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  1. 07 Aug '15 10:54 / 1 edit
    http://journals.lww.com/greenjournal/Fulltext/2015/07000/Four_Residents__Narratives_on_Abortion_Training__A.9.aspx

    In 1996, the Accreditation Council for Graduate Medical Education Obstetrics and Gynecology Programs required that “access to experience with induced abortion must be part of residency education.”1 In 2014, the American College of Obstetricians and Gynecologists recommended that “all obstetrics and gynecology residency programs provide training in comprehensive women's reproductive health care, including opt-out abortion training, in which training is routinely integrated into residency but residents with religious or moral objections can opt out of participation.”2 We present narratives from four residents, in this commentary, hoping to encourage a more nuanced discussion of abortion among obstetrician–gynecologists (ob-gyns). We will describe the aspects of our residency program that facilitate open dialogue and respect across diverse viewpoints and demonstrate that the clear distinction between being pro-life and pro-choice often breaks down when one is immediately responsible for the care of pregnant women.

    The decision on the part of obstetrics and gynecology residents to opt in or out of abortion training is, for many, a complex one, often involving much soul-searching. In our residency program, a large majority of our 32 residents participate in abortion training. During a 6-week rotation, all residents complete a didactic curriculum on contraception, abortion, and miscarriage management. In addition, those who opt in perform abortions at a local clinic and in our hospital. Among residents who opt out of abortion training, most participate in an observational experience at the clinic.

    Abortion is a frequent topic of conversation, and open discussion with faculty and peers about the training experience is encouraged. Prospective residents are told that all residents are expected to counsel about pregnancy options and provide preabortion and postabortion care. Residents may opt out of doing abortion procedures, but only for moral or religious reasons.

    Mentoring is central to our residency program. Each intern is assigned three mentors–a midwife, a community physician, and a third-year resident. Although direct feedback is given on performance, there is a strong emphasis on emotional support. From the beginning, residents know they are cared for and are expected to be reflective and participate in difficult conversations. There is a values-clarification session on abortion for interns just before a formal meeting to declare their opt-in or opt-out status. All interns learn manual vacuum aspiration and provide miscarriage management in our emergency department. A faculty midwife meets with each second-year resident during his or her abortion training to give the resident an opportunity to process the experience. It was out of these conversations that this commentary piece was born. Four residents with wide-ranging views were asked to share their experiences in writing. In addition, it became clear that more opportunities for conversation would be welcome.

    Formed by a core group of willing faculty and motivated residents, the Resident Abortion Providers Support Group provides a confidential, safe environment to share experiences and provide support. Meetings occur six to eight times per year and include discussions about journal articles, movies, and topics such as late-term abortions and the effects of family of origin on the decision to perform abortions. Residents report that, even if they do not attend a Resident Abortion Providers Support Group gathering, the conversation often continues the next day in the resident lounge. The residents are given much control over their residency experience and in shaping the climate of the program. As one intern put it, “the reputation is that everyone is kind to each other, so when we arrive we are met with kindness and support from coresidents and faculty. We are kind and supportive in return.”

    Although the public debate surrounding abortion can be filled with incendiary rhetoric and passion on both sides, the residents often discover that the boundaries between pro-choice and pro-life beliefs are not so neatly divided. Residents train with colleagues who do not share their views, and they develop tremendous respect for these colleagues. Some residents struggle with the real-life experience of providing abortions, whereas others experience angst over lacking the skills to terminate a life-threatening pregnancy.

    Two of the resident authors have undertaken abortion training and two have not. To provide anonymity, the order of authorship does not correspond to the order of narratives. The residents' stories reveal how their backgrounds influence their choice and views, how they experience providing or not providing abortions, how they reconcile the often competing values placed on fetal life and women's autonomy, and how being in a supportive residency has allowed them to explore the complexity of abortion.
  2. 07 Aug '15 10:56
    NARRATIVE ONE

    ∼When I started residency, I was open to the possibility of providing terminations. I was and remain uncertain about when life begins, and I used to hope that a deeper understanding of fetal development might help me make such a decision empirically. Over the course of internship, I came to understand embryonal development as a fluid yet constant march toward being human in which an embryo at 6 weeks is an entirely distinct entity from an anatomically formed fetus 2 months later. Unfortunately, this acquired knowledge has failed to help me fully define my position.

    Increasingly, I have found myself caught up in an endless array of rhetorical questions. Is there not a more profound difference between 10 and 20 weeks than between 20 and 30? If my first task as a physician is to do no harm, how can I justify harming a fetus? I do not pretend to know the answers to these questions, but given what I perceived to be an abyss of ambiguity, I chose not to provide elective terminations. Our program director supported my choice, saying, “If anyone makes you feel uncomfortable about that choice, I need you to tell me right away.”

    Discussions with coresidents have helped me consider the individual woman who has the courage to request an abortion. Since opting out, I have realized that my line of thinking has been feto-centric at best and over-intellectualized at worst. Nonetheless, in the absence of a clear moral understanding of abortion, I can only do no harm. Before my own observational experience at Planned Parenthood, my classmates had told me that patients there were appreciative in a way that was entirely unique among the services we provide. At Planned Parenthood and in our own resident clinic, I have participated in terminations with varying levels of involvement. Based on these experiences, I know for certain that a pregnancy termination is one of the most life-changing interventions we can offer.

    At the least involved, I have held a conscious patient's hand during vacuum aspiration, learned how to counsel her, provided discharge precautions, and found that I was the direct recipient of her profound gratitude. At the most involved, I have performed a dilation and evacuation at 21 weeks for preterm premature rupture of membranes. I remember my mindset during that case, and how I focused on the potentially life-saving effect of the procedure. I anticipated experiencing existential guilt afterward; however, to this day I feel proud that our team was able to respect the mother's dignity and autonomy as she made a courageous decision.

    I realize through conversations with coresidents that providing abortions does not come easily or naturally to most providers. I am astounded by narratives from senior clinicians who recall the horrors of illegal abortion in the days before Roe v. Wade. These stories make me second-guess my decision on a near-daily basis. I fear that my own indecision regarding the moral status of a nonviable fetus may distract me professionally from the much more pressing issue of women's rights. As someone who entered obstetrics and gynecology because of the opportunities to empower women, I find myself feeling guilty that I cannot get over what increasingly seems to be a theoretical suspicion that life as seen on a two-dimensional ultrasound scan represents actual life.

    I wonder if I will change my mind after residency, if and when I encounter women who have less (or no) access to abortion services. If I lose the convenient excuse that my patients can just as easily see a dozen other providers in my city, could I really turn these women down? I went into medicine because I believe doctors should provide services for underserved patients, and frankly my decision not to provide terminations challenges my identity as a physician and as someone who cares about women's health.

    I appreciate my dialogue with other residents because it exposes me to the indecision that we all feel. Our residency's culture of open communication has allowed me to empathize with coresidents who experience grief from providing abortions, just as I hope they have a deeper understanding of my decision not to provide abortions. These difficult conversations make me believe that, regardless of our ultimate decision and stance, the dialogue about abortion can be mutually constructive. I chose to write about it in that spirit.
  3. 07 Aug '15 10:56
    NARRATIVE TWO

    ∼I grew up in a Catholic family where the pro-life position was dogma. As I grew older and developed my personal beliefs and ideals regarding women's reproductive choices, I began to question this position. Still, at the start of residency, I was not sure if I was ready to perform elective terminations. I realized that the lion's share of my reluctance was driven by “what would my mom think of me?” I struggled with my own faith, and with what God would think.

    On my third-year obstetrics clerkship in medical school, I had my first experience with abortion in a patient with severe preeclampsia at 20 weeks of gestation. There was no provider in the city who felt adequately trained to perform an abortion at this gestational age, and I remember feeling helpless as we watched the patient get sicker. Twenty-four hours passed while a provider was flown in from out of state. The woman's clinical condition improved shortly after the procedure. When I was wavering about opting in for abortion training, I thought of this patient many times.

    In our residency, we are surrounded by supportive colleagues. One particular conversation with a senior resident was instrumental in my decision to participate in the abortion training. She explained that, for her, abortion is not “black and white”; it is not a “feel-good” procedure, but it changes the course of a patient's life. It was so helpful to know that my apprehension was normal. That affirmation, along with my desire to gain gynecologic experience, gave me the confidence to pursue abortion training.

    I was nervous about my first day at Planned Parenthood. I envisioned protesters chanting and throwing objects at me. After my first morning of early abortions, we performed an 18-week termination. Seeing the fetus on an ultrasound scan and then watching it as we did the procedure really shook me to the core. I thought maybe I had made the wrong choice, and I could not stop thinking about what my family would think if they knew what I had done.

    Later that week we had an informal gathering of residents who had struggled with abortion training. It became apparent that others shared similar feelings. Many of us felt more comfortable with early abortions and struggled with second-trimester cases. Regardless of whether we performed abortions or not, it had to do with patient care and, in this case, our patients are the mothers. After listening to the struggles of fellow residents, I convinced myself to return to the clinic. There, I soon realized how powerful it was to be able to comfort and assure such vulnerable patients. I began to frame my interventions at the clinic as life-changing for women.

    Looking back, I am very happy with my decision to participate in abortion training, despite how emotionally challenging it was for me. The residents with whom I work provided tremendous support for me as I struggled with the choice of providing terminations. I feel that my clinical skill set was broadened dramatically, and, subsequently, I have been able to perform other gynecologic procedures with a level of confidence and skill that I did not have before. Although I firmly believe in a woman's reproductive rights and would feel comfortable doing a termination in certain dire circumstances—such as a fetus with a condition incompatible with life or to preserve a woman's life or health—I do not expect to perform terminations in my future practice. This was definitely not a black and white experience for me, but multiple shades of gray.
  4. 07 Aug '15 10:57
    NARRATIVE THREE

    ∼Growing up, a woman's right to choose was unambiguous to me. It was black and white, not a topic for debate. My mom conveyed to me the importance of women's autonomy and reproductive rights. I was taught of a time before Roe v. Wade when women had clandestine abortions in dangerous settings, and I felt that this was unacceptable. Despite wanting to learn how to perform abortions, I had some hesitation. I wondered what it would be like to actually perform an abortion.

    Our residency abortion training is usually done during the second year; however, I was asked to cover the service one day as an intern. I had a clear stance about the right to choose, but being present during the physical procedure gave me pause. Although I did not perform any procedures that morning at Planned Parenthood, I was unsettled by the juxtaposition of two different patient experiences. In the morning we brought relief to one woman by ending her pregnancy; in the afternoon I witnessed the sadness and devastation another woman experienced while miscarrying in our emergency department. Although these disparate experiences initially seemed difficult to reconcile, I found support through conversations with my family, faculty mentors, and coresidents. I discovered that, for each of these women, my role was to provide compassionate, competent care, tailored to her unique set of circumstances.

    When my second-year rotation came along, I was nervous about what it would feel like to perform an abortion myself. As with all surgical procedures, the invasive nature of the act becomes less apparent with increasing experience and the woman's well-being appropriately takes center stage. I was able to see the big picture: the women were incredibly appreciative, the clinicians were caring and sensitive, and we were providing a needed service. I would love to live in a world where no abortions are needed. Countless parents are stretched too thin socially, financially, or personally to take care of another child. Although I might not always understand an individual woman's choices, if she feels that she cannot be a parent for whatever reason, I will support her in that decision. I see little role for my personal values in the shared decision-making process.

    The truth is that being involved in this work scares me. I am fearful of the violence and taunting that protesters have inflicted against providers. Assaulting providers in the name of “protecting life” disgusts me, especially because abortion is legal. This fear for my family and me has affected my interest in pursuing a family planning fellowship.

    Abortion is a necessary procedure that I feel morally obligated to make available to my patients. The future of this service hinges on our society's ability to support its practice, prevent undesired pregnancy, and ensure the safety of abortion providers. I have worked through my own internal struggles, but these broader societal issues will shape how I practice in the future. Participating in abortion services has left me fulfilled and honored, and I consider the provision of this care a privilege.
  5. 07 Aug '15 10:57
    NARRATIVE FOUR

    ∼Medicine is highly politicized, and when it comes to abortions, it often feels like one MUST pick a side. I did not mind choosing a side. In fact, it was quite easy. I am a Born Again Christian, and I believe that life begins at conception. I believe that, since I do not have the power to create life, I do not have the power to take it. I am proud of my choice and do not apologize for it, but that was not always the case.

    I love obstetrics and gynecology—the breadth and depth, the bonds between patients and providers, and the lifelong relationships that are formed. However, I once heard someone say that an ob-gyn who did not provide terminations was not offering their patients the best, most complete care. Initially I shrugged this off as her opinion and deemed it irrelevant to me and to what my practice would become. But as I replayed that statement in my mind, I began to wonder, would I be providing the best care to my patients if offering terminations conflicted with my personal beliefs and passions? Would my patients feel judged and unsupported if I told them that I could not provide a service that they needed? Could I be truly impartial in my counseling?

    In my residency program I am in the minority in my choice and point of view. However, it is also a place where I have found tremendous support from people who feel the way I do and even those who do not. Recently we had a patient with previable premature rupture of membranes. Knowing the facts and figures, I was able to counsel her extensively about her options. While she cried and wrestled with her decision, I held her hand and told her I knew she faced a difficult decision, one that would be difficult for anyone. She ultimately chose to proceed with a termination. I knew the information I had given her had guided her toward this decision, and I was uneasy with the fact that, because of my personal beliefs, I could not start her induction. Thankfully I was able to ask for help from supportive coresidents, who placed the misoprostol. Apart from this physical act, it was not difficult for me to care for the patient and support her through her induction. I reflected back on a discussion I had as an intern with one of my senior residents who also does not perform terminations. I had shared with her my anxiety about not offering “complete” care to my patients. She reminded me why I became an ob-gyn: to care, help, diagnose, treat, and support. I can continue to do all that without being the one to place misoprostol or to perform the dilation and evacuation.

    I realize that not providing terminations does not make me a “bad” ob-gyn. It makes me, well, me: a unique human who has her own passions, beliefs, struggles, and decisions. I also feel that being true to myself and unwavering in my beliefs makes me a better, more honest, and relatable physician. While this issue might not be as black and white as it once seemed for me, I am willing to struggle through it each time questions arise to make sure I am being the best ob-gyn I know how to be.
  6. 07 Aug '15 10:58
    What is striking to me is that all of these highly trained and educated people seem to struggle with the same questions we all do, namely, when does life begin?
  7. 07 Aug '15 11:01
    if you are angsty about abortions, don't become a gynecologist.

    what would it sound like to you if someone wanted to become an airline pilot but absolutely refuse to do any landings because his morals prohibit him from landing a plane? can that person be allowed to become a pilot, then always have someone besides him to do the landings?
  8. 07 Aug '15 11:12 / 1 edit
    Originally posted by Zahlanzi
    if you are angsty about abortions, don't become a gynecologist.

    what would it sound like to you if someone wanted to become an airline pilot but absolutely refuse to do any landings because his morals prohibit him from landing a plane? can that person be allowed to become a pilot, then always have someone besides him to do the landings?
    Why do all of these gynecologists have angst do you reckon? Should they have learned to fly planes instead?
  9. 07 Aug '15 11:50
    Originally posted by whodey
    What is striking to me is that all of these highly trained and educated people seem to struggle with the same questions we all do, namely, when does life begin?
    I'm highly trained and educated and don't "struggle" with that question.
  10. 07 Aug '15 13:11
    Originally posted by whodey
    What is striking to me is that all of these highly trained and educated people seem to struggle with the same questions we all do, namely, when does life begin?
    Wait. So people who perform abortions aren't mindless drones who do as they're told, but are in fact real people who have given these issues lots of thought, and have come to an informed decision?

    I'm SHOCKED!!
  11. 07 Aug '15 13:40
    Originally posted by KazetNagorra
    I'm highly trained and educated and don't "struggle" with that question.
    So you are medically trained like these doctors?

    I often wonder what abortion legislation might look like if professionals educated in the field were actually making laws.

    Perhaps corporations would not be considered as people and, instead, the unborn might be.
  12. 07 Aug '15 13:41
    Originally posted by Great King Rat
    Wait. So people who perform abortions aren't mindless drones who do as they're told, but are in fact real people who have given these issues lots of thought, and have come to an informed decision?

    I'm SHOCKED!!
    One of the arguments for abortion is the notion that women would seek dangerous back alley abortions as an alternative.

    Ironically, since abortion is such a political football this is exactly what is happening with Dr. Gosnell types.
  13. 07 Aug '15 14:06
    Originally posted by whodey
    So you are medically trained like these doctors?

    I often wonder what abortion legislation might look like if professionals educated in the field were actually making laws.

    Perhaps corporations would not be considered as people and, instead, the unborn might be.
    The question of when "life" begins is a purely semantic one. No one seriously considering the ethical issues surrounding abortion will find it relevant.
  14. 07 Aug '15 14:08
    Originally posted by KazetNagorra
    The question of when "life" begins is a purely semantic one. No one seriously considering the ethical issues surrounding abortion will find it relevant.
    Apparently you have been living in a cave and/or unable to read what the physicians said in the OP.
  15. 07 Aug '15 14:09
    Originally posted by whodey
    Why do all of these gynecologists have angst do you reckon? Should they have learned to fly planes instead?
    yes
    or more logical, pick a different specialization during med school.


    anti-vaccination (better term is pro-disease) is all the rage these days. how would you feel about your doctor belonging to that group and refusing to vaccinate you?

    how about a jehovah's witness wanting to be a surgeon all while refusing to allow transfusions during operations because of his moral issues.

    and the list can go on.

    by the way, i would have been a bull fighter but did you know that bull fighters fight bulls and i am against it?