It’s now more than a year since the U.S. Supreme Court issued its decision in Dobbs v. Jackson Women’s Health Organization that overturned Roe v. Wade and endangered reproductive health and safe medical practice.
In the coming residency-application cycle, graduating medical students and other applicants to a number of physician residency specialties—most notably obstetrics and gynecology—are facing a tricky question: How should abortion restrictions or outright bans affect which residency programs they decide to pursue?
Data from the Association of American Medical Colleges (AAMC) may shed light on how some applicants answered that question during the 2022–2023 application cycle. Fourteen states now ban abortion from conception and 11 ban it between six and 22 weeks after the last menstrual period.
According to the AAMC data, the number of unique senior applicants from U.S. MD-granting medical schools to residency programs in states with abortion bans fell by 3%. At this article’s deadline, data was not yet available for applicants from DO-granting institutions.
The impact was felt most dramatically in obstetrics and gynecology, in which programs saw a 5.2% drop in applicant volume from U.S. MD- granting institutions overall, compared with a 1.8% fall in the volume of such applicants across all specialties.
In states in which abortion has been totally banned, the number of applicants to ob-gyn residency programs from U.S. MD-granting schools fell by more than 10% when compared with the prior year. For states with gestational limits on abortion, applicant volume dropped 6.4%.
Across all ob-gyn applicant types, including applicants from DO-granting institutions and international medical graduates, the dips were slightly less pronounced, with a prior-year decrease of 4.9% overall, a decrease of 8.1% in states in which abortion was illegal and a 5.8% decrease in states with gestational limits on abortions.
Training limitations
One concern that applicants may be confronting is that the restrictions may limit their ability to train comprehensively, according to Deborah Spitz, MD, who directs residency training in the Department of Psychiatry and Behavioral Neuroscience at University of Chicago Medicine.
“In the current political climate, not all residencies are able to offer training in all areas,” Dr. Spitz told the AMA. “People applying in ob-gyn need to be mindful of the fact that in large groups of states, they're not going to be able to get comprehensive training, and there are programs in those states that are going to be sending them to other states to get training in providing abortion, for example.”
To Dr. Spitz’s point, requirements from the Accreditation Council for Graduate Medical Education state that “programs must provide clinical experience or access to clinical experience in the provision of abortions as part of the planned curriculum. If a program is in a jurisdiction where resident access to this clinical experience is unlawful, the program must provide access to this clinical experience in a different jurisdiction where it is lawful.”
Other affected specialties didn’t see as big a drop in total applicants as ob-gyn, but those medical students are likely confronting similar questions as they approach the application process, Dr. Spitz said.
Bans or severe restrictions on abortion care don’t just affect obstetric care, she noted.
For example, they affect “psychiatry because we see those people who come into the emergency room and they want an abortion, and are we going to be allowed to say anything about that? Not in some hospitals in Texas,” Dr. Spitz said. “So, trainees need to be mindful that politics—which they may or may not pay a lot of attention to—have now entered into residency training in a way that was never true before.”
The applicant’s vantage point
Despite drops in applicant volume, the fill rate for ob-gyn residency programs was similar to prior years. The fact that the specialty remains competitive is another factor applicants will have to weigh as they determine how to go about applying to programs.
A rising fourth-year medical student at The University of Michigan Medical School, Bryan Aaron plans to apply to ob-gyn in the upcoming residency selection process. Because he and his partner, Aurianna Lajaunie, plan to go through the Couples Match, Aaron believes that, considering his unique circumstances, it may be prudent to apply to programs regardless of state laws.
“There are roughly 290 programs for obstetrics and gynecology, and my partner is applying to [internal medicine-pediatrics] and there are only 80 or so programs for her,” he said. “Given the competitiveness of couples matching and our respective specialties, we have to apply broadly which will include some programs in states with restrictive policies.”
“Some of the top-ranked programs right now are in states with either outright bans or more restrictive policies,” Aaron said. “It's difficult to exactly elucidate if the training at one of these top programs would be worth us being in a state where there may be an increased risk for ourselves legally and for the health and safety of our patients. There’s also shifting policies, so what we are able to provide or not provide is a moving target certainly. It’s not anything that's easy to nail down.”
A KFF survey found that since the Dobbs decision, half of ob-gyns practicing in states where abortion is banned say they have had patients in their practice who were unable to obtain an abortion they sought. The survey also found that 42% of ob-gyns nationally are concerned about their own legal risk when making decisions about patient care and the necessity of abortion.
These figures underscore the complicated—at times conflicting—factors residency applicants must weigh in choosing where to apply. In determining how it will impact his application locations and rank-order list, Aaron thought back to the Hippocratic Oath he spoke on the first day of medical school that implored he and his classmates to “first do no harm.”
“I had some reservations, maybe you could even call it fear, about pursuing a specialty that was under such scrutiny, but I thought about the patients,” Aaron said. “Sure, there may be legal ramifications existing for me, but the health and literal life-or-death situations that some patients would be facing is the reality.”
That stark reality made Aaron feel “emboldened, in the end, to pursue the field to support the health care for over half of our country.”
