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In Texas, clinics that provide abortions are struggling to comply with strict new laws. More than 20 clinics have closed, and more may soon if the U.S. Supreme Court upholds one of those Texas laws. But there's a related issue unfolding. The doctors who provide abortions in Texas are going away. Carrie Feibel at Houston Public Media asked, who would replace them, and found the teaching of abortion is politicized like the procedure itself.
CARRIE FEIBEL, BYLINE: Texas has 18 training programs for obstetrics and gynecology scattered across the state, but only one program allowed me to observe the teaching of abortion and then only if I agreed not to reveal who the doctors were or where the clinic was. The doctor in training agreed to be identified by her middle name, Jane. Although doctors can opt out of abortion training, Jane says she has a professional obligation to learn it.
JANE: Women can choose if they want an abortion or not, but you as their doctor need to be able to provide them with all the choices available.
FEIBEL: Jane has spent the morning performing ultrasounds on pregnant women. A senior doctor is also there to supervise. They examine a printout from a fetal ultrasound. Jane gets some advice.
UNIDENTIFIED WOMAN #1: On this image here, like, you want it more of a plane, as if you were opening it like this, and so that you have the hypothalamus in your picture.
FEIBEL: Jane spends about a month at this clinic during her four years of residency. Abortion is just one of the family planning services she learns. She counsels patients about contraception and STDs. She learns pain management and how to improve those ultrasound skills. Jane says that aspect was especially helpful because OB-GYNs use ultrasounds for all sorts of reasons, and she wanted more experience.
JANE: Here, we do, like, 30 ultrasounds in a morning so it's a lot of good learning about how to do ultrasounds.
FEIBEL: It may be good learning, but in Texas, this training happens quietly, almost in secret.
CAROLE JOFFE: Doctors working in these institutions are walking a very delicate line.
FEIBEL: That's Carole Joffe, a sociologist at the University of California, San Francisco. She studies doctors who do abortions.
JOFFE: Some of them want very much to be able to train residents, but they are fearful of other sectors of the university coming down on them saying, you're threatening our funding.
FEIBEL: Academic medical centers in Texas get tens of millions of dollars every year in state funding, and many of the centers sponsor residencies, which are the training programs that come after medical school. It's understandable why an OB-GYN resident in Texas might think twice about providing abortions. Doctors who do have to think about security issues, state inspections and protesters.
(SOUNDBITE OF RALLY)
UNIDENTIFIED MAN: Well, aren't you glad that you're from Texas, a pro-life state, though?
UNIDENTIFIED WOMAN #2: Yeah.
UNIDENTIFIED WOMAN #3: Yeah.
FEIBEL: Hundreds attended this rally outside the Planned Parenthood in Houston.
(SOUNDBITE OF RALLY)
UNIDENTIFIED MAN: Where we've got great pro-life leaders, one being Senator Ted Cruz, in Washington.
FEIBEL: Doctors who do abortions also have fewer job opportunities. That's because many hospitals and group practices refuse to employ doctors who do abortions even if it's on their own time. A few years ago, 48 doctors in Texas did abortions. Now that's down to 28. And some are getting older, like Dr. Bernard Rosenfeld. Rosenfeld is 74 and hasn't been able to line up a successor.
BERNARD ROSENFELD: They've picketed my house where I live. They've put bullets in our parking lot.
FEIBEL: Rosenfeld provides abortions at one of his two clinics. He bought the abortion clinic from other doctors in 1982, but now he can't find anyone to buy it from him.
ROSENFELD: I've talked to some doctors, but none of them are interested in the political consequences.
FEIBEL: As the number of doctors dwindles, medical educators say it's more important than ever to train the next generation. To find out how much abortion training was going on, I contacted all 18 OB-GYN residencies in Texas. Six of the programs, one third of the total, simply refused to answer questions about how the training takes place. One OB-GYN professor hung up on me. Another agreed to an interview then canceled. In Houston, two residencies are supported by the University of Texas Health Science Center.
(SOUNDBITE OF PHONE CALL)
UNIDENTIFIED WOMAN #4: UT Health does not want to participate in that story.
FEIBEL: That's a spokeswoman who wouldn't reveal anything about abortion training.
(SOUNDBITE OF PHONE CALL)
UNIDENTIFIED WOMAN #4: It's not a story that benefits us.
FEIBEL: In the end, I could only confirm that three programs in Texas had made arrangements for residents to spend time learning at outpatient clinics. Those clinics are where most abortions in Texas take place. The other 15 residencies either can't provide training, won't, or aren't saying. Someone who would talk was Dr. Robert Casanova. He was recently the residency director at Texas Tech in Lubbock. That city's last clinic that provided abortions closed in 2013.
ROBERT CASANOVA: There's really nothing in a close radius to us. I mean, our patients go to Albuquerque. They'll go to Dallas. They'll go to Denver.
FEIBEL: Casanova was also left with no local clinic where residents could learn. To compensate, he created special seminars about abortion and even arranged for guest speakers to fly down from Denver.
CASANOVA: I think the limited choices for our patients pretty much parallels the limited choices for our residents to get training to where they feel comfortable doing something along those lines.
FEIBEL: OB-GYN programs are required to offer residents an opportunity to learn abortion, and if they don't, it could affect their accreditation. Today, all 18 Texas programs are accredited, even ones in places like Lubbock, where there are no more clinics. So if they're not teaching abortions in the clinics, what exactly are they teaching? I asked Dr. Tony Wen. He's the residency director at the University of Texas Medical Branch in Galveston. There's no clinic in that city, either.
TONY WEN: We cannot teach them the procedure itself. Can we teach them the concept and describe the procedure and that sort of thing? Yes, we can do all that.
FEIBEL: Wen says his residents don't seem all that bothered.
WEN: So if this part of the training is very important to them, more likely, they probably will choose other residency programs go to.
FEIBEL: But Wen has adjusted the curriculum in other ways. He says getting an abortion is becoming harder in Texas, and he fears some patients will buy pills to induce abortion.
WEN: Yeah, in Texas, they could easily cross the border and get that medication. And, you know, a lot of people's thinking process is, if five tablets good, 10 must be better.
FEIBEL: Wen now teaches his residents how to diagnose a woman who has overdosed on that medication and what to do to save her life. For NPR News, I'm Carrie Feibel in Houston.