The Impact of Dobbs on Medical Education and the Pipeline from OB/GYN Training to Clinical Practice

Editor’s Note:  Among the immediate impacts of the Dobbs v. Jackson decision on the American health care landscape are profound challenges for the educational and training ecosystem for physicians, particularly those entering obstetrics and gynecology (OB/GYN). In a new white paper, summarized below, Manatt Health organizes the known consequences and open questions stemming from Dobbs and the resulting states’ actions to severely restrict or ban abortion. The paper addresses the impact of Dobbs on the pipeline of physicians specializing in OB/GYN in the United States and, in particular, the effects on medical schools and on accredited OB/GYN residency programs.¹ To download a free copy of the full white paper, click here.

Family planning, contraception counseling and abortion services are required elements of OB/GYN residency curricula and training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME), the national accrediting body for all graduate medical education programs in the United States. State limitations or bans on abortion services resulting from Dobbs complicate the ability of residency programs to meet their accreditation requirements and to graduate fully trained OB/GYN physicians. The ACGME recently reaffirmed requirements for didactic and clinical training for comprehensive family planning that include surgical and medical abortion.²

Undergraduate medical education and training also are affected. While family planning and abortion care are not a required part of accredited medical school curricula, many medical schools provide didactic courses and affiliated teaching hospitals offer clinical clerkships to medical students in family planning and abortion services. These offerings may now be limited or eliminated in states with severe restrictions or bans on abortion services.

The compounded impacts on undergraduate medical school education and graduate residency training will undoubtedly create a long-term shock to the supply of OB/GYN physicians in the United States overall, not just for those who provide abortion services. With many parts of the nation facing physician shortages, the impact on access to all OB/GYN care in certain geographies could be catastrophic.

The Ever-Changing Landscape in a Post-Dobbs World

Since the Dobbs decision, medical schools and teaching hospitals are operating in a patchwork of state-level legal environments. This patchwork is evolving as courts take action to block or unblock state laws, legislatures propose and pass new laws, and abortion-related initiatives are placed on statewide ballots.

This changing landscape is having, and will continue to have, a profound effect on medical schools and teaching hospitals that operate in states where there are abortion bans or where there are severe restrictions.  When we look at statistics on medical students and OB/GYN residents across states, we can clearly see the significant implications Dobbs can have on medical education and training, as well as on the pipeline of practicing OB/GYNs:

• In academic year 2021, almost 12,000 first-year allopathic medical students enrolled in medical schools where abortion is illegal or where abortion may soon be illegal, pending court action. This represents over half of the total first-year class of medical students in all allopathic medical schools in the United States who enrolled in 2021.
• Currently, 139 OB/GYN residency programs teaching over 700 first-year residents are sponsored by teaching hospitals in states where abortion is illegal or may soon be illegal, pending court action. This represents 47% of all ACGME-accredited OB/GYN residency programs and 47% of all first-year OB/GYN residents who enrolled in an accredited OB/GYN residency program in 2021.
• An accredited OB/GYN residency program takes four years to complete. This means that in under a decade, should nothing change, more than 5,000 newly board-certified OB/GYNs may enter the workforce without formalized hands-on clinical training in abortion care completed in their home institutions.³

Issues Facing the Medical Education and Training Ecosystem and the Pipeline of OB/GYN Specialists Into Clinical Practice

No Hands-On Abortion Training Required as Part of Medical Education. Although neither undergraduate medical education accrediting body—the Liaison Committee on Medical Education (LCME) for allopathic medical schools and the Commission on Osteopathic College Accreditation (COCA) for osteopathic medical schools—requires family planning and abortion training for medical schools to receive and maintain accreditation, many schools offer this kind of education. Key issues Dobbs raises include:

• Loss of clinical experience in abortion care for medical students in states where abortion is banned. Students enrolled in medical schools in states that ban or severely limit abortion will likely have limited or no opportunity for hands-on clinical training in abortion care as part of their curriculum.
• Potential influence of state governments in nonclinical education standards for medical students. State governments may seek to influence medical education curricula being delivered in their states directly, limiting even didactic education regarding family planning and abortion care.
• Shifting enrollment trends away from medical schools in states where abortion is banned. Enrollment trends may be impacted, with students, particularly those interested in women’s health, opting to forgo considering medical schools in states that ban or severely restrict abortion.

Obstetrics and Gynecology Residency Programs Face Accreditation Challenges.  The ACGME Review Committee for Obstetrics and Gynecology has reaffirmed requirements for all accredited programs to include, “didactic and clinical experience in comprehensive family planning.” According to the ACGME, if a program is in a jurisdiction where resident access to this clinical experience is unlawful, the program must provide access to this clinical experience in a jurisdiction where it is lawful. This requirement was affirmed by the Review Committee in updated accreditation requirements effective September 17, 2022. Key issues Dobbs presents include:

• Financial burden and capacity constraints linked to out-of-state completion of abortion training. Programs in states that ban or severely limit abortion services will likely look to partner institutions in other states to accommodate their own students for required clinical rotations in family planning and abortion (typically a four-week rotation). Structuring these agreements (referred to as “program-level agreements”) is a complex undertaking involving funds flows and medical malpractice issues. This also may place a financial burden on residents to complete this rotation out of state.
• Risk of accreditation loss. Programs that are unable to meet accreditation requirements within their institution or via an out-of-state program-level agreement will be at risk for losing their accreditation.
• Decreased capacity of OB/GYN residency programs nationally. Over time, if programs begin to lose accreditation, there will be more limited training capacity in accredited residency programs for OB/GYN residents, potentially straining the supply of OB/GYN practitioners moving into full-time practice.
• Suboptimal training experience for residents. Residents in OB/GYN programs in states that ban or severely limit abortion will likely not be exposed to teaching opportunities with medical students—a common model in teaching hospitals where residents supervise medical students during their clinical clerkships.

Clinical Practice Patterns May Negatively Impact Women’s Access to Services. The effects of the Dobbs decision and state actions to limit or ban abortion care will likely have a profound impact on the practice of obstetrical and gynecologic medicine. While changing practice patterns will not be fully known for some time, several impacts are likely:

• Practice employment patterns may shift, with more physicians completing residency and seeking employment in states where abortion remains legal. This may exacerbate already critical shortages in certain geographic areas for OB/GYNs generally, not just those who provide family planning and abortion services.
• Some procedures used for abortions are used for other types of women’s health care, such as for miscarriages. Lack of clinical training for OB/GYN residents in the provision of these services will impact the ability of these trainees once in clinical practice to treat a wide range of clinical problems that women may face.
• Some OB/GYNs who are currently practicing but whose practice does not include family planning and abortion care may reorient their practice to provide those services. This cohort may require education and training depending on how long out of practice those physicians may be.
• Provider groups recruiting and employing OB/GYN physicians after residency may need to develop training programs for physicians who completed residencies without the required education in family planning and abortion care.

Perspective on Additional Unknowns

There are many additional unknowns with respect to the impact of Dobbs on the medical education and training ecosystem in the United States. Some of the most critical unknowns include:

• What will the impact be on women’s health overall and, in particular, women’s health in communities already facing significant shortages of women’s health providers?
• Will medical school application volume trends shift away from schools located in states that ban abortion? If so, will the overall capacity of the medical education system be able to absorb the needed matriculating students to maintain the overall pipeline of physicians trained and deployed in the United States, particularly in women’s health?
• Under the reaffirmed ACGME requirements, will OB/GYN residency programs begin to lose accreditation, and if so, what will the impact be on the availability of adequate training slots for GME trainees in OB/GYN medicine?
• Will OB/GYN programs in states that permit abortion be able to absorb the training needs of OB/GYN residents in states that ban abortion?
• Could Medicare, through its GME funding authority, change funding to teaching hospitals where OB/GYN residency programs lose accreditation and are not providing required training in family planning and abortion care?
• Will employment practice patterns materially change in the next decade as the next two classes of OB/GYN residents complete their training and enter the workforce? Which patient populations and geographies will be most affected?

In addition, there are critical questions regarding other medical specialties that provide women’s services, particularly Family Medicine, as well as other health professionals, such as nurses.  Restrictions on abortion will also significantly impact the education and training pipelines of these provider types and further exacerbate overall issues relating to access to women’s health services.

Looking Forward

As a result of the Dobbs decision, women’s health providers across the country are now navigating an ever-changing and complex legal landscape. This new complexity extends upstream into the educational and training programs for women’s health providers of all types. Leadership is needed to bring together stakeholders across the country both to successfully navigate the immediate-term issues that educators are facing and to protect the integrity of the education and training system in the long term.

_{¹ The Dobbs decision affects many provider types in medicine (i.e., other medical specialties such as Internal Medicine, Emergency Medicine, Family Medicine, Pediatrics, and Surgery) and in other health professions such as nursing and pharmacy. This analysis focuses on medical specialists in OB/GYN only.}

_{² ACGME Program Requirements for Graduate Medical Education in Obstetrics and Gynecology. September 17, 2022. https://www.acgme.org/globalassets/pfassets/programrequirements/220_obstetricsandgynecology_9-17-2022.pdf}

_{³ This number does not take into account OB/GYN trainees in years 2–4 who may also not receive this training before program completion. Therefore, this number is likely underestimated.}