A challenge for antiabortion states: Doctors reluctant to work there

The Washington Post

By Christopher Rowland

August 6, 2022

In a few years, Olgert Bardhi’s skills will be in high demand. A first-year resident in internal medicine at the University of Texas Southwestern Medical Center in Dallas, he’ll be a full-fledged physician by 2025 in a nationfacing a shortage of primary care doctors.

The trouble for Texas: Because of the state’s strict antiabortion laws, Bardhi’s not sure he will remain there.

Although he doesn’t provide abortion care right now, laws limiting the procedure have created confusion and uncertainty over what treatments are legal for miscarriage and keep him from even advising pregnantpatients on the option of abortion, he said. Aiding and abetting an abortion in Texas also exposes doctors to civil lawsuits and criminal prosecution.

Texas, Ohio top courts allow abortion bans to take effect

“It definitely does bother me,” Bardhi said. “If a patient comes in, and you can’t provide them the care that you are supposed to for their well-being, maybe I shouldn’t practice here. The thought has crossed my mind.”

He is balancing his concern with his sense that he can do more good by staying, including counseling patients on obtaining contraception.

Bardhi’s uncertainty reflects a broader hesitancy among some doctors and medical students who are reconsidering career prospects in red states where laws governing abortion have changed rapidly since the Supreme Court struck down Roe v. Wade, according to interviews with health-care professionals and reproductive health advocates.

One large medical recruiting firm said it recently had 20 obstetrician-gynecologists turn down positions in red states because of abortion laws. The reluctance extends beyond those interested in providing abortion care, as laws meant to protect a fetus could open doctors up to new liabilities or limit their ability to practice.

It remains unclear how thoroughly career decisions being made amid the upheaval and confusion since the Supreme Court’s decision on Dobbs v. Jackson Women’s Health Organization will translate to a lasting geographic shift.But amid a national shortage of reproductive health practitioners, the early evidence indicates that red states have, at minimum, put themselves at a disadvantage in the competition for crucial front-line providers, experts said.

One large health-care staffingfirm, AMN Healthcare, said clients in states with abortion bans are having greater trouble filling vacancies because some prospective OB/GYN candidates won’t even consider opportunities in states with new or pending abortion bans.

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Tom Florence, president of Merritt Hawkins, an AMN Healthcare company, cited 20 instances since the Supreme Court ruling where prospects specifically refused to relocate to states where reproductive rights are being targeted by lawmakers.

“To talk to approximately 20 candidates that state they would decline to practice in those restrictive states, that is certainly a trend we are seeing,” Florence said. “It is certainly going to impact things moving forward.”

Three candidates turned down one of the firm’s recruiters, who was working to fill a single job in maternal fetal medicine in Texas, he said: “All three expressed fear they could be fined or lose their license for doing their jobs.”

In another example, a physician contacted by phone by an AMN Healthcare recruiter trying to fill a post in an antiabortion state “simply said, ‘Roe versus Wade,’ and hung up,” Florence said.

Florence said the shift has especially serious implications for small, rural hospitals, which can afford just a small number of maternal specialists or, in some cases, only one.

“They can deliver hundreds of babies each year and see several thousand patients,” he said. “The potential absence of one OB/GYN that might be in their community, if not for the Supreme Court decision, is highly significant. The burden will be borne by the patients.”

Tellingly, Florence added, none of the recruiters had encountered a single physician seeking to practice in a state because it had banned abortion.

In a 2021 Kaiser Family Foundation survey, 75 percent of OB/GYNs said their practices do not provide abortions for the purposes of terminating a pregnancy.

Yet broadly written abortion bans across the United States have cast a chill across the broader practice of reproductive health, say mainstream physician leaders who support abortion rights. In states without exceptions for the life and health of the woman, they say, routine standards of care are being scrapped.

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They worry that limits on training for new doctors will undermine recruitment of young talent. They are concerned about restrictions on fertility treatment. They anticipate that conservative legislatures will seek to impose bans on certain types of contraception, including IUDs and Plan B medication. Most Republicans in the U.S. House voted last month against a measure protecting the right to contraception.

Additionally, many OB/GYN doctors, even if they don’t perform abortions themselves, believe strongly in patient autonomy and decision-making, said academic and clinical leaders.

“Even physicians in restrictive states have never had to deal with this kind of political interference and legislative oversight,” said Eve Espey, chair of the department of obstetrics and gynecology at the University of New Mexico and a physician at the UNM Center for Reproductive Health. “It’s an incredible intrusion into a wide swath of reproductive health care.”

A third-year OB/GYN resident at U-N. M., Alana Carstens Yalom attended medical school at Tulane University, in New Orleans. She had entertained the idea of going back to Louisiana for her medical practice. Not anymore. She wants abortion care to be a part of her OB/GYN practice, and Louisiana has a ban.

“Now I don’t think that is even an option for me,” she said.

Physicians, medical residents and medical students said in interviews they are worried about the impact on the profession. How to navigate careers in the new landscape is a major topic of discussion among both doctors and trainees, they said.

Mayrose Porter, an Austin native who is a student at Baylor College of Medicine in Houston, said she will apply to residencies in her home state but that the rest of the choices on her list will only be in states where abortion is legal. In the long term, Porter, a member of Medical Students for Choice, does not expect to practice medicine in Texas.

“The idea that myself and other future doctors are just not going to be here is sad for me personally and sad for the community,” she said, emphasizing she was speaking for herself only, not Baylor. “There’s some guilt that I’m abandoning the community I grew up in.”

In Nebraska, Methodist Health System in Omaha has just two specialists with expertise in high-risk pregnancies who also can perform dilation and evacuation procedures to remove a fetus. The hospital permits abortions only in situations that threaten the health and life of the woman. A group of OB/GYNs from Nebraska, including Methodist maternal fetal specialist Emily Patel, have formed a local political action committee to urge the legislature not to pass an abortion ban.

They are warning about “downstream effects” of an abortion ban on reproductive health more broadly.

A common example is for a woman whose water has broken around 18 or 19 weeks. The risks of continuing that pregnancy to the health of the woman and the fetus include developmental problems for the fetus and the risk of infection for the woman.

But under the proposed abortion ban in Nebraska, Patel said, it is not clear whether even explaining termination options in such a circumstance would be legal.

“Imagine we are in a state with a ban, and that fetus has a heart rate, and the patient sitting in front of me is not ill. This is going to be a tough situation for a physician to be in,” Patel said. “A physician is not going to want to be in a position where they are going to be criminally prosecuted for providing routine care and counseling.”

It’s the sort of legal uncertainty and danger that top doctors will seek to avoid, she added: “These states where bans are going into effect are going to have trouble recruiting for the next generation of OB/GYNs.”

Opponents of abortion said worries about legal jeopardy and restrictions beyond elective abortions are overblown.

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“There’s a lot of mythology and misconception about what this means for reproductive health,” said Sandy Christiansen, an OB/GYN who is medical director of a Maryland Care Net pregnancy center, which encourages women to continue pregnancies. “There shouldn’t be any problems” treating a miscarriage with medication or surgical intervention, she said.

“They shouldn’t have to worry about their licenses if they are practicing a standard of care,” said Christiansen, who is a member of the American Association of Pro-Life Obstetricians and Gynecologists.

She did acknowledge some confusion: “Hopefully, the laws that will come along will clarify some of these things.”

Another member of the antiabortion physicians’ group, associate professor Susan Bane, at Barton College, a small Christian-affiliated institution in North Carolina, said she believes reluctance to move to states with abortion bans will be limited to the small percentage of OB/GYN doctors who want to perform elective abortions.

“If you’re going to be in medical school and you want to be an obstetrician and want to do abortions, you will choose a state where it’s legal,” she said.

Hospital systems in states with abortion restrictions, including Utah, Texas, Mississippi, Alabama and Ohio, did not respond to requests for comment or declined to respond to questions about how they are approaching potential retention and recruiting challenges.

A large health system based in Utah, Intermountain Healthcare, lists 10 OB/GYN physician vacancies on its website, the most of any specialty for which it is recruiting. A spokeswoman at Intermountain, apparently inadvertently, included a Post reporter on an email to the public relations team after The Post asked about challenges filling those vacancies in light of Utah’s abortion law: “We need to strategize a response to politely decline so that we can stay away from this issue.”

Doctors said they are grappling with the fallout from broadly worded legislation written by politicians without detailed medical knowledge. The environment creates a high degree of legal and professional risk for specialists, said David Turok, an associate professor of OB/GYN at the University of Utah who is also a board member of Physicians for Reproductive Health, which supports abortion rights.

“What we have is laws that are not representative of medical practice, that are not framed in ways that we think or speak as medical professionals,” Turok said, “and that makes it confusing.”

Officials in some states are working to clarify how abortion bans are going to be applied. The Louisiana Department of Health on Monday issued a list of 25 fetal conditions that can justify termination.

The legal uncertainty adds to the burdens on OB/GYNs. Theymust respond to deliver babies 24 hours a day, emergencies are emotionally stressful, and practitioners face some of the highest rates of malpractice lawsuits and accompanying insurance costs.

The federal government has said the United States needs 9,000 more OB/GYNs and that the shortage will reach 22,000 by 2050.

In Michigan, an old, pre-Roe abortion ban was renewed after the Supreme Court ruling. The looming ban has prompted Tim Johnson, a veteran of high-risk pregnancy care at Michigan Health, to consider moving out of the state. Although he is 73 and no longer provides elective abortions, he still treats patients and is not ready to retire. If Michigan’s abortion ban sticks, he may move to Maryland to practice, he said.

“I always said if (Roe were overturned) quickly like this, it would be terribly disruptive,” he said, “We are starting to understand how truly disruptive it is.”