AUDIE CORNISH, HOST:
A few years ago, 48 doctors in Texas performed abortions. Today, there are 28 doctors who do so. It's a quiet but growing issue in a state where most of the attention has been on the dwindling number of clinics providing abortions. But without the clinics, doctors have nowhere to practice or to teach the next generation of physicians. Carrie Feibel of Houston Public Media asks what is lost to medical education when these facilities shut down.
CARRIE FEIBEL, BYLINE: Abortion is one of the more common procedures performed in the U.S., more common even than getting your appendix out. But as clinics in Texas close, learning to do them is getting harder for obstetricians and gynecologists in training.
UNIDENTIFIED WOMAN: There are places in Texas where there are medical schools and there are residents, there are OB-GYN residents who can't get anywhere to be trained.
FEIBEL: That's a doctor at a Texas clinic where OB-GYNs in training, called residents, can still come to learn abortion. She asked not to be named to avoid backlash from anti-abortion groups. Clinics have closed recently in Lubbock, Odessa and other Texas cities. The professor says her clinic can't pick up the slack.
UNIDENTIFIED WOMAN: We've been approached by many different residency programs about the ability to train their residents, and unfortunately we just don't have the capability to train everyone.
FEIBEL: We spoke inside the clinic where she was soon joined by an OB-GYN resident. They prepared to enter a procedure room.
UNIDENTIFIED WOMAN: OK, so this is the next patient that we're going to see. She's 21 years old, and this is her first pregnancy. She is at about eight weeks today. Do you have any questions about what we're going to be doing or the procedure?
FEIBEL: The resident asked to be identified by her middle name, Jane. Jane is not required to learn to perform an abortion. Any doctor with moral or religious objections can simply choose to skip the training. But Jane wanted to come here. She says the experience improved her medical skills but also gave her a new political perspective on what it means to be a doctor.
JANE: It makes it even more obvious how important it is for women to have access to abortions, and thus if I think a woman needs access and I have the skills to provide access, I should.
FEIBEL: I asked the professor if it's hard to teach abortion. She says it's not.
UNIDENTIFIED WOMAN: The technical procedure is the same whether you are doing it for a miscarriage or whether you're doing it to terminate an ongoing pregnancy.
FEIBEL: That procedure is known as a dilation and curettage, or D and C. You dilate the cervix and insert a suction instrument to remove tissue from the uterus. It's also used to stop excessive bleeding or to take a biopsy.
UNIDENTIFIED WOMAN: I like to say that a D and C, a suction D and C, even, is bread and butter gynecology.
FEIBEL: So there's nothing controversial about a D and C, per se. But when it's done because a woman chooses to end a pregnancy, it's called an elective abortion, and that requires additional training. Doctors must learn how to counsel the patients and manage their pain. They need to learn about medical abortions, the ones that use pills.
In many states like Texas, regulators require extra paperwork and steps, such as having the woman listen to the fetal heartbeat. Residents who want to learn all that have to go to a separate clinic. In Texas, there are only 18 left for a population of 27 million. That worries Lori Freedman, a medical sociologist at the University of California, San Francisco.
LORI FREEDMAN: How can you have abortion provision if you don't have trained doctors?
FEIBEL: Freedman says abortion training has become more common, but only in some places around the country.
FREEDMAN: So we've trained a lot of people, but they're staying in relatively liberal, urban areas.
FEIBEL: Texas has 18 OB-GYN residencies. All of them undergo periodic reviews, and the reviewers check whether residents have opportunities to learn about abortion. So I called the group that does the reviewing, the Accreditation Council for Graduate Medical Education, in Chicago. I asked Dr. John Potts how Texas residencies could fulfill that obligation if all the nearby clinics have closed. Potts says the abortions don't have to be elective. Residents can learn to terminate pregnancies in the hospital for other reasons.
JOHN POTTS: As long as they're getting sufficient experience in some form of abortion, you know, those where the mother's life is in danger or where there's substantial neonatal abnormality.
FEIBEL: In other words, if you can do a D and C, you're considered more or less trained. Residents can also learn about abortion through lectures and simulations. Some Texas professors say that's good enough given the circumstances. I asked Dr. Bernard Rosenfeld, who's been providing abortions in Houston for decades, if he thought it really was enough.
BERNARD ROSENFELD: No, absolutely not. It's so much different.
FEIBEL: He says when residents are learning to do D and Cs, they usually do them in the hospital and the patient is often asleep. But most abortions in this country take place in outpatient clinics. Patients get a local anesthetic or none at all. That actually makes the abortion safer, but it requires more skill on the part of the doctor.
ROSENFELD: Time is a big factor and causing as least pain as possible and having a very gentle touch, but all that is learned.
FEIBEL: Rosenfeld says residents need to do dozens of outpatient abortions before they are truly trained.
ROSENFELD: Nobody would ever say that about a cesarean delivery or a regular delivery - that, OK, you saw one or two so you can just do them. You know, lots of times, you'll have uterine abnormalities and you're not going to know unless you've done many procedures what to do with a uterine abnormality.
FEIBEL: And there's one more thing residents get during training. Here's how the resident Jane summed it up.
JANE: Every woman has a different story and a different reason why she chooses to end her pregnancy.
FEIBEL: It's the opportunity to hear why women get abortions. Dr. Jody Steinauer teaches at the University of California, San Francisco. She says when residents hear the patient's stories, they learn valuable bedside skills like compassion and empathy.
JODY STEINAUER: When they spend time in a setting that provides abortion care, they have real epiphanies. They become more aware of their biases. They're surprised that more than half of women having abortion are already mothers, for example.
FEIBEL: But there are those who question the need for more training. Some doctors say residents who really want it can leave Texas to get training and then come back. And others condemn the entire concept because they believe terminating a pregnancy is killing an unborn child. Dr. Donna Harrison, in Michigan, directs the American Association of Pro-Life Obstetricians and Gynecologists.
DONNA HARRISON: If you do a procedure that you have moral qualms with, there's a kind of desensitization that goes on. And the attempt to force residents to participate in abortion is an attempt to desensitize those residents so that they will have less ability to think clearly about what that procedure is actually about.
FEIBEL: Harrison acknowledges residents can opt out of training but says some might still feel pressured to go along. But Lori Freedman, the medical sociologist, says doctors will always have patients whose life decisions they privately disagree with.
FREEDMAN: Things happen to people that they don't want, health-wise, all the time, and we just need doctors to know how to do this.
FEIBEL: The Supreme Court is expected to decide soon whether to uphold a Texas abortion law. If it does, more Texas clinics will close, leaving fewer than 10. For NPR News, I'm Carrie Feibel in Houston.
CORNISH: This story is part of a reporting partnership of NPR, Houston Public Media and Kaiser Health News.
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