6. The Next Generation
SYNOPSIS
Illustration by Nicole Xu
How has the Dobbs decision impacted medical education? In this episode we talk to trainees and educators about how Dobbs has impacted their lives in the classroom, and explore what we lose when we lose abortion training.
LISTEN
Featuring
Anastasia Anazonwu, MD Candidate
Bria Peacock, MD
And other contributors who wish to remain anonymous
Credits
Host & Co-creator: Ali Block, MD
Co-creator: Emily Silverman, MD
Lead Producer & Editor: Molly-Rose Williams
Producer, Editor & Audio Engineer: Sam Osborn
Producer & Editor: Jessica Yung
Audio Engineer: Jon Oliver
Student Producers: Anjali Walia, Dahlia Kaki, Fiona Miller, Mulki Mehari, and Treya Tompkins
Assistant Producer: Carly Besser
Chief Operating Officer: Rebecca Groves
Series Illustrator: Nicole Xu
Music: Blue Dot Sessions
Resources
Sponsors
The Nocturnists: Post-Roe America series was made possible in part by the Josiah Macy Jr. Foundation and the Danziger Family Fund at The Chicago Community Foundation.
Support for The Nocturnists’ medical student producer program comes from the California Academy of Family Physicians Foundation.
The Nocturnists is supported by the California Medical Association, and people like you who have donated through our website and Patreon page.
TRANSCRIPT
click to expand
The Nocturnists: Post-Roe America
Episode 6. The Next Generation
Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Ali Block
Welcome back to The Nocturnists: Post-Roe America. I'm Dr. Ali Block. This week, we're looking at a very specific corner of the abortion world. It's an issue we've heard about over and over again as one of the most important impacts of the Dobbs decision. But it's also been one of the least covered. So today we're diving into medical training and education. Training to be an abortion provider has never been like training for any other medical specialty. It's rarely covered in med school, and only certain residency programs even offer abortion training at all. When I was in residency, even in an unrestricted state with a strong abortion care program, I still did an elective in Mexico City. Simply to get the practice I felt I needed to be trained to competence. And this is common for many abortion providers to travel out of state or even out of the country to get this basic skill set. The Dobbs decision has only further limited training opportunities. And when we're talking about medical education, we're also talking about the type of care an entire generation of clinicians will be able to provide. So to start today's episode, we asked one of my mentors to give us a crash course on what you need to know if you're learning how to do an abortion.
Julie
So, okay, the vagina is a dark canal. At the end of the dark canal, there's like the cervix, that's a little doughnut. And it's a doughnut that is very tightly closed. That doughnut, it's made by a muscle and it it has a canal, right, that's going from there up into the uterus where the fetus is.
Ali Block
She wanted to stay anonymous, so we'll call her Julie. As someone who has spent years teaching others this procedure, Julie really impressed upon us the importance of hands-on practice.
Julie
And in order to get into the uterus to empty it, you got to be able to find your way through that twisty canal. As you can't see it, it's a total feel thing. You got to feel, you got to know like how much pressure to put. Am I putting enough pressure? Am I putting too much pressure? Because you can create a false passageway you can like force a really sharp instrument to go into the muscle. We call it a "gritty feeling" that you have when you're making a false passage and you need to know that and back off and try something different. Get into that uterus in the right way. And then of course, the other risk with any time you're putting something into the uterus is that you go through the uterus, so you go into the uterus and then out the back into the abdominal cavity. And so that's making what we call a perforation, a hole in the uterus, and then that can cause damage to the bowels, and bleeding and, you know, perforations can cause hysterectomies, and loss of life. Every body is different. The body does not read the anatomical textbooks.
Ali Block
I think it can be helpful to compare performing an abortion to something like administering anesthesia or flying an airplane. It's mostly routine, straightforward, even rote. But like anything in medicine, there can be complications. There rare, but when they do happen, they happen fast and can be life threatening. The ramifications of losing out on this hands-on training extend beyond just abortion care.
Julie
The thing about abortion is that it's really good practice for doing things that you need to be able to do to take good care of women who are having miscarriages or want IUDs, or any of the things where you need to pass an instrument through the cervix. And it's terrifying for me to know that there is a generation getting trained in whole states where they're not learning these things in a way that they're going to be able to be competent.
Meredith
Six hours after the Dobbs decision came down, I get a phone call. That's like, "The judge ruled and the six-week ban is in effect." You know, one moment we could do one thing, and then the next moment, that's it.
Ali Block
This is Meredith, an OB-GYN and educator in Cincinnati, Ohio. After the state and after its six-week ban in June of 2022, it became essentially impossible for her to teach abortion in any kind of hands-on way.
Meredith
I think the hardest part for me was in July, when I had to like send an email to all the fourth-year medical students that were so excited about their elective and be like, "Hey, guys, I don't know what your elective is going to look like." Right? Like, "it's supposed to be a very hands on elective. And as of now it's going to be virtual online learning." It's so hard and it's so hard to explain to other people why then residents might not want to come to states like Ohio, if they can't learn the skills, and they can go to New York or California, and learn the skills and learn everything else that they would learn here, right? Like, we're not adding anything extra. And so it puts you in a hard place as an educator because you're like, how am I going to teach these people what they need to learn if I can't even do it myself?
Ali Block
So Meredith is now in the position of trying to figure out what skills can she feasibly teach her trainees, given the political and legal context? And what skills do her students need to leave the state to learn? Like this year, she had one resident who wanted to focus on abortion care for her third-year elective.
Meredith
We had a lot of conversations around, should she just stay in Cincinnati and do it with us? Should she look somewhere else. She's from the West Coast, should she go back out there? And so it's been hard because a lot of the other places in protected-access states are struggling to balance the influx of trainees, but it definitely took like, calling up a friend and being like, "Hey, are you gonna take it out of state residents?" Like "she's awesome, you know," but that, to me is also really hard as an educator to say like, "Okay, well, I'll just send my residents out of state," like, I don't want to do that, like, I went into academics to be able to train trainees and I went to fellowship to learn these skills to pass on to somebody else. And so then to have to say, like, "well just go to a different state," it makes me feel like a bad educator, like it makes me feel like I'm letting my trainees down.
Ali Block
So beyond making training harder to access, Dobbs has also impacted the kinds of students that go to residency in places like Ohio, restricted states are left mostly with students that are okay with not getting trained, leaving the state with fewer and fewer clinicians able to offer this care at all. Meanwhile, the students who do want that training and are vying for the extremely limited spots in unrestricted states like California and New York, there just aren't enough training spots for everyone who wants them. The impact of this deficit can get pretty serious pretty fast.
Julie
So I had one of my grads, she did her training at our residency, and then she was doing an OB fellowship in Utah. And they had a young woman who was, I think, 16 or 17 weeks and had a pre preterm premature rupture of membranes bag of water broke, which is not compatible with that fetus surviving – it's too early. But she wasn't being given the option to have that pregnancy terminated. She was just waiting to see what would happen. And then she hemorrhaged, and she was bleeding out in the hospital bed. And my resident was working alongside an OB-GYN attending who had not had abortion training, and felt like she could not do a D&C to save that woman. And so my resident had to step in and do it and saved her life. You know, she felt perfectly capable, she just did it. But it is really chilling to know that that scenario is going to become more and more prominent, and without good abortion training that people are not going to know how to do that. And that's going to have massive implications for women's health. And if our OB-GYN residents are not getting that training, and our family medicine docs are not getting that training...it's chilling.
Meredith
You know, it's like if you had a general surgeon, and you said, "Okay, well, you can't do appendectomies. You're going to only have to watch them virtually, and read about them. But then, when you're the attending doctor, there will probably be someone who comes in and who will almost die from a ruptured appendicitis. And in that moment, you need to do that appendectomy. But maybe you only did one or two in an emergency situation as a resident, but still, we expect you to have that skill." That's really scary, right? Like you when you go to do those emergency procedures, whether it's an appendectomy, whether it's a septic abortion, you want to have done dozens, if not hundreds, before then, so that you're comfortable with a complicated case.
Meredith
I do think that by limiting what residents and medical students can learn, you are going to put patients at risk. I think you're also going to find that you're going to have a really bifurcated training map. And so you're gonna have entire states that have people who can't even counsel a patient on an abortion, or that option if they wanted it. And I think that's a, that's a sad reality, because it's just part of reproductive health care, and it's not going away.
Ali Block
Part of what makes this post-Dobbs reality so upsetting is that while the consequences of not having adequate access to training can be dire, the training itself is just not that difficult or time-consuming to complete.
Julie
A lot of places don't offer abortion every day. But let's say you were coming to a place that offered abortion every day. I mean, I think you could be trained to competency in a week or two. It's not that hard. I mean, early abortion. I'm not talking about second tri. I'm just... early abortion or manual vacuum aspiration. Yeah, a week, two weeks, maybe.
Ali Block
Julie said that pre-Dobbs, she'd always seen the solution as making abortion training opt-out, instead of opt-in, at Family Medicine and OB-GYN residency programs. That way, at least everyone would get basic training, unless they specifically opted out due to religious or moral objections.
Julie
I have found over the years that I am not very good at actually predicting who's going to be the ones that go on to provide. I don't think when you start residency, you don't really know what you want to do. And some people are really much more gung ho. But then what they really end up caring about is living in the San Francisco Bay Area. And there's plenty of providers in the Bay. So they're not necessarily going to be able to provide there. Whereas other people might not be that interested, but then they get trained, and then they find themselves in rural North Carolina where nobody else is offering and they're like, "Okay, I'm gonna do this."
Ali Block
But since Dobbs, training has become such a limited resource, that even making it opt out, in all the programs that remain, wouldn't account for the thousands of residents in restricted states missing out on any training at all. So what's it like to be seeking training in such a divided landscape? We talked to a lot of trainees in the past year and a half. And one of the things that struck us most was how varied their considerations have to be, not just what kinds of technical training the program offers now, but also the likelihood that it'll say the same, given the political context of the state. Even the culture and attitudes around abortion at the school have become a consideration.
Ali Block
Anastasia Anazonwu is currently on the threshold of the critical jump between medical school and residency.
Anastasia Anazonwu
My name is Anastasia Anazonwu. And I am a third-year, literally, like two weeks away from being fourth-year medical student at University of Missouri in Columbia. Currently, I'm very burnt out. So what I do in a day is focus on the next step, which is getting to residency.
Ali Block
Anastasia grew up in a very conservative southern family that went to church twice a week. Her mom was once proudly arrested for protesting outside an abortion clinic. Abortion was a dirty word in her household growing up, she told us. But when Anastasia went to college in New York, everything changed. She began to question the beliefs she'd been raised with. And by the end, what she wanted more than anything else was to be an abortion provider.
Anastasia Anazonwu
So, when I was applying, and when I was thinking of how I would shape my mouth around like, "I want to do, what's the word?" I didn't say the "A" word, right? Because I'm like, "I gotta get any, any means necessary." Like I have to get this training, so I can get to the next step. So family planning is what I talked about a lot.
Ali Block
When she was applying to medical school, she was already living in Missouri, and volunteering as an abortion clinic escort, helping patients get past protesters and inside the building. Despite the protesters, Missouri seemed like an okay place to learn how to be an abortion provider.
Anastasia Anazonwu
Washington University in the city of St. Louis has a medical school. And they had this group called Medical Students for Choice. And they like came out to events sometimes, or sometimes they would organize like groups of medical students to do clinic escorting as well. And I was just like, "Wow, like, look at them out here in a city where they could actually like learn abortion care training." I thought, at the time, "I can start even learning about this as a medical student." Like I thought I'd have to learn about this as a resident. So when I came to this school,
Ali Block
which is a couple hours away from St. Louis and Columbia,
Anastasia Anazonwu
I was like, "Oh, my gosh, there's a Medical Students for Choice, this is going to be so exciting." And then it was just really bogged down. The folks who are working here, were very, maybe understandably hesitant to push boundaries, or ruffle feathers, or like, say, the word "abortion." And I was like, "Okay, cool, big bet. But like out in St. Louis, they're fucking shit up! Like they're going to rallies, they're like, doing all these things." And I think that's just like really timid.
Ali Block
Like, she told us about this one time, the student group was putting on an abortion clinic documentary, they would show a screening, and then afterwards, there would be a discussion.
Anastasia Anazonwu
So there was this discussion of like, "Okay, should we send this out to like the entire class, or just to people who have signed up to be on our listserv?" And I was, like, "Let's send to the entire class!" It's just a documentary that you know, four people show up to or not, you know, just like all the other documentaries. And it was like, "No, no, no, no. For everyone's privacy, we should go ahead and just invite the people who are like on the listserv," and I was like, "Okay, fine." And then, we have this long discussion about, "Okay, should we get butcher paper to cover the windows and transparent doors, so that people's privacy is protected? So that no one can like walk by and say something ugly? Or like, should we not?" And I was like, "No, like, we don't need to do that. We're not doing anything bad. And we don't want a fight. But like, if someone comes into the space and picks a fight, that's a different story than us just like existing and being."
Ali Block
Now Anastasia is considering where to go for residency training, and experiences like this loom large in her decision-making process.
Anastasia Anazonwu
In Central Missouri, I'm at an institution that's affiliated with, like a state-funded, federally-funded place. You can't say "abortion" to patients. Like literally it's like, "Alright, so you're pregnant. If that's a result that is upsetting to you, then maybe Google online where you could not be upset." Like literally like that kind of language, you know, "Wink, wink, nudge, nudge, you should maybe go to Planned Parenthood, if you had questions about this pregnancy." That would really, that would really grind me down. I'd just be worried that this great passion that I think defines me, just because I'd be so exhausted and like mentally worn down, I'd be worried that that passion would leave me in exchange for like, you know, a little bit more mental health a little bit more, like, peace with a situation. Oh, my God. Oh, that's like really... I'm really scared about that, shit! Shit!
Ali Block
If Anastasia were to stay at her current program in Central Missouri, she'd not only be navigating the cultural stigma around abortion training, but she'd also need to leave to get technical training in a less-restricted state. So she talked to her advisor, Dr. Bhavik Kumar, one of the voices we heard in episode two.
Anastasia Anazonwu
He was like, "Don't do that," like, "Go somewhere where you're celebrated, where you don't have to... Where like everyone wants to get that training. Go somewhere where you don't have to say 'family planning' when you mean to say 'abortion'."
Ali Block
And so under the guidance of Dr. Kumar, Anastasia has decided to apply only to programs in states where they have abortion training easily available.
Anastasia Anazonwu
He's just like, "I want to do abortions, I want to treat and care for Black, brown, and queer people. And I want to be in a place where I can just talk about abortions, like the fucking regular-ass medical procedure that it is. I'm gonna go where I can actually learn it. And I'm like, if you're listening to this, Dr. Kumar, like, I'm just so grateful that he got me on that path. Because that final, like, nudge, is what's gonna get me to this kid who said she wanted to be an abortion care provider – at some point, maybe when I was 18, I'm like, literally 10 years older now – you know, like, that's gonna get me to actually being an abortion care provider.
Ali Block
So for Anastasia, whose top priority is to become an abortion provider, no matter what it takes, leaving a restricted place like Missouri is the decision that makes the most sense. But for other people, whose draw to abortion care is less clear-cut, the calculus around where to train and practice feels more complicated. Meet Bria Peacock.
Bria Peacock
So I'm Georgian through and through, like peaches, pecans, you know – Georgia.
Ali Block
Bria's doing her OB-GYN residency in California at UCSF. But Georgia is really where her heart is.
Bria Peacock
My family's from Cordele, Georgia, which is the watermelon capital of the world. That's our call to fame, which we have been in for five generations. But you know what that means – Black people in the South. Like those were our roots here, and all that came with that. I come from a family of survivors. Of course, being out here in California, it's so interesting to – and then even going to school in DC – seeing the impacts of the Western flight and the northern flight after slavery, and just feeling a lot of sense of pride that my family stayed and survived. After all of that in the South, which is the pride that I have, and why I want to go back.
Ali Block
Provision for what her life would be dedicated to – her mission – became really clear to her very young.
Bria Peacock
I was born and raised in Atlanta, the best city in the world, in my opinion, by a single mama. And my upbringing was very intentional, like getting me into a city, certain schools, moving, you know, apartment to apartment, so that I can have a chance. You know, I grew up around teen moms is a, what you call, generational curse in my family, whatever you want to call that. I just understood very early what that meant. You know, everybody talks about adolescent pregnancy prevention. But what about when they do get pregnant? Why does the village go away? What are we doing as a society and why are we failing these people and why are they Black? Not just like, you know, you people here, "Oh, I want to do stuff with my hands." Like I was never that. What what what can I do to make the impact that I need to make? I want to work with teen moms, do abortions, and move back to Georgia. It's been the same.
Ali Block
But for now, she's not in Georgia. Now that she's a resident and needs to be trained to be the abortion provider she wants to be. She's at UCSF.
Bria Peacock
What people are doing out here, in the health care realm and the advocacy realm, in the community realm. I couldn't get that back home. I can build it when I get there though. But I really wanted to make sure that I got the groundwork, that I got the expertise, so that nothing falls through the cracks.
Ali Block
It isn't always easy though, she says. She's getting the training she wants, but it can be hard to be so far from home. When Dobbs fell the first thing she thought about, naturally, was Georgia.
Bria Peacock
Like it's gonna be very scary for my cousins. You know, who might not have a car, might not have $300 to make it up to Atlanta. That was already a struggle. Now what? I didn't have that sigh of relief, that a lot of people had here, because they knew that their communities were going to be protected in the state of California. I'm not from here, I bleed Georgia. And so I thought about home first.
Ali Block
Georgia has a six-week ban, essentially eliminating abortion in the state. But even if she won't be able to practice abortions in Georgia, Bria says, her plan is still to go back.
Bria Peacock
My vision has never been within four walls of a clinic, within four walls of a hospital. I've never felt that way. That wasn't my vision for why I wanted to become a doctor, why I decided to be an abortion provider. It's all about the people. It will always be about the people. And so when you're from a community, there's a different kind of understanding that you have. And what I understand is the true impacts don't come from academic journals that we don't have access to. There's the education piece, there's the community impact piece, there's a village piece, there's a policy piece. Like the medicine is a part of it, but it's not all of it. They come from being in the community and that's my goal.
Ali Block
Since Dobbs, almost half of the OB-GYN residency programs in the country are in states with complete or partial bans, and only 40 of the country's almost 800 Family Medicine residencies offer integrated abortion training. During the Roe era, I think we took for granted that we could always train new generations of abortion providers. There was a hopefulness to that. Going forward, as current providers age out and approach retirement, it's not clear if there will be people there with the training they need to fill those shoes.
Ali Block
If you're looking for ways to get involved, check out our website at the nocturnists.com. The Post-Roe America page has an advocacy toolkit with resources to help you get started. And next week, we look ahead to the future of abortion care. Where do we go from here?
The Nocturnists: Post-Roe America was created by me, Ali Block and Emily Silverman. Our lead producer was Molly Rose-Williams and our producers were Sam Osborn and Jessica Yung. Jon Oliver helped with the mixing and Carly Besser assistant produced. Thanks to medical student producers, Anjali Walia, Dahlia Kaki, Fiona Miller and Mulki Mehari, and pre-health intern, Treya Tompkins. Our Chief Operating Officer is Rebecca Groves. The series illustrations are by Nicole Xu. The Nocturnists theme music is by Yosef Munro and all additional music comes from Blue Dot Sessions.
The Nocturnists: Post-Roe America series was made possible in part by the Josiah Macy Jr. Foundation. The Nocturnists is supported by the California Medical Association, a physician-led organization that works tirelessly to make sure that the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org.
Our show is also made possible with donations from listeners like you. Thank you for supporting our work in storytelling.
If you enjoy our show, please follow us in your favorite podcast app so you don't miss an episode. You can also help others find us by telling your friends and colleagues, posting this episode on social media, and leaving us a rating and review in your favorite podcast app.
To contribute your voice to an upcoming project or to support our work with a donation, visit our website at thenocturnists.com. You can also find resources with more information about the state of abortion in the U.S., as well as ways to advocate and get involved, at the series website. I'm your host, Ali Block. See you next week.