摘要：The US Supreme Court’s 1973 Roe v Wade decision had clear implications for American women’s reproductive rights and physician ability to carry out patient choices. Its effect on physician abortion training was less apparent. In an effort to increase patient access to abortions after Roe , provision shifted from hospitals to nonhospital clinics. However, these procedures and patients were taken out of the medical education realm, and physicians became vulnerable to intimidation. The consequent provider shortage created an unexpected barrier to abortion access. Medical Students for Choice was founded in 1993 to increase abortion-training opportunities for medical students and residents. Its mission ensures that motivated medical students will learn and a growing number of physicians will commit to comprehensive abortion provision. THE 1973 US SUPREME COURT decision on Roe v Wade had far-reaching implications for the training and acceptability of abortion practice among physicians in the United States. Almost overnight, there was a shift in abortion provision from hospital centers to nonhospital clinics. Following Roe , the percentage of abortions performed in nonhospital clinics rose from 51% in early 1974 to 61% in 1976 1 and reached 95% in 2008. 2 Although the shift of abortion provision out of hospitals increased the number of sites where women could access abortion and other critical family planning services, it unintentionally took the procedure, relevant reproductive health care topics, and the patients out of the realm of hospital-based medical education accessible to medical students and residents. Training in family planning became uncommon in residency programs, and by the early 1990s, only 12% of obstetrics and gynecology (OB/GYN) programs offered training in abortion care. 3 The exodus of abortion provision away from the safe haven of hospital medical centers and into specialized clinics also produced a shift in the focus of anti-abortion activists toward individual physicians and their clinics. 4 Eventually, harassment previously reserved for clinic sidewalks moved to target the private homes of physician providers. Anti-abortion activists strove to intimidate and make pariahs of these health care professionals on a very personal level. In early 1993, thousands of medical students across the country were mailed a vulgar and menacing pamphlet of jokes by an anti-abortion group in Texas entitled, “Bottom Feeder: The Abortionists’ Jokebook.” One inclusion from the pamphlet read, “Q: What would you do if you found yourself in a room with Hitler, Mussolini and an abortionist, and you had a gun with only two bullets? A: Shoot the abortionist twice.” 5 (p9) Later that same month, David Gunn, an abortion provider in Pensacola, Florida, was shot and killed in front of the clinic at which he worked. He was the first of many physicians, clinic staff, and volunteers to fall prey to the violent tactics of extreme anti-choice activists. The anti-abortion movement’s violence against physicians and attempts to influence medical students’ opinions on abortion met resistance from an unexpected, rising leader. Infuriated by anti-abortion tactics, Jody Steinauer, then a first-year medical student at the University of California, San Francisco, decided to take a year’s hiatus from school to counter these attacks on current and future physicians. Her attention became centered on the lack of abortion-related education and training within medical school curricula. 6 Working as an intern at the National Abortion Federation, Steinauer began contacting like-minded medical students and quickly uncovered a burgeoning pro-choice medical student community yet to be organized. What started as a small gathering of medical students at the 1994 National Abortion Federation annual meeting quickly grew into a cohesive national community of pro-choice advocates. These students joined together to form a new organization named Medical Students for Choice (MSFC). In an environment that is often resistant to change and controversy, medical student activists of MSFC have worked steadily for almost two decades to reinstate abortion training in their medical education and to reverse the steady decline in the number of US abortion providers. Programming efforts have been at the heart of this work, including innovative medical-school curriculum reform strategies and clinical training opportunities including the Reproductive Health Externship, which provides financial and administrative support for medical students to gain exposure to abortion counseling and procedures. Although impressive inroads have been made, there remains a lack of comprehensive reproductive health education in medical school curricula nationwide. 7 The loss of hospital-based abortion experiences for medical students and residents following the Roe decision has unfortunately made access to training more difficult for these students. Hence, it has potentially added to the lack of access to safe abortion care. Countless studies over the past decade have highlighted the necessity of comprehensive abortion training and reproductive health education for medical students. In a 2005 study, Espey et al. found that almost a quarter of medical schools provided no formal education on abortion in the third-year OB/GYN clerkship. 8 A subsequent 2008 study showed that the majority of medical students view abortion education as an appropriate and valuable experience that they would recommend to others. 9 Perhaps of most importance, increased exposure to abortion care has not only been shown to correlate with improved attitudes toward abortion among medical students, 10 but also with more medical students considering abortion provision in their future careers. 11 The impact of the lack of abortion education and training on access has been profound. A recent study of practicing obstetricians and gynecologists in the United States shows that those who graduated from medical school between 1990 and 2000 have the lowest rate of abortion provision. 12 In turn, these years correspond with the years of steepest decline in access. The most striking recent data show that 87% of US counties, home to one third of all women of reproductive age, have no abortion providers. 13 Lack of abortion training is directly related to this provider shortage and causes a decreased access to options for patients. Since its inception, MSFC’s mission has been to increase medical student and resident exposure to and training in abortion procedures. This aim includes educating future obstetricians and gynecologists, family practitioners, emergency medicine physicians, pediatricians, and any other type of physician wishing to gain knowledge or skills in abortion provision. Ensuring adequate access for all women to safe and legal abortions requires a collaborative effort from physicians across the various specialties. In MSFC’s 2011 Alumni Survey, results showed that more than two thirds of OB/GYN alumni and one fourth of family medicine alumni provide abortions, and an array of physician alumni practicing pediatrics, internal medicine, and emergency medicine also provide abortion services to their patients ( Table 1 ). TABLE 1— Alumni Survey Results for Abortion Provision, by Medical Specialty: Medical Students for Choice, 2011 Medical Specialty Total Response, % Respondents Providing Abortion Services, No. (%) Obstetrics and gynecology (n = 98) 31.5 65 (66.3) Family medicine (n = 74) 23.8 24 (32.4) Internal medicine (n = 34) 10.9 0 (0) Emergency medicine (n = 22) 7.1 1 (4.5) Pediatrics (n = 21) 6.8 1 (4.8) Psychiatry (n = 18) 5.8 0 (0) Othera (n = 44) 14.1 3 (6.8) Total (n = 311) 100 94 (30.2) Open in a separate window Note. Total surveys mailed = 670. Response rate = 46.6%. The estimated response rate by specialty: obstetrics and gynecology, 47.1%; family medicine, 53.6%; internal medicine, 45.9%; emergency medicine, 50.0%; pediatrics, 24.1%; psychiatry, 52.9%; other, 51.8%. aOther specialties included adolescent medicine, allergy/immunology, anesthesiology, colorectal surgery, critical care, dermatology, endocrinology, general surgery, geriatrics, infectious disease, neurology, obstetric anesthesia, ophthalmology, orthopedic surgery, pathology, pediatric dermatology, pediatric emergency medicine, pediatrics, physical medicine and rehabilitation, preventative medicine, pulmonary, radiology, rheumatology, sports medicine, transplant surgery, urology, and vascular surgery. As medical students, we are entering our profession at a time when national hostility toward abortion and reproductive health is once again at near-fever pitch. For the first time in decades, more Americans identify as “pro-life” than “pro-choice.” 14 In 2011 alone, 67 abortion-restricting laws were enacted, in addition to a flurry of budget restrictions placed on family planning funding and reproductive health care facilities. 15 In only the first six months of 2012, 39 more anti-abortion regulations have gone into effect to limit patient access. A majority of these new restrictions specifically and intentionally target abortion providers and their ability to practice. 16 Almost half of all American women will seek an abortion in their lifetime, 17 and thus the lack of training for physicians may have profound public health implications. The decades of unrelenting harassment of physicians have ensured that abortion is still a procedure that most doctors will perform only under the guise of anonymity for fear of professional and personal consequences. Even more troubling is that many physicians who support women’s access to abortion are reluctant to advocate for their patients within this hostile environment, inadvertently adding to abortion’s stigma with their silence. 18 Even those physicians who complete abortion training note the challenge of finding a practice or hospital that will accept them for affiliation if they choose to provide abortions. This current shortage of trained physicians means a lack of willing teachers who can provide training for medical students on a full range of reproductive health care topics. Although 97% of practicing obstetricians and gynecologists report that they have encountered patients seeking abortions, only 14% provide this service. 12 Lack of training remains the most commonly cited reason by MSFC alumni for not providing abortions, including practicing OB/GYN alumni. Also cited frequently as a barrier were institutional policies prohibiting abortion training and provision by residents and physicians. In addition, many medical students attend schools that are openly against abortion, and these students will likely never even hear the procedure mentioned in their four years of training outside of a possible discussion on its ethics. Yet, amid continued attacks from the anti-abortion movement, there are some positive signs of progress. For the first time since the early 1980s, there was no significant decline in the number of abortion-providing facilities between 2005 and 2008. 13 Even more encouraging is the finding that obstetricians and gynecologists younger than 35 years are the most likely age group to provide abortions in their practice. With the majority of abortions in the United States currently being provided by physicians older than 50 years, 2 this younger generation ensures many years of future provision, and that is what MSFC cultivates through its student membership. 13 Lastly, it has been found that exposure to abortion education while in medical school and subsequent development of an intention to provide abortions are the most powerful predictors of future abortion provision. 11 This fact reinforces the importance of MSFC’s continued commitment to increasing exposure and training opportunities for the new generation of pro-choice medical students and resident physicians. Forty years ago, a woman’s constitutional right to privacy when making personal reproductive health decisions was affirmed. Twenty years later, a group of medical students set out to ensure that this right could be exercised through the creation of caring, educated, and well-trained physicians. On this important anniversary of Roe v Wade , we honor the passion and fortitude of the Roe -era abortion providers and former medical students such as Steinauer who paved our way forward. Today, in the face of increasing adversity, we also renew our own commitment to the patient’s right to make informed medical decisions about her own body. We recognize the challenges women continue to face when seeking an abortion, including the barriers of stigma, cost, and lack of access, all of which continue to unjustly afflict our country’s most vulnerable populations. We will always remember the countless women who lost their lives seeking the chance to build their families on their own terms before Roe , and unfortunately even after. 19 We also honor the many sacrifices of the outstanding and courageous physicians who have ensured the right of women to have agency over their futures through their willingness to act. Without these physicians, there would be no “choice.” This ability to make private reproductive health decisions has been hard won, and it cannot exist without competent and compassionate abortion providers and pro-choice physicians—precisely the doctors that MSFC strives to create.
