A race to teach abortion procedures, before the bans begin
KNOXVILLE, Tenn. - As he aborted 11 pregnancies at a clinic here one busy Friday this month, Aaron Campbell also was training a medical student in a procedure that soon could be outlawed in this state and many others. Case by case, he narrated the nuances of pelvic examination, pain-blocking injection, cervical dilation and, ultimately, the removal of embryonic or fetal tissue.
Lindsey Gorman observed throughout and participated when appropriate, under Campbell's guidance. With her hands she checked the size and tilt of the uterus. She also practiced ultrasound techniques and used speculums, swabs and local anesthetic to prepare patients. The student from Lake Erie College of Osteopathic Medicine in Pennsylvania was the seventh trainee to work with him in the past year, following medical residents from East Tennessee State University and the University of Tennessee's teaching hospital in Knoxville.
Campbell and other abortion providers are racing to train the next wave of specialists in the field as the days tick toward a Supreme Court decision that could imperil the legal foundation of their practice and lead to upheaval across the country for education and training in reproductive health.
Barring a surprise ruling, a geographic split looms: Some states will provide full access to abortion training for medical residents and students. Some will have limited access. And some will have virtually no access without long-distance travel. That, in turn, could influence where many doctors, especially those focused on obstetrics and gynecology, choose to live and work.
The leak of a draft court opinion in May showed that justices are poised to overturn the 1973 precedent Roe v. Wade, which would be a monumental victory for the antiabortion movement. If the court overturns or narrows Roe, an array of medical institutions will face state scrutiny over how abortion is taught.
While abortion rights advocates worry and wait, Campbell performs elective abortions for as many patients as he can at the Knoxville Center for Reproductive Health and trains as many medical students and residents as he can.
"We can pass as many laws as we want, for or against access," Campbell said, "but at the end of the day, if you don't have trained providers, you don't have choice."
The trainer and trainee shared a sense of mission as they worked in this city where an arsonist on New Year's Eve destroyed another clinic that provided abortions.
Campbell, 31, whose father was an abortion provider, has an image of a wire clothes hanger tattooed onto his right forearm - a reminder, he said, of "what happens when abortion is illegal." Gorman, 25, has a wire-hanger tattoo on her left wrist. "As long as I am legally able to provide this care," she said, "I know I will."
Abortion training is common in obstetrics and gynecology and can play a role in other medical fields. To maintain accreditation, OB/GYN residency programs are required to "provide training or access to training in the provision of abortions," according to the Accreditation Council for Graduate Medical Education. Residents are allowed to opt out for religious or moral reasons.
"All programs must have an established curriculum for family planning, including for complications of abortions and provisions for the opportunity for direct procedural training in terminations of pregnancy for those residents who desire it," the council said.
In many places, compliance with that requirement soon could prove difficult. The Guttmacher Institute, which tracks abortion laws and policies, finds 22 states have "trigger laws" or other statutes to ban abortion, with limited exceptions, if the Supreme Court allows. Four other four states are likely to seek abortion bans as soon as possible, according to the institute.
In April, researchers with the University of California at San Francisco and UCLA reported in a study that 44% of about 6,000 OB/GYN residents nationwide would be certain or likely to lack access to in-state abortion training if Roe falls.
Those figures probably understate the issue. Abortion intersects with the curriculum in various ways, experts say, during medical school and afterward in medical residencies and fellowships. Family medicine residents often seek abortion training. So do doctors who pursue advanced training for complex pregnancy situations. So do medical students, like Gorman, who might be exploring aspects of reproductive health before they apply for a residency.
Kavita Vinekar, one of the study's authors, is an assistant clinical professor of obstetrics and gynecology at UCLA. She predicted significant ripple effects if abortion training is curtailed. "Those skills are applicable to so many other aspects of reproductive care," Vinekar said. Hands-on experience in terminating pregnancy helps doctors counsel patients in many situations and treat complications of miscarriage, she said. "This is not just about abortion."
Doctors who oppose abortion rights disagree. "Abortion isn't health care, and I don't believe it has a place in health-care training," said Christina Francis, who is on the board of directors of the American Association of Pro-Life Obstetricians and Gynecologists and will become its chief executive next year.
Francis, herself an OB/GYN specialist in Fort Wayne, Ind., said she never observed or participated in abortion during her residency. But she said the training she received in managing miscarriages - particularly the uterine-emptying procedure known as dilation and curettage - would have enabled her "very easily" to perform an elective abortion if she had chosen to do so.
Dilation and curettage, or "D and C," which typically uses an instrument to suction tissue from the uterus, is a standard option for aborting early pregnancies. Dilation and evacuation, or "D and E," is a similar procedure for second-trimester abortion that uses additional tools, such as forceps.
New limits on abortion would not impede the training of OB/GYN residents, Francis said. All that would be diminished, she said, is "the capability of ending the lives of preborn children." Francis said she doesn't want patients to be scared of such changes. "This narrative that really is being pushed by the abortion industry and its allies, that physician training is going to suffer significantly if a state happens to restrict abortion in some way, is a complete lie," she said.
However the Supreme Court rules, it seems almost certain that abortion training will be affected. Roe legalized abortion nationwide until the point of fetal viability, now generally considered to be around 23 or 24 weeks.
If Roe is narrowed to protect abortion only up to 15 weeks - the threshold under the Mississippi law before the court - there are likely to be fewer opportunities for medical residents to learn methods of second-trimester abortion.
If Roe is overturned, residents and residency programs in states that ban abortion may have to scramble to find abortion training slots in states where it is still legal. And there is no guarantee that enough slots would be available to meet demand.
There is another wild card: the rise of medication abortion in the first 10 weeks of pregnancy. The two-drug combination of mifepristone and misoprostol, taken as pills, accounts for slightly more than half of abortions in the United States, according to the Guttmacher Institute. Many states allow only doctors to provide mifepristone. Those doctors must learn how and when to dispense the pills and monitor outcomes, a process likely to draw growing scrutiny.
But procedural training is shaping up to be a major challenge. Here in Tennessee, there are OB/GYN residency programs at the Vanderbilt University Medical Center and hospitals associated with the University of Tennessee and East Tennessee State, among other institutions. A state abortion ban, which would be triggered if Roe is overturned, could force medical residents who want abortion training to travel to Illinois, North Carolina or Virginia.
Nikki Zite, an OB/GYN professor at the University of Tennessee Graduate School of Medicine and former director of the residency program here, has been a vocal opponent of abortion bans. She spoke with The Washington Post on the condition that an article would note Zite does not speak for the university.
Worried about the fallout of a Supreme Court ruling, Zite drafted a statement about what may happen to OB/GYN programs. She said she was consulting with academic leaders in the state to see if they would sign onto it.
"We fear that both resident education and patient care for miscarriage will be compromised by the abortion ban," the statement said. "We also acknowledge that we will be unable to offer the mandated training in our state and this will likely compromise the ability to recruit future doctors to train and practice in Tennessee."
The University of Tennessee Health Science Center, which oversees teaching hospitals in Knoxville and elsewhere, declined to comment on possible disruptions to abortion training. So did the Vanderbilt medical center. East Tennessee State said it will follow state laws and accreditation requirements.
Representatives of Tennessee's governor, Republican Bill Lee, did not respond to email and phone messages seeking comment. He has backed multiple abortion bans, including a 2019 law that would make it a felony to perform an abortion if Roe is overturned. There would be exceptions for cases in which a pregnant person is at risk of death or serious injury.
North Carolina, which is not expected to ban abortion, could become a hub for abortion training in the South. Matthew Zerden, an OB/GYN specialist, coordinates training efforts in the state for Planned Parenthood South Atlantic. "There will be a huge surge of patients coming our way," Zerden said, referring to possible bans in nearby states. With that surge would come a demand for specialists to perform abortions. "We are committed to training the next generation of providers," Zerden said.
In the future, Zerden said, he worries aspiring OB/GYN specialists will shun residency programs in states with limited or no abortion training. Such a trend, if it occurs, could have far-reaching consequences. Doctors tend to settle near where they completed their residency, Zerden said. "Eventually you're going to set up almost a two-tiered system," he said. "States able to provide the full complement of obstetric and gynecological care, including abortion care . . . and places that just don't."
To some extent, views among medical students and residents over abortion echo divisions in society. A group called Conscience in Residency supports trainees in biomedical sciences "who object to performing certain procedures or providing certain services," including abortion. "You're not crazy, and you're not alone," the group says on its website.
A video on the site advises applicants to OB/GYN programs who oppose abortion and contraception on moral or religious grounds. "In your application I would not recommend . . . mentioning your stance on those things directly because I think it's a better conversation to be had in person," one doctor says.
Some residents who support abortion rights are fearful of speaking out. One doctor who trained under Zerden said she plans to provide abortions for patients from the Southeast. She spoke on the condition of anonymity because she feared professional repercussions. You never know, she said, how a particular clinic manager, department head or academic dean might react to the publicity if she applies for a position. "How will having my name out there as an abortion provider affect the kind of work I can do?" she asked.
But this doctor also seemed confident in her path: "Abortion care I find extremely meaningful. I'm really proud to be able to provide that care in a safe and acceptable way."
Shelbie Fishman, 24, from Rockville, Md., is the co-leader of a group called Medical Students for Choice at Washington University in St. Louis. Missouri has a "trigger ban" that puts abortion rights in jeopardy. But Fishman said she and her classmates feel comfortable talking about abortion as health care, "depoliticizing it, trying to strip it down to what it really is." She is also glad a state that protects abortion rights and abortion training is just across the Mississippi River. "We definitely view Illinois as a safe haven," she said.
The Washington University School of Medicine said in a statement that it offers abortion training to OB/GYN residents in accordance with accreditation standards and state law. "It is too early to know how our training programs would be affected by the upcoming Supreme Court decision," the school said.
Gorman came to Knoxville for abortion training with financial help from Medical Students for Choice. She grew up in a suburb of Pittsburgh and is entering her second year of medical school. Gorman was a technician in labor and delivery at a hospital while she was an undergraduate at the University of Pittsburgh. She also worked for a time as an assistant for Planned Parenthood.
Those experiences showed her "complex social situations," she said, as well as the high stakes of difficult pregnancies. She saw one woman die of a rare condition during childbirth and comforted her husband afterward. Another time, she met a 13-year-old who got an abortion after convincing a judge she needed one. "She was the strongest person I think I've ever met," Gorman said.
She views her weeks as a trainee in Knoxville as a potentially fleeting opportunity. "This might be the bulk of my family planning training that I ever have," Gorman said.
The Knoxville Center for Reproductive Health, an outpatient clinic, occupies a two-story building near the University of Tennessee campus and just across the street from a Civil War memorial honoring peace and reconciliation. The clinic provides various services, including medication abortion and abortion procedures for pregnancies up to 18 weeks.
After nearly 47 years of operation, the clinic is preparing to shut down if the Supreme Court ruling allows the state abortion ban to take effect.
Aaron Campbell's father, Morris Campbell, was the center's medical director for several years until he died in 2012. Campbell took over a year ago, after finishing medical school at East Tennessee State and his residency in Pittsburgh.
Working with Campbell is an 80-year-old doctor named Richard Manning, who counsels patients and dispenses abortion medication. Manning said he has provided tens of thousands of abortions in various states since performing his first one in 1975, two years after Roe. He can't believe abortion rights may soon vanish here. "Disaster," he said. "Just a disaster."
Before seeing their first patient on June 10, Campbell and Gorman showed visitors one of the treatment rooms. A music player with headphones was perched on a window ledge. Tacked onto the ceiling, where patients would be looking up during the procedure, a small sign said: "It is OK to cry. It is OK to feel relief. Never apologize for having an abortion."
After he finishes training Gorman, this month or next, Campbell is mulling where to go if the clinic shuts down. He is considering Charlotte and Las Cruces, N.M., which draw numerous abortion patients from out of state.
He's also thinking about future trainees. But they would have to wait.
"My first step has to be to establish someplace to be able to help people before I can train people," he said.
Related Content
What a 1978 trial could tell us about future criminal abortion cases
A Black Republican tries to bring in Black voters to the GOP
