Anticipated Impact of Dobbs v Jackson Women's Health Organization on Training of Residents in Obstetrics and Gynecology: A Qualitative Analysis Open Access

On June 24, 2022, the Supreme Court of the United States in the case of Dobbs v Jackson Women's Health Organization ended constitutional protection for abortion, thus severely restricting access to reproductive health care for millions of individuals. This decision ended the nearly 50-year-old federal protection for abortion and severely restricted access to reproductive health care for millions of US individuals who can become pregnant.

Abortion care training is essential for obstetricians and gynecologists. The American College of Obstetricians and Gynecologists defines abortion as “a medical intervention provided to individuals who need to end the medical condition of pregnancy”¹ Furthermore, comprehensive abortion care includes “the provision of information, abortion management, and post-abortion care” as well as “care related to miscarriage, induced abortion, incomplete abortion, and fetal death.”^2,3 

The Accreditation Council for Graduate Medical Education (ACGME) requires a minimum of 20 surgical abortion procedures to be completed during obstetrics and gynecology (OB/GYN) residency.⁴  The ACGME Milestones, which guide assessment of physician competence, also include performance of both medical and surgical abortions.⁵ 

Many societies have released statements in response to the Supreme Court decision,^6-10  and many specifically mention concerns about training and competency.^11,12  Of approximately 6000 OB/GYN residents in the United States, 2600 (43%) are located in states that are likely to ban or severely restrict abortion.¹³  The main objective of this study was to qualitatively explore anticipated impacts of the Dobbs ruling on medical training in OB/GYN by stakeholders directly involved in OB/GYN training of medical students, residents, and fellows.

A participatory action research design was chosen for this study. This approach considers key stakeholders as decision-makers and involves collaboration with members of a population to inform or affect change at a community level.^14,15 

As an overview, participatory action research employs a circular process of cycles involving planning, action, and reflection. In this article we present the qualitative findings from 2 focus groups about the potential impact of Dobbs on OB/GYN medical education (reflection step). The next step will be to observe the actual impact of Dobbs on OB/GYN medical education and reconvene these focus groups in about a year to continue to act and reflect.

Leaders of major national OB/GYN professional and academic organizations with missions related to clinical care and training of medical students, residents, and fellows in OB/GYN were approached via email and/or telephone from the president of the Society of Gynecologic Surgeons and the majority selected their president or a designee to participate. Participants were asked to speak on behalf of their organizations. A convenience sample of OB/GYN trainees from the authors' institutions was selected with a focus on selecting a medical student, a resident, and a fellow (Box).

Two focus groups were led by one of the authors trained in qualitative study design (G.H.). Participants chose which focus group session to attend. The sessions were recorded on Zoom in July 2022.¹⁶ 

The interview questions were created by the research team led by G.H. using a literature review and input from a multispecialty and multisubspecialty team of medical educators familiar with abortion and OB/GYN training. Each interview followed a semi-structured interview guide using open-ended questions illustrated in Table 1.

Our study team included 3 researchers who are experts in qualitative methodology (G.H., A.J.B., R.R.). All have received formal training and published multiple qualitative studies in the OB/GYN literature. Two other researchers (C.L.G., S.K.F.) were trained by these experts and have also participated in other qualitative studies.

In order to maintain transparency, the transcripts were not de-identified with regard to the societies represented at this interview. Content analysis was performed, and transcripts underwent line-by-line coding to identify common themes.^17-20  The coding was performed by 2 independent researchers (who did not participate in the focus groups), and discrepancies were decided on by a third reviewer. To make this process iterative, we continuously edited, added, subtracted, and renamed themes until we had a set of themes that captured all of our data. This process was repeated until all 3 members were in agreement on the codes and themes identified. Themes were then organized into categories and subcategories. Dedoose software was used to produce descriptive reports for each code and theme.

Participatory action research design acknowledges that reflexivity exists between participants and researchers and that there is collaboration between researchers and participants in understanding the problem (reflection) and then taking action. All of the researchers are OB/GYNs, have been trainees, and are involved in training and leadership. All authors do likely hold some assumptions, beliefs, and judgements about the research topic. The New York Medical College Institutional Review Board approved this qualitative study.

A total of 26 individuals participated in 1 of 2 focus groups held on July 13 and 20, 2022 (Box). Each focus group lasted between 60 and 90 minutes. Leaders of 16 OB/GYN professional and academic organizations were approached, and the majority selected their president or a designee to participate. Participants included leaders representing 14 different societies and organizations in OB/GYN (response rate 88% [14 of 16]), 4 trainees, and 4 OB/GYN physicians who did not specifically affiliate with an organization but held past or present leadership roles (Box).

The 8 major themes identified include competency, provision of reproductive health care, residency selection, inequity in training, alternative training, law-based vs evidence-based medicine, morality and ethics, and uncertainty and next steps. While some themes overlapped with each other, we felt that they represented distinct concepts and were representative of the discussion. Themes, subcategories, and illustrative quotes are listed in Table 2.

Participants voiced concerns about trainees achieving competency in OB/GYN training programs, with challenges in meeting both procedural and nonprocedural learning objectives.

The concerns regarding the impact of Dobbs on competencies were not only limited to the performance of surgical abortions, but also applied to other skills. For example, from a procedural perspective, participants described how abortion training provides transferable technical skills, including transvaginal ultrasonography, uterine manipulation, hysteroscopy, dilatation and curettage, and intrauterine device insertion. From a nonprocedural perspective, participants identified ways abortion training teaches residents how to counsel patients in challenging situations, such as in pregnancies with lethal fetal anomalies, or in patients with high risks of maternal morbidity associated with pregnancy. Multiple participants described the loss of opportunities to learn effective and compassionate communication skills in difficult encounters, counseling that frequently happens around abortion training. Finally, participants discussed the inability to learn transferrable procedural and communication skills that will impact several layers of learners, including medical students, OB/GYN fellows, OB/GYN residents, and learners in non-OB/GYN specialties.

As a result of trainees not being exposed to full spectrum reproductive health care and facing challenges in achieving competencies, participants expressed concern about downstream implications on the ability of OB/GYNs to provide comprehensive reproductive health care. Participants expressed that concerns about the complexity of reproductive health care in the United States may drive trainees away from the specialty of OB/GYN. Participants described a fear of a potential “crisis” in which many graduates will lack basic skills and the potential for this to “directly cause an increase in maternal mortality and morbidity.”

The impact on graduates' selection of residency programs and how mentors should counsel and guide them was a commonly reported theme. Participants discussed how to best mentor and advise students and applicants as they are considering where to apply for medical training. Specifically, they focused on the implications that the various state restrictions will have on training experience and concerns that some states will have inadequate and incomplete training in comprehensive reproductive health care. Participants noted that the skills and experience trainees receive will be different depending on the geographic location of different programs. This concern extended beyond obtaining adequate training to obtaining personal reproductive health care for trainees and/or their partners. Concern was expressed that a perceived inability to get adequate reproductive health care, birth control, or abortion health care in many states may affect the residency programs trainees choose to apply to.

Participants expressed concern about trainees having to navigate conversations with residency selection committees on these issues that may impact them without fear of being judged or affecting their admission potential. These conversations may include asking about curricula and ability to learn various aspects of reproductive health care.

Participants described specific examples of how the restrictions would lead to inequity in training experiences, depending on whether a training program is located in a state where abortion is restricted or not. Trainees who are located in unrestricted states would be able to offer the full spectrum of reproductive health care. Trainees located in restricted states would not be able to gain the same level of knowledge and skills around abortion services, and participants felt that the lack of abortion training would likely impact the quality of training in other procedures. Participants reported that trainees in states that limit or deny access to abortion may also see more pathology as a consequence of anticipated increase in unsafe abortion practices. Participants discussed that programs in states with unrestricted access to reproductive health care may attract stronger applicants and thus possibly create different “tiers” of training: “I see us as facing a crisis where almost half of graduates for however many years will not have those basic skills.”

Strategies and efforts to obtain abortion training for residents and fellows post-Dobbs through alternative means was discussed. Several participants described efforts to employ simulation as a method to replace live clinical learning, using models and didactic materials. Discussants stated that relying on simulation alone to teach abortion care was not ideal. A significant portion of the discussion centered around organizing travel to away rotations for trainees in restricted states in order to obtain training in abortion care. Other participants discussed barriers including lack of capacity to accommodate additional learners in existing programs in unrestricted states, concerns about obtaining licenses in different states, as well as the personal, social, and financial hardships on trainees who need to leave their home programs. Participants also discussed that short-term rotations to obtain abortion care training was not comparable to learning skills over a 4-year residency program.

Concern that evidence-based medicine will no longer be taught, learned, or practiced by trainees due to state laws and fear of criminalization was another theme. Discussion surrounded a forced standard of care that was no longer evidence-based but designed to align with state laws (law-based), and participants referred to “the need to incorporate ideology and non-medically, non-scientifically based legal approaches to care into the way that these trainees are learning how to take care of patients.” Further, concern was expressed that this change in how reproductive health care would be practiced makes trainees vulnerable to criminalization: “It's not just evidence-based medicine [that is lost], but people walking around with the fear that anything they say or do could result in prosecution” and “we may be putting some of [the residents] at risk for licensing and criminal issues.”

The conflict between evidence- and legal-based practice of medicine was identified as a potential stressor for trainees. The moral implications of these changes on trainees and health care professionals in general were discussed. Participants noted that the health care system is already fragile as a result of recent years of facing the COVID-19 pandemic, and there is grave concern about adding “insult to injury on an already broken health care system.” There was concern about the loss of autonomy for both patients and trainees and a recognition that “moral injury” was a threat to trainees who may see patients suffer preventable harm or death while not feeling protected in doing the “right thing” for their patients. There was specific discussion surrounding the need to “pay attention to the emotional needs of residents in [this] process.”

During the focus groups, there was concern about the lack of clarity on how each state might legislate aspects of reproductive health, and how programs would have to respond accordingly to state-specific laws. Participants suggested measuring the impact of Dobbs using case logs, objective outcomes such as morbidity and mortality rates, application patterns to OB/GYN training programs over time, and surveys to program directors and trainees.

In this qualitative study on the effect of Dobbs on medical training in OB/GYN, 8 themes surrounding current and future implications on training, career selection, and the health care system at large were identified. Barriers to achieving proficiency in essential abortion skills were predicted to impact the ability to train full-spectrum OB/GYNs and the provision of reproductive health care at large.

Since the Dobbs decision, various authors have published commentaries and opinion pieces focusing on the wide-ranging anticipated impacts of the changing landscape of abortion access and provision in the United States. These publications have highlighted concerns about training experience and therefore competency of physicians as well as challenges faced by training institutions to ensure opportunities in restricted states.²¹  These concerns are not limited to only OB/GYN training but also affect other specialties like emergency medicine, family medicine, and pediatrics. These authors also note that lack of abortion training will have negative impacts on achieving skills related to miscarriage management, pregnancy options counseling, and other elements of care beyond the provision of abortions.²²  Published literature has also discussed the increased likelihood of moral distress and ethical conflict among trainees. Mengesha et al note, “Abortion bans challenge the core tenets of physician professionalism and medical ethics, [and] violations of these core medical profession principles heighten the risk of moral distress.”²³  The themes that emerged from our study confirmed that these are areas of focus and concern among multiple leaders in OB/GYN who represent various specialties in our field.

Multiple publications related to the Dobbs decision on training and medical education do not yet exist, and those that do are the aforementioned commentary and opinion pieces representing perspectives of one or only a few individuals. Prior to the Supreme Court decision, Vinekar et al assessed the number of OB/GYN programs projected to ban abortion if Roe v Wade was overturned,¹³  and a large academic hospital shared their experience in preparing for the overturn of Roe, noting that “patients will feel the downstream effects if abortion training halts.”²⁴  We successfully gathered key stakeholders in OB/GYN across the breadth of the specialty in a focus group that occurred after the Dobbs decision. The perspectives of these participants are clearly aligned with what others have published, but this format represents a unique opportunity to explore the effects of the Dobbs ruling on our specialty from the perspective of multiple stakeholders within OB/GYN.

There are limitations which may have influenced our study findings. First, the results may not be generalizable to all specialties that provide reproductive health care (internal medicine, family medicine, pediatrics). We purposely limited our participants to the leaders of OB/GYN societies, “boots on the ground” physicians, and trainees in order to elucidate the most important factors affecting OB/GYN training at a national level. While participants were representing these groups and not themselves, we do acknowledge that their demographic details likely impact their viewpoints and discussion, and this information was not collected. We held only 2 virtual focus groups. However, these included leaders representing most OB/GYN societies as well as learners. The themes that emerged from these 2 discussions appear representative of discussions being held across the country.^25-29  Finally, these discussions were held within weeks of the decision, forcing our leaders to strategize during a crisis when they may not have yet identified all the areas for concern.

We plan to revisit this discussion within 12 months to reflect on the actual consequences of these legislative changes and to continue our participatory action research by reflecting, planning, and acting to develop an action plan with the focus on providing the best educational environment for our trainees which will directly impact the care they are able to provide for their patients in the United States.

Leaders and learners in OB/GYN are concerned about the impact of the Dobbs decision on the training of medical students, residents, and fellows, anticipating a decrease in breadth of competencies, including procedural skills, and a rise in ethical dilemmas when standard of care is law-based and not patient centered. Participants expressed concern that the pattern of medical student applications to residency will likely change, and there may be 2 types of residency training in the United States (in restricted vs unrestricted states), which may limit the ability of future OB/GYNs to provide comprehensive health care to their patients.