laws posed additional challenges: “laws have…strict guidelines about whether or not you can perform an abortion…and the definitions of a threat to the mother’s life vary wildly from state to state.” (R2) Concerns about legal repercussions that could impede care delivery were common: “laws that are very unclear [have] resulted in physicians being scared to provide care because they’re unclear if it’s in line with the law.” (R13) As another participant noted, “fear in many circumstances drives a lot of our medical decision-making.” (R3) This manifested in several ways, with one resident describing the challenge: “I certainly would have to pause and think about it.” (R8) The clarity of legal boundaries played a pivotal role, with one participant expressing that if a certain action “wasn’t illegal,” the role of a physician would be straightforward, allowing one to “focus on caring for the patient.” (R9)

Documentation to mitigate legal risk was frequently mentioned, with participants describing the need to document consultations with experts and the decision-making process to justify their actions: “I would have to…say…for defense of my chart. I have talked to another expert…and we have both decided…medication abortion…is appropriate for this patient.” (R1) Alternatively, some participants considered omitting certain details from the medical record to reduce potential liability: “…I may leave certain details out of the chart.” (R5)

Before making clinical decisions, many participants would seek legal advice to discern the best course of action, given the potential legal repercussions of their actions. One resident mentioned the need to liaise with legal teams: “I think I might ask for guidance honestly before I write anything down.” (R13) The potential loss of their medical license weighed heavily on participants’ minds: “If I give certain medications that can potentially terminate a pregnancy, am I jeopardizing my license for practicing medicine?” (R11) Another participant pointed out the risks of both action and inaction, stressing the potential loss of their medical license for not adhering to standard care. (R7) This dilemma appeared to be influenced by participants’ personal values, with one resident’s reflection highlighting the moral dilemma: “If a patient is asking me to save their life… I would call my lawyer and say, ‘I’m saving this patient’s life…we should start figuring out our defense.’” (R13)

Participants believed these changes underscored their potential role beyond the clinical environment. Advocacy and activism emerged as avenues to shape the health care landscape, with one resident emphasizing the importance of “advocating for these issues in health care.” (R11) Another participant highlighted the repercussions of physicians remaining uninvolved in policy dialogues, pressing the need to “engage with organizations discussing these changes with legislators.” (R12)

This situation prompted some participants to consider more active involvement in the legislative process. One participant emphasized the broader role of a physician, stating: “Developing as a physician, being a physician, practicing as a physician…is more than just the clinical skills we apply during our shifts. With patient care now significantly governed by state and federal regulations responsive to major national events, we, as physicians, must remain attuned to national occurrences. This is evident with the ramifications of the Dobbs decision affecting our practice.” (R12)

While not all saw themselves as activists, many believed in grassroots efforts. One resident differentiated between being an activist and simply being active within one’s community: “I don’t know that I consider myself an activist…but I think we all have a role to play.” (R13) Going further, one resident reflected on the importance of community education, “for a long time I was content to be like ‘don’t engage,’ [but] at a certain point there might be a role to combat misinformation.” (R13)

The identified themes reveal a complex interplay between legislation, practice environment, personal values, and professional obligations, illustrating the broad impact of the Dobbs decision on EM residents (Figure). Variations in awareness and concerns about abortion legislation (theme 1) influenced both personal and professional decisions (theme 2), including choices about practice locations and ethical considerations in patient care. These decisions shaped how residents navigated legal uncertainties (theme 3). Ultimately, these experiences prompted residents to consider engaging in advocacy and community involvement (theme 4). Overall, the themes suggest unique challenges that these residents have not encountered in their training.

This study explores the professional and practice implications of the Dobbs decision for EM residents in one of the 17 states with protected abortion rights. We highlighted the significant effects on trainees as their professional identities evolve. Residents face challenges in reproductive health care during an unprecedented time in our nation, resulting in unique experiences not shared by their faculty. The themes provide valuable insights into the impact of these changes on trainees, guiding educators in adapting to the changed learning environment. Our findings reveal that residents are grappling with issues of ethics, law, and advocacy as their clinical practices evolve, underscoring the need for a new curriculum to address these challenges.

Numerous authors have discussed the Dobbs decision’s impact on medical practice, particularly in obstetrics and gynecology, EM, pediatrics, and family medicine.^4,18-20  EM stands out due to its intersection with multiple specialties and its role as the health care safety net, mandated by the Emergency Medical Treatment and Active Labor Act to offer stabilizing care.⁴  Many residents view the ability to care for “anyone, anything, anytime” as central to their identity as EM physicians.²¹  Abortion restrictions challenge this identity, creating a conflict between their duty to provide care and legal barriers.

Navigating tensions between idealized behavior and the reality of medical practice impacts professional identity formation (PIF).²²  PIF refers to the process by which individuals integrate personal values, beliefs, and experiences with the roles, responsibilities, and expectations of their profession, developing a cohesive professional self.²³  Contextual factors such as the clinical environment and available mentorship significantly influence PIF. Studies have shown the considerable impact of the COVID-19 pandemic on PIF, yet less is known about the effects of other broad contextual changes, such as social, political, or legal events.²⁴  In our study, residents wrestled with the Dobbs decision’s impact, encountering situations that conflicted with their existing identities as EM physicians. While some felt less conflict than others, many expressed a need for more information, support, and guidance in navigating these challenges.

The effects of contexts on PIF are highly dependent on support and guidance provided. A lack of support can lead to burnout or lack of professional fulfillment.²⁵  Mengesha et al suggest that the Dobbs decision may cause trainees to experience moral distress, which arises when external constraints prevent them from taking ethically appropriate actions.²⁶  Strategies to mitigate moral distress include increasing education, engaging in ethical discussions, understanding the limits of legal care, and supporting advocacy efforts—actions that align with the challenges described by residents in our study.^26,27 

Experiences of moral distress are linked to workforce attrition and avoidance of high-stress roles.²⁷  Participants in our study expressed concerns about practicing in restricted states, indicating a preference to avoid such locations. This sentiment reflects broader trends in medical education, where students and residents increasingly avoid states with abortion restrictions.^8,28-31  This trend could worsen maternity care deserts, exacerbated by physicians leaving states with abortion restrictions.³²  Further research should explore the best ways to advise students and residents on where to train and practice given these new restrictions.

The Dobbs decision significantly affects residents’ PIF. Without support, residents may experience burnout and moral distress and may avoid practicing in regions with abortion restrictions. Alternatively, faculty mentorship and educational initiatives by residency programs, medical schools, and national organizations could help trainees feel confident and efficacious when providing pregnancy-related care in states with and without abortion restrictions. Supporting residents in advocacy or research efforts will enable them to impact policies that restrict their ability to care effectively for their patients.

This study has several limitations. Focusing exclusively on PGY-4 residents from a single institution in California may not capture the experiences of EM residents at different levels or in varied training environments. Although we achieved thematic sufficiency, our small sample size might limit the transferability of our findings. Virtual interviews might have constrained responses compared to in-person methods. Despite efforts to minimize bias, the risk of confirmation bias or a lack of candor remains. The dynamic nature of abortion legislation suggests that views and experiences may change over time, necessitating periodic reevaluation. Future research should include a more diverse set of respondents and use complementary data collection methods, such as anonymous surveys.

This study highlights the significant impact of the Dobbs decision on EM residents in states with protected abortion rights. The findings reveal that residents are facing unique ethical, legal, and advocacy challenges as their clinical practices evolve, which may have important effects on their professional identity formation.

The online supplementary data contains the interview guide used in the study.

Funding: The authors report no external funding source for this study.

Conflict of interest: The authors declare they have no competing interests.