Did Ob/Gyn Residencies Take a Hit From Abortion Bans?

Emilee Gibson, MD, recently graduated from Southern Illinois University School of Medicine and starts her ob/gyn residency at Vanderbilt University Medical Center in Tennessee later this month. Abortion is permitted in Illinois but banned in Tennessee, a factor she weighed cautiously when she applied for residencies.

Gibson told Medscape Medical News that medical students, not just those interested in ob/gyn, are starting to think more about what it means to move to a state where it might be difficult to access abortion care. "Just from a personal standpoint, that's a little scary."

The Supreme Court's decision to overturn Roe v Wade abortion rights last June threatened to derail ob/gyns in training from pursuing the specialty or locating in states that have banned or limited abortion.

Early signals from the Dobbs v Jackson decision suggest a potential decline in ob/gyn residents choosing abortion-restrictive states, but some industry leaders, residents, and medical students say it may be too early to judge the full impact of the ruling because most students were already far along in their decision and application for a 2023 residency position.

At this point, some ob/gyn students are planning careers on the basis of whether they have family ties in a particular state, whether limiting their search might hurt their potential to match in a competitive specialty, and whether their faith in the family planning and abortion training being offered by a program outweighs the drawbacks of being in a state with abortion bans or restrictions.

Lucy Brown, MD, a recent graduate of Indiana University School of Medicine, told Medscape Medical News that she'd be "very nervous" about living and practicing in abortion-restricted Indiana if she were ready to start a family.

Brown said that she mostly limited applications in the recent Match to ob/gyn residencies in states that protected abortion rights. Though she applied to a program in her home state of Kentucky, she noted that it — along with a program in Missouri — was very low on her rank list because of their abortion restrictions.

Ultimately, Brown matched at Johns Hopkins University, where she will receive abortion training and assist with abortions throughout her residency. Maryland's pro-choice status was a big attraction, she said. "Abortion is integrated into every aspect of the education."

By the Numbers

For students applying to residencies this summer, evaluating the state legislative landscape is a little clearer than it was 1 year ago but is still evolving. As of June 1, 56 ob/gyn residency programs and more than 1100 medical residents are in states with the most restrictive bans in the country (19% of all programs), according to the Bixby Center for Reproductive Health at the University of California in San Francisco.

In terms of the latest abortion laws: 14 states banned abortion, two states banned abortion between 6 and 12 weeks, and nine states banned abortion between 15 and 22 weeks, whereas abortion is legal in 25 states and Washington, DC, according to a recent analysis by the Kaiser Family Foundation.

The impact on residencies? The Association of American Medical Colleges (AAMC) recently reported a 2% drop in the number of US MD seniors who applied to residencies and a 5% decline in the number of seniors who applied to ob/gyn residencies. In states where abortion was banned, the number of senior applicants to ob/gyn programs dropped by more than 10%, according to AAMC's Research and Action Institute.

"US MD seniors appear, in general, more likely to avoid states where abortions are banned," said Atul Grover, MD, PhD, executive director of the Research and Action Institute. "That's a big difference between states where there are abortion bans and gestational limits and states with no bans or limits; it's almost twice as large," Grover told Medscape Medical News. "The question is: Was it a one-year blip or something that will be the beginning of a trend?"

In a statement to Medscape Medical News, officials from the American College of Obstetricians and Gynecologists (ACOG) and the Association of Professors of Gynecology and Obstetrics (APOG) said that they were aware of the AAMC data but needed to further evaluate the impact of the Dobbs ruling.

A survey released at ACOG's annual meeting in May found that 58% of third- and fourth-year medical students were unlikely to apply to a residency program in a state with abortion restrictions. Conducted after the Dobbs ruling last year, the survey found that future physicians are choosing where to attend residency according to state abortion policies, indicating that access to abortion care is changing the landscape of medical practice.

"For personal as well as professional reasons, reproductive healthcare access is now a key factor in residency match decisions as a result of Dobbs," lead author Ariana Traub, MPH, told Medscape Medical News. She studies at Emory University in Georgia, where abortion is restricted.

"Many students, including myself, struggle when trying to decide whether to stay in restricted states where the need is greatest (highest maternal mortality, infant mortality, lower number of physicians), vs going to an unrestricted state" for more comprehensive training and care, Traub said. "Regardless of this decision, Dobbs and subsequent abortion laws are making students question what matters most and how they can provide the best care."

In another recently published survey, University of Miami Miller School of Medicine fourth-year student Morgan Levy and colleagues found that 77% of students would prefer to apply to a residency program in a state that preserves access to abortion. Ensuring access to those services for themselves or a family member was a key factor, according to the paper published in the Journal of General Internal Medicine.

For Levy, who plans to graduate from a school in abortion-restricted Florida and apply to ob/gyn residencies, the Dobbs decision made her more committed to becoming an ob/gyn, an interest she's had since college, she said.

"I do not intend to limit my search," Levy told Medscape Medical News. "In the states where there are restrictions in place, it's really important to make sure that people are getting good care," she said.

Differing Perspective

Though survey and anecdotal data show that students and residents expressing hesitation about states with bans or restrictive laws, it appears that most who applied to residency programs during the 2023 Match did not shy away from those states. Almost all the open ob/gyn residency positions were filled, according to the National Resident Matching Program (NRMP).

There was no change in how US MD seniors applying for 2023 residency ranked programs on the basis of whether abortion was legal, limited, or banned in the state where a program was based, Donna Lamb, DHSc, MBA, BSN, president and CEO of the NRMP, told Medscape Medical News.

"We're seeing what we've seen over the past 5 years, and that is a very high fill rate, a very high rate of preference for ob/gyn, and not a heck of a lot of change," Lamb said, noting that ob/gyn programs continue to be very competitive. "We have more applicants than we have positions available," she said.

In the most recent Match, there were 2100 applicants (more than half US MD seniors) for about 1500 slots, with 1499 initial matches, according to NRMP data. The overall fill rate was 99.7% after the Supplemental Offer and Assistance Program and Electronic Residency Applications process, NRMP reported. The results are similar to what NRMP reported as its previous all-time high year for ob/gyn placements.

There was a dip in applicants from 2022 to 2023, even though the slots available stayed the same, but it was not markedly different from the previous 5 years, Lamb said.

"While the Dobbs decision may, indeed, have impacted applicant and application numbers to residency programs, interventions such as signaling may also contribute to the decrease in numbers of applications submitted as well," AnnaMarie Connolly, MD, ACOG chief of education and academic affairs, and Arthur Ollendorff, MD, APOG president, said in a statement to Medscape Medical News.

For the first time in 2022, Match Day applicants were required to "signal" interest in a particular program in an effort to reduce the number of applications and cost to medical students, they noted.

Personal View

When it was time for Gibson to apply for ob/gyn residencies, she wondered: Where do you apply in this landscape? But she did not limit her applications: "If I don't apply to Indiana, Missouri, Tennessee, Wisconsin, Iowa, I'm taking a lot of really great programs off the table." She did not want to hurt her chances for a match in a competitive specialty, she said.

"Being in Tennessee is going to give me a very different, unique opportunity to hopefully do a lot of advocacy and lobbying and hopefully have my voice heard in maybe a different way than [in Illinois]," Gibson added.

Cassie Crifase, MPH, a fourth-year student at the University of Wisconsin School of Medicine and Public Health applying to ob/gyn residencies in next year's Match, told Medscape Medical News that she's concerned about the health risk of living in a state with abortion restrictions. Wisconsin is one of those.

"My list skews toward programs that are in abortion-protected states, but I also am applying to some programs that are in restricted states." Those states would have to help her meet the Accreditation Council for Graduate Medical Education training requirements. And, she said, she'd want to know if she could still advocate for abortion access in the state.

Sereena Jivraj, a third-year medical student at Texas Christian University in Fort Worth, told Medscape Medical News that she won't apply to programs in Alabama, Mississippi, Arkansas, and other nearby states with abortion restrictions. However, Texas is still on her list. "I'm from Texas, my family lives in Texas, and I go to school in Fort Worth, so I have made those connections," Jivraj said.

Student advisers generally encourage ob/gyn hopefuls to apply to 60-100 programs to ensure that they will match, Jivraj said. "How are you supposed to apply to 100 programs if many of them fall within states with high restrictions?"

What the Future Holds

Jivraj said that she's concerned about what the future holds, especially if the law does not change in Texas. "I don't want to go to work every day wondering if I'm going to go to jail for something that I say," she said.

Crifase has similar fears. "I want to be able to provide the best care for my patients and that would require being able to do those procedures without having to have my first thought be: Is this legal?"

"Things feel very volatile and uncertain," Pamela Merritt, executive director of the nonprofit Medical Students for Choice in Philadelphia, where abortion is permitted, told Medscape Medical News. "What we're asking medical students to do right now is to envision a future in a profession, a lifetime of providing care, where the policies and procedures and standards of the profession are under attack by 26 state legislatures and the federal court system," she said.

"I don't think you're going to see people as willing to take risk." She added that if someone matches to a program and then has regrets, "You can't easily jump from residency program to residency program."

Levy believes that the impact of the Dobbs decision is "definitely going to be a more common question of applicants to their potential programs."

Applicants undoubtedly are thinking about how abortion restrictions or bans might affect their own health or that of their partners or families, she said. In a 2022 survey, Levy and colleagues reported that abortion is not uncommon among physicians, with 11.5% of the 1566 respondents who had been pregnant saying they had at least one therapeutic abortion.

Students are also considering the potential ramification of a ban on emergency contraception and laws that criminalize physicians' provision of abortion care, Levy said. Another complicating factor is individuals' family ties or roots in specific geographic areas, she said.

Prospective residents will also have a lot of questions about how they will receive family planning training, Levy commented. "If you're somewhere that you can't really provide full-spectrum reproductive healthcare, then the question will become: How is the program going to provide that training?"

Alicia Ault is a Saint Petersburg, Florida–based freelance journalist whose work has appeared in publications, including JAMA and Smithsonian.com. You can find her on Twitter @aliciaault.

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