Farah Yousry/Side Effects Public Media
Early on a Monday morning, a group of young obstetrics and gynecology residents gathered for a daily meeting. The young doctors, dressed in blue coats and white coats, sat in the auditorium of Indiana’s largest teaching hospital.
The meeting was an opportunity to share updates and make announcements. But they also had to address the elephant in the room.
“Other questions about abortion care? Dr. Nicole Scott, director of the residency program, asked the interns.
One of the residents spoke after a few moments of rigorous silence: “How is Dr. Bernard?”
“Bernard is actually in a very good mood. I mean, relatively,” Scott replied. “She has 24/7 security, has her own lawyer.”
They refer to Dr. Caitlin Bernard, an abortion provider from Indiana and one of the physicians who trains residents at this teaching hospital. Bernard was recently caught up in a political whirlwind after telling a reporter about an abortion she performed on a 10-year-old rape victim who crossed the state line from Ohio. The doctor has been the target of attacks from pundits and political leaders on national television, including the Indiana attorney general.
The vitriol struck home for this group of residents. Bernard has been a mentor to most of them for years. Many of these young doctors were sure they wanted to practice in Indiana after their training. Lately, some have felt more ambivalent.
“See what [Dr. Bernard] went through was scary,” said Dr. Beatrice Soderholm, a fourth-year obstetrics-gynecology resident and one of Bernard’s mentees. “I think that was part of the point for those who put him through this. [It] was to deter others from doing the work she does.”
Indiana Republican Governor Eric Holcomb signed a near-total abortion ban last week, making Indiana the first state to pass new legislation restricting abortion access since reversal by the Supreme Court. Roe vs. Wade in June.
Before lawmakers voted, thousands of Indiana providers expressed concern about the likely worsening outcomes for their patients. It’s also unclear what this will mean for suppliers.
And that worries resident physicians — early-career doctors who are training for four years to become OB-GYNs.
Doctors weigh their options
These days, Scott, the director of the residency program, has found that the scope of her work has expanded beyond clinical and academic responsibilities. Her meetings with residents include policy updates and she tells them there are mental health services available if they need them.
“I mean, our residents are devastated,” Scott said, fighting back tears. “They’ve pledged to provide comprehensive health care for women. And they’re being told they can’t do that.”
She expects this to “have a profound impact” on how Indiana hospitals recruit and retain healthcare professionals.
Indiana, like many Republican-run states, lacks suppliers. A 2018 March of Dimes report found that 27% of Indiana counties are considered maternal care deserts, with no or limited access to maternity care. The state has one of the highest maternal mortality rates in the country.
Scott said new laws restricting abortion will only make those statistics worse.
Third-year resident Dr. Wendy Tian recently said she was scared and worried about her safety. Tian grew up and went to school in Chicago and chose to come to Indiana for his residency because the program has a strong focus on family planning. She was also open to practicing in Indiana when she completes her training.
But that has changed.
“I always thought I wanted to do family planning. Now I’m thinking about doing something else,” she said. “I know I still want to get into it. But I definitely don’t know if I’ll be able to stay in Indiana after graduation with what’s going on.”
Still, she feels “guilty for abandoning” some of Indiana’s most vulnerable patients.
Even before the Supreme Court reversed Roe vs. Wade, Tian said the medical climate in Indiana can be hostile and frustrating. Indiana, like other states that impose abortion restrictions, allows nearly all health care providers to opt out of providing care to abortion patients.
“We come across other people we work with on a daily basis who oppose what we do,” Tian said.
Tian said sometimes she and her colleagues had to cancel scheduled procedures because the nurses on call were not comfortable helping a patient who was having an abortion.
“Frequently we have to call anesthesia ahead of time, because there are only certain providers who are willing to provide anesthesia [for abortion patients]“, said Tian.
Abortion education at risk
Still, the OB-GYN program in Indiana has been able to provide residents with comprehensive training, which includes abortion care and family planning. This is important for more than abortion cases.
“Miscarriages are handled in exactly the same way as first-trimester termination procedures,” Scott said. “But what pregnancy termination procedures allow you to do is that kind of rehearsal and understanding of female anatomy, and how to deal with the complications that can arise from miscarriages.”
Farah Yousry/Side Effects Public Media
And that worries Scott, because removing abortion dramatically reduces the hands-on experience that OB-GYN residents can get at his hospital.
Scott’s program explores ways to compensate for this. They could send out-of-state residents to learn in places with no abortion restrictions. But Scott said it would be a logistical nightmare.
“It’s not as simple as walking into an office and saying, ‘Can I observe?’ This includes obtaining a medical license for out-of-state interns, as well as funding travel and accommodation costs,” Scott said. “It adds a lot to what we are already doing. to educate future OB-GYNs.”
Nearly half of all OB-GYN residents in the United States are in states where abortion is prohibited or may be prohibited. This means there will be an influx of residents looking to move out of state to make up for lost training opportunities. The Accreditation Council for Higher Medical Education, the body that accredits residency programs, has proposed changes to graduation requirements for OB-GYN residents to reflect this changing landscape.
The difficult choice to stay or go
For some residents, like freshman Veronica Santana, these political hurdles are actually a welcome challenge. Santana is Latina, grew up in Seattle, and has been involved in community organizing since she was a teenager. She chose obstetrics and gynecology partly because the field of medicine intersects with social justice.
“It’s political. It always has been and it continues to be. And obviously, especially now,” she said.
After Roe was knocked down, Santana took to the streets of Indianapolis to participate in abortion rights rallies. So have many of his co-residents and mentors.
Most of them, including the program director, asked not to name the medical school or hospital system they work for because they fear a backlash. Some said their employer remained coy in supporting staff when it comes to the abortion debate in Indiana.
In a way, Indiana might be the perfect battleground to quench Santana’s zest for advocacy and social activism. But lately, she said she was “very unsure” whether staying to practice after residency made sense as a doctor who wants to provide the full range of healthcare services.
Soderholm, a fourth-year resident physician, said there was a lot to think about.
Soderholm will finish training in a few months and will start training soon. She grew up in Minnesota, but over the past few years has felt a strong connection to the patients at Indianapolis County Hospital. She was so certain she wanted to practice in Indiana. But lately, her family in Minnesota – where abortion remains largely protected – wondered why she would stay to practice in a hostile medical climate like Indiana’s.
“There was a lot of hesitation. But the women [and] the people of childbearing age whom we have cared for, especially at our county hospital, [make it] really hard to leave. Sorry,” she said, breaking into tears.
It was for these patients that Soderholm decided she was likely to stay. The same cannot be said for many other future doctors.
This story comes from a reporting collaboration that includes the Indianapolis Recorder and Public media on side effectsa public health information initiative based in WFYI in Indianapolis.