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Abortion Ban Travels Across Country •
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In Med Schools, the Abortion Curriculum Has Left the Classroom
By Louisa Pyle
RH Reality Check
Tuesday 08 April 2008
As recently as six or seven years ago, abortion was included in my medical school's curriculum, but no longer. The comprehensive curriculum I naively expected that would provide medical students with the knowledge to meet the common needs of their female patients simply does not exist. At a party last weekend I asked a few second years, four twenty-three-year-old men, to report back to me if they hear the "A" word at any time this semester. They gleefully dubbed themselves the "Medical Student Moles for Choice." Abortion is a shadow that wisps in and out of medicine, much like the quiet shadow of abortion in many women's lives, not addressed directly, not discussed in coffee shops or over family dinner.
Medical school is, in many ways, a language school. Someone told me once that a medical student learns over 20,000 new words in their first two years of school, and in addition to the new vocabulary, I soon became capable of saying things over dinner that one should never say. "Rectum" no longer induces giggles and "vagina" is boring, not sexy or empowering. And yet, the word "abortion" is still said with a pause, a nod, a little quieter than the rest of the sentence. I'm happy when we talk about it at all: for me, the problem is the deafening silence. That a procedure more common than an appendectomy would never be named: In the halls of science and healthcare, that to me is an abomination.
At one time at my medical school, a state institution of strong reputation in the Deep South, the physician responsible for the classroom teaching in women's reproductive health, "Dr. L," included a full hour lecture on the medicine and science of abortion care in the OB/Gyn curriculum. She included her own stories of patients, the hooks on which we medical students hang all this physiology and chemistry in our overtaxed memories. Even so, the students of this relatively conservative locale responded with powerfully reproachful marks on the course feedback forms. As student feedback influences not only the next year's teaching of any course but also the tenure and performance assessment of the teachers, physicians, themselves, Dr. L. was forced to remove the lecture. During the following few years, including my turn with her, she managed to sneak in ten minutes on abortion safety when discussing contraception. "Abortion is safe," was the message I heard, "but if you have a problem with it, you better be sure you know how to offer your patients appropriate birth control."
The real blow didn't come until the following year. Dr. L. moved on to another institution. With her went any mention of the science and medicine of abortion; the ethics class debate on the subject remains. This is how abortion education disappears from our medical schools - subtly and quietly. The students come and go, teaching physicians come and go, and few of us notice this loss from the classroom, the laboratory, the hospital room.
Is it hopeless? Of course not. I have a dream curriculum, and I believe it can be attained. Including questions on abortion and other aspects of comprehensive reproductive healthcare in national medical board exams would re-enforce to medical schools that the subject should and must be taught. Recommended curricula from professional bodies like ACOG (the American College of OB/Gyns) could encourage directors of curricula at both the medical school and residency level to include abortion care requirements. Specific line item requirements from the national accreditation bodies could remind medical school deans every eight years that abortion is part of normal medical care. Until that day comes, with the support of Medical Students for Choice, we students will continue to fight for our own education. At the University of Alabama at Birmingham, we've invited abortion providers to talk with us about their careers and to teach us about the practicalities of the abortion procedure and running a practice, shadowed providers at a local clinic, and lobbied the administration for permanent, sustainable curricular change.
And what kind of curricular change would we endorse? No medical student can expect to graduate proficient in any single surgical technique, including abortion. But medical schools do spend four years preparing us to do anything in medicine, and preparation requires at minimum that one can say the word. The ethics of abortion can be discussed. Along with lectures on infertility and ovarian cancer, there would be lectures on the medical facts, the evidence-based medicine, of abortion. Specific training would be required on options counseling, just as we learn specific phrasing for eliciting a sexual history, or helping a patient quit smoking. The pharmacology of mifepristone (medical abortion), Plan B, and hormonal contraceptives would be used to help students understand the complexity of hormonal changes that result in the menstrual cycle. Electives would be available in the history of women's reproductive control, family planning, and abortion. And lastly, as part of the OB/Gyn rotation completed by every medical student, they would observe an abortion (with an opt-out option only), just as they observe birth, assist in C-sections, and perform routine Pap smears. This is the reproductive health curriculum I dream of at night, where students who do not wish to comprehensively serve their patients are forced to defend their position. Quite simply, this is a curriculum where abortion is included where appropriate, just like any other common, safe procedure.
Medicine today is "evidence-based." Treatments must be proven, tested, and extensively evaluated - the application of the scientific method for the benefit of consumers of medicine. In this way we protect our patients from damaging or unproven treatments. But in my medical school experience, it is very specifically the evidence surrounding abortion care that is omitted. We would like to think that medicine is a special place, constituted exclusively with those passionate about healing, not judging. The fact is, medicine is a community of human beings, every member carrying their own perspectives and prejudices. Our lack of abortion education has little to do with the choice of institution, or location, and everything to do with the universal issues of politics and fear.
Every activist for choice faces possible retaliation and danger; it is a risk we know well. In medicine, however, a relatively benign level of sidelining can suddenly block a physician, or nurse, or any healthcare provider from the community altogether. Without sanction from the professional field, in the form of a practice license, or training opportunity, or job, we cannot offer ourselves to the women and families we are here to serve. By nature an outspoken person, I sometimes now choose silence myself, thinking to the far-flung future, and my someday patients. Sometimes, without the support I get from my fellow students through Medical Students for Choice, I suspect my anxiety would win and I would never speak up at all.
I'm listening to Ani DiFranco's "Hello Birmingham." The song is for me a sort of lullaby, sung from the city of Buffalo to my city, Birmingham, recognizing the anti-choice violence survived by both cities. I listen to it when I'm angry, or moreover, when I need to remember to be angry. I turn it on when I find myself becoming numb to the norms of silence and misinformation. Sometimes, I turn it on when I get afraid, when I wonder if someone has me on a hit list. Would they even bother? I'm only a student. I have not yet performed an abortion, not yet had the chance to walk away from a day's work knowing I have changed someone's life, gave them myself, my hands, my years of training, as the tool they need to empower themselves, take back their control, perhaps just begin to unravel this one moment in their life. I cannot imagine any greater privilege.
Louisa Pyle is the President of Medical Students for Choice, a bi-national grassroots nonprofit organization that focuses on creating tomorrow's abortion providers and pro-choice physicians by improving reproductive education in medical schools. Her day job is as an MD and PhD student at the University of Alabama at Birmingham.
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State Legislative Trends: Abortion Ban Travels Across Country
By Rachel Gold and Elizabeth Nash
RH Reality Check
Tuesday 15 April 2008
At the end of March 2008, just over 800 measures had been introduced in the 43 state legislatures that have convened so far this year. And with the legislative year in full swing, some interesting trends are emerging, largely in the wake of last year's Supreme Court decision in Gonzales v. Carhart.
In its most direct effect, the Court's decision to uphold the Federal Partial-Birth Abortion Ban Act of 2003 set a major precedent that state legislators seem to be following. Twenty-three bills banning "partial-birth" abortion have been introduced in 11 states so far this year. In four states (Alaska, Kentucky, Michigan and Wisconsin), the measures have passed one house of the legislature and are pending in the second chamber. A fifth measure has been approved by the legislature in Arizona. (It was vetoed by Gov. Janet Napolitano [D] in April).
Almost all of the states in which legislation has been proposed already have adopted a ban that has been enjoined and so is not in effect (see Bans on "Partial-Birth" Abortion). Some of pending measures attempt to modify these enjoined laws while others seek to enact a whole new law; in either case, these bills are drawing upon language from the federal ban in hopes that that they will pass constitutional muster.
Most of these measures are characterized by their definition of the procedure, lack of a health exception and strict penalties. The Court upheld the federal ban, in part, because it found the definition of the procedure to be sufficiently precise so as to exclude most common second trimester procedures. To follow this precedent, the pending state measures generally lift the federal ban's definition almost verbatim.
While it does include an exception for those instances where a "partial-birth" procedure is necessary to save a woman's life, the federal ban does not make an exception to preserve a woman's health. Again, state legislation is following suit. While all of the bills under consideration include a life exception, most fail to include an exception to preserve the woman's health.
Finally, the pending bills would expand local discretion in deciding when to prosecute a case and the penalties that could be assessed. Although federal prosecutors would need to bring charges under the federal ban, local authorities, who might come under intense political pressure, would be empowered to file charges against physicians under the state provisions. Moreover, some of the bills pending in the states would permit penalties even stiffer than those provided for in the federal ban.
In addition to upholding the federal ban on "partial-birth" abortion, the Court's decision in Gonzales v. Carhart included language essentially inviting states to utilize their abortion counseling requirements to include the provision of information aimed at dissuading women from obtaining an abortion. (For additional information see State Abortion Counseling Policies and the Fundamental Principles of Informed Consent.) So far this year, most of the attention given to issues related to abortion counseling has been focused on measures that would mandate the provision of information or services related to ultrasound prior to an abortion.
The 16 measures that have been introduced in 11 states take a variety of approaches. Measures in eight states (Colorado, Georgia, Kansas, Missouri, New Jersey, New York, South Dakota and West Virginia) would require abortion providers to offer information related to ultrasound and/or refer the woman to agencies where the procedure may be obtained. In three states (Kansas, Ohio and South Carolina), the measures would require the abortion provider to offer the woman the opportunity to view the ultrasound image whenever the procedure is performed as part of the preparation for an abortion.
Most dramatically, measures in eight states (Florida, Kentucky, Missouri, North Carolina, Oklahoma, Tennessee, Virginia and West Virginia) would go so far as to require the provider to perform an ultrasound prior to any abortion. Some of these would require that the woman be given the opportunity to review the image, while others would not give her that choice. Bills that have passed one house of the legislature in Kentucky and Oklahoma require the provider to review the image with the woman, while permitting the woman to "avert" her eyes from the image if she chooses.
So far this year, two states have enacted new laws. A new law in South Dakota requires every woman seeking an abortion to under go an ultrasound and to be given the option of viewing the image. A law adopted in Ohio requires that a woman be offered the opportunity to view an ultrasound whenever one is performed in preparation for an abortion. With the addition of these new measures, 15 states have laws on ultrasound provision. (For additional information see Requirements for Ultrasound.)
For More Information:
For summaries of major state legislative actions so far this year, click here.
For a table showing legislation enacted in 2008, click here.
For the status of state laws and policies on key reproductive health and rights issues, click here.
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