Sunday, November 18News That Matters

The 'elective' issue: Medical schools are failing to teach doctors to discuss abortion


Safe, legal abortion is an essential part of health care. Nearly one-quarter of American women will have an abortion in their lifetimes, despite barriers such as closed clinics, lack of insurance coverage, and various forms of stigma. Providing abortion care also has its barriers, due in large part to the anti-abortion activism that distorts this basic health service. But there are hidden contributors as well, which pose more insidious risks to abortion access: Aspiring doctors are learning harmful ways of discussing abortion and their medical schools are doing little to stop it.

To understand this, several colleagues and I analyzed interviews with 74 students in their final year of medical school who were planning to specialize in obstetrics and gynecology. We reported our findings in the journal Social Science & Medicine.

During lengthy interviews, more than half of the students used the term “elective” to differentiate some abortions from others. This piqued our interest because “elective” has a very specific — and confusing — medical meaning. Within medicine, “elective” describes procedures that can be scheduled in the future, and differentiates them from procedures that must be performed immediately. “Elective” does not imply anything about the value or importance of the procedure; indeed, a lifesaving surgery should be called elective if it doesn’t need to be done today. Using this framework, the vast majority of abortions performed in the United States are appropriately categorized as elective.

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Outside of medicine, however, “elective” means voluntary or optional.

Almost all of the students who used the term “elective” in their interviews misunderstood the difference, and used its non-medical meaning. They inappropriately juxtaposed “elective” and “medically necessary,” and used “elective” to describe abortions they considered to be sought for “social” or “convenience reasons.” The few who mentioned abortion after rape and incest were careful to clarify that those were unique social situations where abortions were not to be considered elective. In our interviews, students used “elective” to mark abortions sought for what they considered less-acceptable reasons or by what they considered less-acceptable people. Many students conveyed this bias by expressing that they would likely refuse to provide “elective” abortions in their future practice despite being willing to provide others.

Not a single student questioned their non-medical use of the term, and many described this use of “elective” being reinforced by their educational environments. Some noted how teachers ignored or glossed over the topic of elective abortion; others clarified that unless students went to certain clinics on certain days, they would only be exposed to what they were told were medically necessary abortions or, more commonly, no abortions at all.

One student related a story of seeing a patient transferred to an academic center from a freestanding abortion clinic for medical complications of pregnancy, but then having the patient be unable to receive care because no available faculty members would participate in an abortion that was considered elective.

Categorizing any abortion as unnecessary or unacceptable, especially when couched in co-opted medical jargon, is egregiously unprofessional. It places patients at risk of inferior treatment, and is also squarely at odds with standards set by the American College of Obstetricians and Gynecologists and other specialties that provide reproductive health care. But with some medical schools providing no formal education about abortion and the majority offering a single lecture or a non-required rotation, medical students’ hazy or incorrect knowledge about abortion care should not be a surprise.

In a vacuum, medical students get their knowledge from informal systems sometimes referred to as the hidden curriculum. As we describe in our report, misuse of the term “elective” exposes a hidden curriculum for abortion care that teaches students to make medically meaningless distinctions between abortions, to make inappropriate refusals of care, and to judge patients.

This hidden curriculum may make abortion more difficult to access, but it could also create a generation of physicians who are unprepared to even talk with their patients about abortion. At a time when physicians should be speaking out against threats to essential health care services, our research suggests that future obstetricians and gynecologists are ill-equipped to do so. As medical schools ignore the topic, medical trainees learn incorrect information through informal means, and ultimately abortion care becomes more stigmatized and more critically threatened.

Recent calls to train more abortion providers are timely, but they will founder without sustained institutional support. Medical schools must immediately set formal standards for how to discuss abortion with patients and with colleagues. They must then expand the role of reproductive health experts in developing required classroom and clinical experiences around abortion. And when students’ beliefs require they have no direct role in abortion care, schools must teach them how to mitigate any resulting delays or lapses in care for their patients, and to frame their refusals in a way that does not magnify abortion stigma.

Medical schools have a responsibility to ensure that future physicians appreciate the health impacts of safe and legal abortion care, regardless of political efforts to change its legality. Their future patients’ lives depend on it.

Benjamin E.Y. Smith, M.D., is a faculty member at the Fort Collins Family Medicine Residency at Poudre Valley Hospital.

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