Early on a Monday morning, a group of young obstetrics and gynecology residents gathered for a daily meeting. The young doctors, dressed in blue scrubs and white coats, sat in the auditorium of Indiana's largest teaching hospital.
The meeting was a chance to share updates and make announcements. But they also had to address the elephant in the room.
"Any more abortion care questions?" Dr. Nicole Scott, the residency program director, asked the trainees.
One of the residents spoke after a few harsh moments of silence: "How's Dr. Bernard doing?"
"Bernard is actually in really good spirits. I mean, relatively," Scott answered. "She has 24/7 security, has her own lawyer."
They're referring to Dr. Caitlin Bernard, an Indiana abortion provider and one of the physicians who trains residents at this university hospital. Bernard was recently caught in a political whirlwind after she spoke to a reporter about an abortion she provided to a 10-year-old rape victim who crossed the state line from Ohio. The doctor was the target of attacks from pundits and political leaders on national television, including Indiana's attorney general.
The vitriol hit home for this group of residents. Bernard has been a mentor for most of them for years. Many of these young doctors were certain they wanted to practice in Indiana after training. Lately, some have felt more ambivalent.
"Watching what [Dr. Bernard] went through was scary," said Dr. Beatrice Soderholm, a fourth year OB-GYN resident and one of Bernard's mentees. "I think that was part of the point for those who were putting her through that. [It] was to scare other people out of doing the work that she does."
Last week, Republican Indiana Gov. Eric Holcomb signed a near-total abortion ban into law, making Indiana the first state to pass new legislation restricting access to abortion since the Supreme Court struck down Roe v. Wade in June.
Before the lawmakers voted, thousands of Indiana providers voiced concerns that outcomes would likely get worse for their patients. It's unclear what this will mean for providers too.
And that's worrying medical residents – the early career doctors who spend four years training to become OB-GYNs.
Doctors weigh their options
These days, Scott, the residency program director, has found that the scope of her job has expanded beyond clinical and academic responsibilities. Her meetings with residents include political updates, and she tells them there are mental health services available if they need them.
"I mean, our residents are devastated," Scott said, holding back tears. "They signed up to provide comprehensive health care to women. And they are being told that they can't do that."
She expects this will "deeply impact" how Indiana hospitals recruit and retain medical professionals.
Indiana, like many Republican-led states, has a shortage of providers. A 2018 report from the March of Dimes found 27% of Indiana counties are considered maternal care deserts, with no or limited access to maternity care. The state has one of the highest maternal mortality rates in the country.
Scott said new laws restricting abortion will only make these statistics worse.
Dr. Wendy Tian, a third year resident, said lately she is scared and worried about her safety. Tian grew up and went to school in Chicago and chose to come to Indiana for residency because the program has a strong family planning focus. She was also open to practicing in Indiana when she completes her training.
But that's changed.
"I always thought I wanted to do family planning. I'm now thinking about doing something else," she said. "I know I still want to incorporate it. But I, for sure, don't know if I would be able to stay in Indiana postgraduation with what's going on."
Still, she feels "guilty for giving up" on some of the most vulnerable patients in Indiana.
Even before the Supreme Court overturned Roe v. Wade, Tian said the medical climate in Indiana could be hostile and frustrating. Indiana, like other states with abortion restrictions, allows nearly all health care providers to opt out of providing care for abortion patients.
"We encounter other people who we work with on a daily basis who are opposed to what we do," Tian said.
Tian said sometimes she and her colleagues have to cancel scheduled procedures because the nursing staff on-call are not comfortable helping a patient who is having an abortion.
"Frequently, we have to call anesthesia ahead of time, because there's only certain providers that are willing to provide anesthesia [for abortion patients]," Tian said.
Abortion training in peril
Still, the OB-GYN program in Indiana has been able to provide residents with comprehensive training, which includes abortion care and family planning. This is important for more than for abortion cases.
"Miscarriages are managed the exact same way as first-trimester termination procedures," Scott said. "But what termination procedures allow you to do is that kind of repetition and that understanding of the female anatomy, and how to manage complications that may happen with miscarriages."
And that concerns Scott because taking away abortion dramatically reduces the hands-on experience OB-GYN residents can get in her hospital.
Scott's program is exploring ways to make up for that. They could send residents out of state to learn in places without abortion restrictions. But Scott said this would be a logistical nightmare.
"This is not as simple as just showing up to an office and saying, 'Can I observe?' This includes getting a medical license for out-of-state trainees. This includes funding for travel and lodging," Scott said. "It adds a lot to what we already do to educate future OB-GYNs."
Nearly half of all OB-GYN residents in the U.S. are in states where abortion is banned or likely to be banned. This means that there will be an influx of residents looking to go out of state to make up for lost training opportunities. The Accreditation Council for Graduate Medical Education, the body that accredits residency programs, proposed modifications to the graduation requirements for OB-GYN residents to account for this changing landscape.
The difficult choice to stay or leave
For some residents, like first-year Veronica Santana, these political hurdles are actually a welcome challenge. Santana is Latina, grew up in Seattle, and has been involved in community organizing since she was a teenager. Part of why she chose obstetrics and gynecology was because of how the field of medicine intersects with social justice.
"It's political. It always has been and it continues to be. And obviously, especially now," she said.
After Roe was overturned, Santana took to the streets of Indianapolis to participate in abortion rights rallies. So did many of her co-residents and mentors.
Most of them, including the program director, have asked not to name the school of medicine or hospital system they work for because they fear backlash. Some said their employer remains timid in supporting the staff when it comes to the abortion debate in Indiana.
In a way, Indiana could be the perfect battleground to quench Santana's zest for advocacy and social activism. But lately, she said she is "very unsure" if staying in to practice after residency makes sense as a physician who wants to provide the entire scope of health services.
Soderholm, a fourth year medical resident, said it's a lot to think about.
Soderholm will complete her training in a few months and start to practice soon. She grew up in Minnesota, but over the past few years has felt a strong connection to patients at the county hospital in Indianapolis. She was so certain she wanted to practice in Indiana. But lately, her family in Minnesota – where abortion remains largely protected – questioned why she would stay to practice in a hostile medical climate like Indiana's.
"There's been a lot of hesitation. But the women [and] the childbearing people that we've taken care of, especially at our county hospital, [make it] really hard to leave. Sorry," she said, starting to cry.
It's for those patients that Soderholm decided she'll likely stay. The same can't be said for many other future doctors.
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