Educating physicians in a post-Roe world

Earlier this month, in a nondescript conference room in the Westin Hotel in downtown Buffalo, about 40 professors and leaders in obstetrics and gynecology gathered to have lunch and discuss a matter that poses a direct threat to the very field to which they have committed their professional lives.

The attendees were chairs and former chairs of departments of obstetrics and gynecology at medical schools throughout the U.S., as well as former and current physician executives for the American Board of Obstetricians and Gynecologists, and the American College of Obstetrics and Gynecology. All are members of the American Gynecological Club (AGC), the nation’s oldest professional medical organization focused on women’s health.

They were in Buffalo for their annual meeting, organized by Sarah Berga, secretary of the AGC and chair of the Department of Obstetrics and Gynecology at the Jacobs School of Medicine and Biomedical Sciences.

The focus of the luncheon on Sept. 16, sponsored by the UB Gender Institute, was “A Medical-Legal Dialogue on the Impact of Dobbs,” the case that the Supreme Court used to overturn Roe v. Wade in June. A recording of the talk is available on the Gender Institute's website.

Because of the sensitive subject matter, the Jacobs School photographer agreed to photograph only the speakers, not the attendees, some of whom were shaking their heads in disbelief that the U.S. had, in 2022, arrived at a juncture where physicians have found themselves suddenly unable to practice medicine in accordance with the standards of care and more vulnerable than ever to legal jeopardy for doing so.

Carrie Tirado Bramen, professor of English, College of Arts and Sciences, and director of the Gender Institute, opened the talk. She and Jo Freudenheim, deputy director and SUNY Distinguished Professor in the School of Public Health and Health Professions, had invited Allison Brashear, vice president of health sciences at UB and dean of the Jacobs School, to speak after UB posted her statement responding to the Supreme Court’s decision handed down on June 24.

Brashear came to UB last December after serving as dean of the University of California, Davis School of Medicine. She is an internationally renowned neurologist and researcher in movement disorders, and a powerful advocate for promoting diverse leaders in medicine and frequent lecturer on the importance of diversity in medicine.

Also invited to speak was Lucinda Finley, Frank G. Raichle Professor of Trial and Appellate Advocacy in the School of Law, a national expert on reproductive health, who has successfully argued an abortion case before the Supreme Court. Finley’s mentor was the late Supreme Court Justice Ruth Bader Ginsburg, her professor at Columbia Law School.

Upon taking the floor, Brashear held up a small button that read: “Don’t tell me what to do with my own body.” She got the button when she was in grade school, having been raised in the years prior to Roe v. Wade by a mother who was passionate about women’s rights. Brashear said her mother had taken her to the Equal Rights Amendment debate in the Indiana legislature. She also made sure to educate her daughters about the abortion issue.

“So now her namesake, who is 22 years old, is now living in the world that I lived in as an elementary and middle schooler,” Brashear said. “Sometime in the future, with the power of everybody in this room and many others, maybe there’ll come a time when this button doesn’t need to exist.”

Brashear acknowledged that the fallout from Dobbs is so dramatic that providers and educators are still trying to fathom the extent of its impact. What has resulted is a system where residency programs in obstetrics and gynecology will vary widely, depending on the state in which they reside. In states with abortion bans, Brashear said, it will now be impossible for obstetrics and gynecology residents to get the training required by the Accreditation Council for Graduate Medical Education (ACGME), the residency accrediting body.

That’s because abortion care, including counseling and pain management, is part and parcel of comprehensive reproductive health care as defined by the ACGME. The skills and techniques involved in doing abortions, Brashear explained, are the same, or very closely related, to those required to treat common conditions, including miscarriages, excessive uterine bleeding and uterine biopsies.

“Right now, almost half of OB-GYN residents won’t get proper training in states that are poised to ban abortion,” she said. “I don’t know how they’re going to train students or residents. And I don’t know how they’re going to end up having students who want to go into obstetrics and gynecology. It’s going to be a really big challenge.”

It may therefore be necessary, she suggested, to expand obstetrics and gynecology residency programs in blue states. “That is something we really need to think about in terms of expanding the number of providers,” she said, especially because many women see their obstetrics and gynecology provider as their primary care physician. 

The impact of Dobbs has extensive social and demographic implications. Brashear cited research from the Kaiser Family Foundation and others noting that states with abortion bans tend to have higher numbers of uninsured women ages 19-64, as well as poorer health outcomes. Research has also found that women who have children early in life without sufficient support are challenged for many years after with fewer educational opportunities, lower wages and mental health challenges. She said there will also be effects in the pediatric world, as Dobbs results in more young women having children.

“As someone who has always supported women and women in leadership, it makes me wonder whether or not we’re going to have less opportunities for women to advance,” she said. “We’re lucky to live in a state that’s blue,” she continued, noting that Gov. Kathy Hochul has been absolutely committed to supporting comprehensive health care for women. She noted that Hochul has now pledged a total of $55 million to provide that care, not just for the women of New York but also for women who will be coming to New York to access the health care they can no longer get in their home states.

Brashear noted she is passionate, and the Jacobs School faculty collectively are passionate about making sure women’s health care is a priority.

“I do feel very fortunate to be in a state and a system where we can put out a strong statement with full support and no backlash,” she added. “Not all schools of medicine have that.”

Finley didn’t mince words when she took the floor. She said Bramen had asked her to address in her talk how OB/GYN physicians can practice in states where abortion is illegal.

“The answer,” she said, “is they don’t. They can’t.”

Bramen also asked her to address how OB/GYNs know what they can and cannot do in providing medically necessary care without being worried about prosecution. Again, she said, “The answer to that question is very simple: you can’t.” 

Finley traced the legal history of abortions in the U.S. and described how physicians and physicians’ groups have historically played crucial roles in the abortion debate. She said that prior to the 19th century, there had been few laws governing abortion in the U.S. But in the 19th century, partly due to the rise of the American Medical Association, some physicians began to move to take control of childbirth, essentially to “stamp out” midwives.

“Basically there was a group of male physicians who wanted to get rid of women providing reproductive health care to women,” she said, referring to the central role that midwives had played in childbirth.

Physicians also teamed up with the anti-vice crusade spearheaded by organizations, such as the Young Men’s Christian Association, which held that alcohol, prostitution and sex outside of marriage led to men’s degeneration. “They felt that abortion kind of let men off the hook for their sexual indiscretions,” she said.

So abortion was criminalized. By the middle of the 20th century, though, the tide began to turn again. There was a growing awareness among physicians and physicians’ groups of the deaths and injuries caused by illegal abortions and a recognition by physicians that they had the ability to provide abortions safely. They began to lobby for reform. At the same time, Finley said, the women’s rights movement was gaining momentum. Both began to pave the way toward reforms in state legislatures to decriminalize or reform abortion laws.

In 1971, before Roe v. Wade, New York decriminalized abortion. 

“My point here is that physicians’ groups were very important to the reform efforts and ultimately to Roe,” said Finley.

She added that the Roe decision was written by Justice Harry Blackmun, who had earlier in his career served as general counsel to the Mayo Clinic. “If you read it carefully, it’s much more an opinion about the sanctity of the doctor-patient relationship and the importance of the law not interfering with that, rather than women’s rights,” she said.

Then she warned the group that she was about to make what might be seen as a controversial political remark.

“In the years and decades after Roe, despite all the wonderful amicus briefs that have been filed in court cases,” Finley said, “I think physicians’ groups largely went what I call politically silent, basically abdicating any political or public defense to doctors who only provide abortions, abortion providers who were easily stigmatized, ignored, brushed off.”

She said that since Roe, there hasn’t been a continued public, political effort to argue for abortion. She looked at the physicians in the room and told them, “You are now much more important than the lawyers.”

She referred to the recent, attention-getting headlines showing the horrific effects of the abortion bans, such as the woman made to carry a dead fetus for weeks or the 10-year-old rape victim who had to leave her state to get an abortion. While she praised the media for revealing these tragic, personal stories, she pointed out they are only one piece of the impact of the overturning of Roe v. Wade.

“I’m concerned that we are developing a political sense in this country about good abortions and bad abortions, good women and bad women,” said Finley. “You’ve got to start articulating why any abortion, not just the medical emergencies or the incomplete miscarriage or the 10-year-old rape and incest victim, is such an urgent matter of health care, of autonomy and dignity for patients.”

Finley advised the physicians: “You need to figure out ways as health care providers to explain why all women should have the right to safe and legal reproductive health care, including abortions.”