It’s been two years since the Dobbs v. Jackson Women’s Health Supreme Court decision that overturned the constitutional right to an abortion in the U.S. Since then, 14 states have instituted full bans on the procedure. Now new research shows that states with these bans are seeing less residency applications from medical students. Katie Hansen is an administrative chief resident at Oregon Health & Science University. Ian Fields is an OB/GYN and the program director for OHSU’s OB/GYN residency program. They both join us to share the impact the Dobbs decision has had on schools, communities and healthcare.
This transcript was created by a computer and edited by a volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. It has been two years now since the Dobbs Supreme Court decision overturned the constitutional right to an abortion in the U.S. Fourteen states have instituted full bans on the procedure. A recent study found that this is having a big effect on where medical students are seeking to continue their training. States with these bans saw a nearly 7% decrease in OB/GYN residency program applications. States without bans saw a slight increase in applications last year. Katie Hansen is a chief resident in Obstetrics and Gynecology at OHSU. Ian Fields is a urogynecologist and the director of the OB/GYN residency program. They both join us now. It’s great to have both of you on Think Out Loud.
Katie Hansen: Yeah, happy to be here.
Ian Fields: Thanks for having us.
Miller: Katie Hansen, first. How did you decide that you wanted to be an OB/GYN?
Hansen: I think I always knew that this was a specialty I wanted to go into as a medical student. As an OB/GYN, I get to take care of people in some of the most vulnerable and important moments of their lives, be that the birth of a child or providing full spectrum reproductive health care, including abortion care. This work just feels extremely fulfilling and I’m really glad that this was the choice that I made.
Miller: You grew up in the Portland area, in Gresham, then you went to med school in Texas and graduated four years ago. What were reproductive laws like in Texas when you were getting your MD?
Hansen: So when I was in Texas, there was a 22-week ban at the time, which it’s funny looking back on it, that felt incredibly restrictive. In addition to that, all kinds of TRAP (Targeted Regulation of Abortion Providers) laws, including mandatory waiting periods and other restrictions that made access to abortion care incredibly challenging even amongst people who were under that 22-week age limit.
Miller: How did that affect your medical training at the time when you did, I guess it’s called a rotation in obstetrics and gynecology? Even when it was less restrictive there than it is now in Texas and in many states, did it affect the way you were able to get your medical education?
Hansen: Yeah, I had a huge effect on it. I never participated in or observed abortion care. I never participated in or observed pregnancy options counseling. Even some contraceptive care was a bit limited at the hospital that I trained at as a medical student. It was a Catholic hospital. And so the first time I ever participated in that care was as a resident in Portland, Oregon. So, that was education that I had to really seek out as a medical student. It was not easy to access.
Miller: When you were figuring out where you wanted to do your residency – again, this was before the Dobbs decision – how much were state-based abortion laws at play in your decision?
Hansen: I think even back then it was a huge part of my decision. I didn’t even apply to states that had a lot of abortion restrictions at the time. Abortion is a basic component of comprehensive medical care. For an OB/GYN, it is as important as providing a pap smear or prenatal care, STI screening. And so for me being at an institution that values that kind of care and is able to offer that care and training to its residents without restrictions, felt incredibly important,
Miller: Katie, I want to hear more about your decisions and what it’s been like to come here, but Ian Fields is with us as well. He is the director of OHSU OB/GYN residency program. I mentioned that a national study found a huge discrepancy in OB/GYN residency applications in states with abortion bans and those without bans. What have you been seeing at OHSU in the last two years?
Fields: So I think this is actually kind of a funny question to answer because there has been a lot of change in the OB/GYN application process for residency over the last couple of years. We’ve moved to mostly a virtual interview format and we’ve seen a huge spike in the number of applications, because applicants no longer have the burden, the heavy cost and time burden of having to travel to all of these interviews. And so we’ve seen a large spike in the number of applications that we’ve received over the past few years.
Last year, we instituted something called signaling, which basically allows applicants to sort of choose their favorite programs out of the multitude that they apply to. And because of that, we’re trying to actually decrease the number of applications that we get to residency. So two years ago, we saw a large increase, but this last year, we actually saw a decrease, which is a good thing for us. But one of the interesting things is that the number of signals that we received did not change, which I think is the more telling data that we can go off of specifically regarding the topic at hand.
Miller: The authors of the recent study that I’ve been referencing wrote that residency programs in states with complete abortion bans have continued to fill their residency position. So it doesn’t seem that they have vacancies, but the authors also wrote that continued decreased interest in training in these states could negatively affect access to care. How would that be if all of their slots are being filled?
Fields: So let’s tackle the first part of this question here, which is OB/GYN is a very competitive residency specialty to get into. I think in the match process, there is never a spot that goes unfilled at the end of the whole match process. And in fact, there’s always more people wanting to do OB/GYN than the number of residency spots can actually fill.
One of the caveats here is that every accredited residency program for OB/GYN has to provide abortion training to their residents. This is not something that programs can opt out of. It’s something that residents can choose to opt out of when they’re there, but they still have to go through being able to counsel patients about contraception options counseling and where to access these things. And so as going to any residency program, no matter if you’re in an abortion restricted state or not, you have to have that training.
I think the thing that we’re going to see, unfortunately, is really the downstream effects from this decision, which is we’re seeing that residents aren’t going to these states with abortion restrictions. But more importantly, we’re seeing OB/GYNs leaving states with abortion restrictions. And we know that the state of maternal morbidity and mortality in the United States is not great as it is right now and especially for marginalized communities. I think that this is going to just further that divide and to put our more marginalized communities at even higher risk for maternal morbidity and mortality.
Miller: I’m glad you mentioned not just residents but doctors who are in the middle of their careers because there’s definitely been reporting about that in the Northwest as well. A report came out in February showing that more than 50 obstetricians in Idaho stopped practicing there since their near total ban went into effect in 2022. Have you seen an influx of doctors from states like Idaho to Oregon?
Fields: I am not so intimately involved in the hiring of OB/GYNs at our institution. I haven’t really seen a whole lot of that, but what I can tell you is that I’ve definitely heard the stories. We are sort of a close knit community here in the Pacific Northwest. And the sad part about it is that the patients still exist there, right? You have all of these reports that came out. I think just earlier this week, the New York Times reported on the number of people that had to leave their States to access abortion care because they just couldn’t have the providers there or it was in a state where there was a ban, but the patient still exists there.
The crux of the situation is that it’s not sustainable at some point. We can’t have physicians leaving the states to just leave these patients high and dry for them to the added burden of having to access care, to find child care, to find resources, to get out of the state, to find whatever they need to access the care that they need.
Miller: Katie Hansen has one week left in her OB/GYN residency at the hospital.
Katie, first of all, congratulations on almost being done with the residency. But when I was asking you some questions, we were still in the pre-Dodds world. Do you remember where you were when you heard either about the leak of the decision or the decision itself?
Hansen: Yeah, I do remember hearing about the leak about a month before the actual decision came down. I was working in the hospital like I am most hours of the week, it feels like, but I remember seeing the story pop up on a TV in a patient’s room and just feeling like the wind had been knocked out of me.
And not really being able to focus on where I was or what I was doing. And I just felt immediately overcome with this incredible sadness and fear thinking about all the unnecessary pain and trauma that a lot of people were about to experience.
We know that when people seek abortion but are unable to obtain an abortion, we know that those people go on to experience a lot of physical and mental health challenges as well as economic insecurity. And I could just foresee those effects of forcing people basically to carry undesired pregnancies to term what that was going to mean for our future patients.
Miller: We’ve been talking about the big decrease in residency applications in states with bans. I just mentioned that you’re about to finish your residency. You’re going to be staying at OHSU for a fellowship for a couple of years. How much of a connection is there between where people do their residency training and where they end up practicing medicine, spending their careers?
Hansen: I think that there’s a pretty large connection there. I can’t give you exact numbers, but of course, it’s easier to find jobs in the community where you trained and where you know people in hospital systems. So I think a lot of the time, people end up staying at least in a geographic area in which they trained.
Miller: One of the things that I found striking about the latest version of these studies looking into residency applications is that they didn’t just see big differences between OB/GYN applications in these two sets of states, and states with abortion bans and those without. They also found that for all residency applications, there is a gulf now for all residency applications if you look at states with abortion bans and those without. How do you explain that?
Hansen: I think you could look at it a couple of ways. One, if you’re a pregnancy capable individual moving to a state with an abortion ban, I think that can be a little bit unnerving. And so I understand why people might not want to relocate to those kinds of states if they’re someone that may need to seek that kind of medical care someday. And then abortion does not just affect women and their providers, but it really trickles down to all different types of medicine, be it cancer patients who need chemotherapy or treatment who happen to be pregnant. That care is really hard to provide and obtain in a state with an abortion ban. It’s really a lot more nuanced and has a lot more downstream effects than I think people realize.
Miller: Ian Fields, I’d love to get your take on this. The fact that there is a growing gulf in in the numbers of residency applications in these two sets of states, if part of it could be explained, not just by looking at abortion restrictions but other politicized issues — efforts to ban transgender care, or to ban K-12 curricula that don’t conform to conservative ideology, or differences in gun laws, or the news this week out of Louisiana where the 10 Commandments are going to have to be displayed in every single classroom – do you think these issues as a whole are having an effect on where medical school graduates want to practice?
Fields: Yeah, I think it’s kind of a hard issue to tease out because there are so many different confounding variables in the application process to residency. The residency application process is kind of a beast in and of itself. And most people generally find themselves lucky to have found a spot anywhere.
I do know that all of the studies that have come out looking at this issue specifically show that it’s very much at the forefront of an applicant’s mind. There was just a study of urology applicants looking at their application, the things that they’re considering when they’re applying to residency. And this is definitely something that they’re considering. As Dr. Hansen so aptly put it, it affects every medical specialty. You will be taking care of pregnant individuals or people with the capability for pregnancy no matter what specialty you go into. So we tend to focus a lot on the OB/GYN experience because it affects us day in and day out, but it affects every aspect of medicine.
I think medical students are really considering a lot of different things when they are choosing to spend a majority of the formative years of their training. It really has an impact, like where you train and what you’re doing. So I think a lot of these issues are definitely at the forefront of applicants’ minds when they’re going through the process
Miller: Katie Hansen, how much did you talk with your fellow med school classmates four years ago or five years ago when you were all talking about where you might want to go for your residency training?
Hansen: We talked about it a lot. It was a hugely consuming part of our final year of medical school. For my co-medical school classmates who were going into obstetrics and gynecology – there were four or five of us – I think that access to full spectrum reproductive health care was something that we all valued and considered. But I don’t think any of us saw Dobbs coming and so I’m not sure how much they really thought about that. This is really, really hard to believe that we are where we are now. So I don’t think any of us quite saw it coming.
Miller: Ian Fields, the legal and political fights over reproductive health have now expanded just in the last year in a shocking way to a lot of people, I think, to include infertility treatments like IVF. Do you expect to see an exodus away from reproductive endocrinology training programs in red states?
Fields: It seems like every day we wake up to more and more sad news like this. One of my friends and residency classmates is the residency program director at the University of Alabama in Birmingham. And she texted me when all of this was happening that she said they had to shut down our IVF program here at UAB for the time being because of everything that was going on. And so I think we’re just starting to scratch the surface with all of the effects that we’re going to see that trickle down from the Dobbs decision, and this potentially being one of them.
REI training is again very competitive. That’s reproductive, endocrinology and infertility. These are the providers who do IVF care. I think that’s certainly going to be, again, another thing that applicants have to take into consideration when they’re looking at where they want to train and whether or not their training may be in jeopardy at some point because of this.
Miller: You had noted at the beginning that every residency program for obstetrics and gynecology has to at least offer training and abortion care, but if I understand correctly, residents don’t have to take part if they choose not to. Would it be possible for a school like OHSU to provide, I don’t know, a fuller version of that training for students at some hospitals who don’t feel like their programs offer a complete enough education? Would something like that even be possible?
Fields: Well, I’m glad I’m glad you mentioned that because we actually have a program at OHSU right now. One of our complex family planning physicians,
Dr. Alyssa Colwill is running a program where we’re actually bringing in residents from states that have abortion restrictions to train them at OHSU for a four-week period, to give them all of the training they need to go out and provide that competent clinical care.
The hard part is that we are limited by the number of weeks in the year and the number of spots that we can do. We are bringing in 12 to 14 residents a year. And although it’s great that we have the ability to do that, that is in no way going to replace the training that all of these individuals need across the country. It’s just again scratching the surface of the need and we’re sort of thinking of it as doing our part. But really, we’re going to need something like a national collaborative to sort of figure this out as this continues.
Miller: I appreciate the answer to this question. But since I asked it, now as I’m listening to it, I’m wondering what the point of that training actually is if they’re going back to practice medicine in a state where for all intents and purposes, they can’t provide abortions. What’s the purpose of training them in abortion care?
Fields: Yeah, it’s not just about the abortion care itself. There are so many facets that go into it, as I’m sure Dr. Hansen can mention to you too. There’s so many facets of it. It’s the options counseling, it’s contraceptive counseling, it’s full spectrum reproductive health care. It’s not just about abortion, although it is. And so these residents may not stay in the state that they train at forever. So we’re still giving them the skills that they need to go in, and impact the communities that they live in.
And not only that, but we have a lot of people at OHSU who are intimately tied into research involving and informing legislation in Oregon and nationally. So they’re not only learning these skills, but they’re also learning advocacy and research, and how to have an impact on a much larger scale.
Miller: Ian Fields and Katie Hansen, thank you very much.
Fields: Thanks so much for having us.
Hansen: Thanks for having us.
Miller: Ian Fields is a urogynecologist and the director of OHSU’s OB/GYN residency program. Katie Hansen is one of the chief OB/GYN residents at OHSU. She will graduate from the residency program next w
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