Implications of the Dobbs Decision for Medical Education: Inadequate Training and Moral Distress

"I'm supposed to be a helper": Spiritual distress of abortion providers after the Dobbs decision

Background

The Dobbs v. Jackson Women's Health Organization decision has undoubtably affected the practice of abortion providers nationally. We hypothesized that Dobbs has also impacted the ways in which providers experience meaning and purpose through their work, which are elements of spirituality.

Objective

We sought to describe the spectrum of spirituality of abortion providers and understand whether and how the Dobbs decision caused spiritual distress.

Study Design

For this qualitative study, we conducted video interviews with 26 abortion providers from 17 states between November 2022 and February 2023. States were classified according to the Guttmacher Institute classifications from most restrictive to very protective as of December 2022. Interviews included questions such as, "Can you describe your own sense of spirituality or spiritual identity?" and "How does your spiritual belief inform your response to the Dobbs decision?"

Results

Participants' states of practice were well-distributed across the abortion restrictive-protective spectrum. The majority of participants were spiritual, while less than half identified as part of an organized religion. Many participants felt a spiritual call or obligation to provide abortion care and 46% described abortion as a spiritual act for provider and/or patient. Most participants experienced spiritual distress (74%), including those practicing in states across the restrictive-protective spectrum. Of note, 92% of participants described their spirituality as helpful in coping with the effects of the fall of Roe v. Wade. Sources of strength included advocacy, agency, legislative work, and community; over half specifically cited the abortion provider community.

Conclusions

The Dobbs decision-and subsequent state-level abortion restrictions-impacts abortion providers by causing spiritual distress. While many abortion-restrictive laws are influenced by religious or spiritual beliefs, it is important to recognize that abortion providers are also spiritual individuals.

The impact of Dobbs v. Jackson on abortion training in obstetrics and gynecology residency programs: A qualitative study

OBJECTIVES

The Ryan Program collaborates with obstetrics and gynecology (OBGYN) residency programs in the United States (U.S.) to ensure that abortion and contraception care are incorporated into resident curriculum as required. We sought to understand the impact of the Dobbs v. Jackson decision on OBGYN residency abortion training programs from the perspective of Ryan directors and to understand barriers and facilitators to maintaining abortion training in OBGYN residency programs post-Dobbs.

STUDY DESIGN

We conducted qualitative, semi-structured in-depth interviews with Ryan program directors at U.S. academic medical centers. We coded the data iteratively and analyzed the data thematically.

RESULTS

From January to April 2023, we conducted 24 interviews, representing 21% (n = 23) of eligible U.S. Ryan directors. Participants were evenly distributed across four geographic regions of the U.S.; 50% (n = 12) of participants were from programs in abortion-restrictive settings. Two themes emerged: (1) Ryan directors experienced stressors related to the administration of Ryan programs post-Dobbs, including perceived difficulty satisfying requirements for abortion training in restrictive states, burnout, and increased financial needs to support training partnerships. (2) Directors face challenges in recruitment and clinical care post-Dobbs.

CONCLUSIONS

Increased state restrictions on abortion place logistical and financial burdens on OBGYN abortion training programs. Dobbs impacted training experiences across the U.S. and made it more difficult for many OBGYN residencies to provide abortion training.

IMPLICATIONS

The research findings will inform strategies for improving the delivery of abortion education post-Dobbs. We anticipate findings will enhance procedures to establish and maintain partnerships post-Dobbs and identify areas where philanthropy and advocacy can be effectively utilized.

"I am putting my fear on them subconsciously": a qualitative study of contraceptive care in the context of abortion bans in the U.S

BACKGROUND

Since the Dobbs vs. Jackson Women's Health Organization decision in June 2022, providers throughout the U.S. have been navigating the shifting legal landscape of abortion bans, which diminish the delivery of evidence-based healthcare. The Dobbs decision has had a detrimental impact on medical training, the physician-patient relationship, and provision of medical care. However, few studies have captured the effects on providers in adjacent fields, including contraceptive care. Our objective was to examine the impact of Dobbs on contraceptive care.

METHODS

We conducted semi-structured in-depth interviews (August 2022-July 2024), with 41 contraceptive healthcare providers across the US, with the majority (63%) in abortion restrictive states. We utilized deductive thematic analysis to assess providers' practice changes and experiences related to contraceptive services.

RESULTS

In reaction to the Dobbs decision, providers noted increased requests for contraception, especially for highly effective methods. Providers worried that certain methods, such as IUDs or emergency contraception, would become restricted, and mentioned advance provision of pills and other ways that they would try to ensure supplies. Providers also discussed that their patients were worried about threats to contraception, including for adolescents. Some expressed concern, however, that the abortion bans may prompt providers to overemphasize high-efficacy methods with directive counseling. Providers shared that it was stressful to practice in contexts of uncertainty, with shifting abortion policies affecting contraceptive care, including emergent needs such as providing contraceptive services to out-of-state patients before they go home. Several providers shared that they felt an increased importance of their role in their communities, and a deepened commitment to advocate for their patients.

CONCLUSIONS

Abortion restrictions profoundly impact providers' contraceptive counseling and care. The effects of Dobbs on providers and their clinical practices underscore providers' legally precarious position in today's reproductive health landscape. Attention to contraceptive access and person-centered care has become a salient public health need across the U.S. The long-term impacts of limited reproductive rights may stretch an already under-resourced healthcare system and further emphasize moral pressures.

Abortion Education for Medical Students in an Era of Increased Abortion Restrictions

Following the Supreme Court's decision in Dobbs v Jackson Women's Health in June 2022, many states restricted or banned abortion. Medical educators have focused on how this change impacts abortion training for residents, but schools must also adapt undergraduate medical education. Medical schools provide the foundation for future physicians' knowledge and attitudes on abortion. Comprehensive, high-quality abortion education for all medical students is essential for the future of abortion care. Here, we present how education champions can lead curricular improvements in abortion education in the preclinical, clerkship, and postclerkship phases of undergraduate medical education.

Navigating the Impact of the Dobbs Decision: Perspectives from Pediatric Surgeons on Reproductive Healthcare

Nationwide abortion restrictions resulting from the Dobbs v Jackson Women's Health Organization (2022) decision have generated confusion and uncertainty among healthcare professionals, with concerns for liability impacting clinical decision-making and outcomes. The impact on pediatric surgery can be seen in prenatal counseling for fetal anomaly cases, counseling for fetal intervention, and recommendations for pregnant children and adolescents who seek termination. It is essential that all physicians and healthcare team members understand the legal implications on their clinical practices, engage with resources and organizations that can help navigate these circumstances, and consider advocating for patients and themselves. Pediatric surgeons must consider the impact of these changing laws on their ability to provide comprehensive and ethical care and counseling to all patients.

State Abortion Policy and Moral Distress Among Clinicians Providing Abortion After the Dobbs Decision

Importance

Moral distress occurs when individuals feel powerless to do what they think is right, including when clinicians are prevented from providing health care they deem necessary. The loss of federal protections for abortion following the Dobbs v Jackson Women's Health Organization Supreme Court decision may place clinicians providing abortion at risk of experiencing moral distress, as many could face new legal and civil penalties for providing care in line with professional standards and that they perceive as necessary.

Objective

To assess self-reported moral distress scores among abortion-providing clinicians following the Dobbs decision overall and by state-level abortion policy.

Design, Setting, and Participants

This survey study, conducted from May to December 2023, included US abortion-providing clinicians (physicians, advanced practice clinicians, and nurses). A purposive electronic survey was disseminated nationally through professional listservs and snowball sampling.

Exposure

Abortion policy in each respondent's state of practice (restrictive vs protective using classifications from the Guttmacher Institute).

Main Outcomes and Measures

Using descriptive statistics and unadjusted and adjusted negative binomial regression models, the association between self-reported moral distress on the Moral Distress Thermometer (MDT), a validated psychometric tool that scores moral distress from 0 (none) to 10 (worst possible), and state abortion policy was examined.

Results

Overall, 310 clinicians (271 [87.7%] women; mean [SD] age, 41.4 [9.7] years) completed 352 MDTs, with 206 responses (58.5%) from protective states and 146 (41.5%) from restrictive states. Reported moral distress scores ranged from 0 to 10 (median, 5) and were more than double for clinicians in restrictive compared with protective states (median, 8 [IQR, 6-9] vs 3 [IQR, 1-6]; P < .001). Respondents with higher moral distress scores included physicians compared with advanced practice clinicians (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P = .005), those practicing in free-standing abortion clinics compared with those practicing in hospitals (median, 6 [IQR, 3-8] vs 4 [IQR, 2-7]; P < .001), those no longer providing abortion care compared with those still providing abortion care (median, 8 [IQR, 4-9] vs 5 [IQR, 2-8]; P = .004), those practicing in loss states (states with the greatest decline in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted incidence rate [IRR], 1.72 [95% CI, 1.55-1.92]; P < .001; adjusted IRR, 1.59 [95% CI, 1.40-1.79]; P < .001), and those practicing in surge states (states with the greatest increase in abortion volume since the Dobbs decision) compared with those in stable states (unadjusted IRR, 1.27 [95% CI, 1.11-1.46]; P < .001; adjusted IRR, 1.24 [95% CI, 1.09-1.41]; P = .001).

Conclusions and Relevance

In this purposive national survey study of clinicians providing abortion, moral distress was elevated among all clinicians and more than twice as high among those practicing in states that restrict abortion compared with those in states that protect abortion. The findings suggest that structural changes addressing bans on necessary health care, such as federal protections for abortion, are needed at institutional, state, and federal policy levels to combat widespread moral distress.

The Impact of the Dobbs v. Jackson Supreme Court Decision on Orthopaedic Residency Programs: A Collaborative Orthopaedic Education Research Group (COERG) Survey

BACKGROUND

Recent changes in reproductive health care policy have now led to state-specific differences in abortion care access across the United States. Members of the medical community in particular have issued concerns regarding these new policies and their potential impact on graduate medical training.  Objectives: The purpose of this study was to sample orthopaedic surgery residency programs to gauge their perceptions of the Dobbs decision and its impact on residency training.  Materials and methods: A 25-item questionnaire was developed to assess the attitudes of orthopaedic surgery residency programs on the Dobbs v. Jackson Women's Health Organization decision. Our survey-based study was first endorsed by and then distributed amongst members of the Collaborative Orthopaedic Education Research Group (COERG). A total of 24 representatives from 24 Accreditation Council for Graduate Medical Education (ACGME) accredited orthopaedic surgery residency programs agreed to participate in the study.  Results: Twenty-four of 24 program correspondents completed the survey (100%). Of the 15 programs (68.2%) who reported that their institution does not have a contingency plan in place, only five (33.3%) see a need for one. Eighteen programs (75.0%) agreed that the ACGME should have a policy protecting residents or significant others needing reproductive care. Ten (41.7%) respondents indicated that the Dobbs decision will impact how students rank residency programs; however, none (0%) believe it will impact their ability to attract a diverse applicant pool.  Conclusion: Although some programs surveyed have a contingency plan in place, the majority believe the ACGME should develop a policy that addresses the reproductive needs of residents. Given the higher rate of pregnancy complications experienced by women training in orthopaedic surgery it is paramount to have policies that protect residents seeking reproductive care.

The Impact of Changing Abortion Legislation on Emergency Medicine Residents in a State With Protected Abortion Rights

Background The US Supreme Court's 2022 ruling in Dobbs v Jackson Women's Health Organization overturned Roe v Wade, allowing individual states to determine abortion restrictions, significantly impacting graduate medical education (GME). While focus has been on states enacting restrictions, the impacts in states where abortion rights are safeguarded are equally important. Emergency medicine (EM) serves as a safety net within the health care system, making it ideal for understanding the broader implications of these legal changes on GME. Objective To explore the experiences and perspectives of EM residents regarding changing abortion legislation in California, an abortion-protective state. Methods We conducted a qualitative study using transcendental phenomenology. Thirteen postgraduate year 4 EM residents from a single large university-based program in California participated in semistructured interviews in 2023. Data were analyzed using thematic analysis. Results Four themes were identified: (1) impact of changing abortion legislation on practice; (2) personal and professional decisions influenced by legislation; (3) navigating legal uncertainties in practice; and (4) advocacy and engagement beyond clinical practice. Residents reported varying levels of awareness and concern about the implications of abortion laws on EM practice, the influence of these laws on their career decisions, the need for legal guidance, and a commitment to advocacy. These themes highlight a complex interplay between legal changes, personal values, and professional responsibilities. Conclusions This study highlights the significant impact of the Dobbs decision on EM residents in California, revealing that residents face unique ethical, legal, and advocacy challenges that may affect their professional identity formation.

Teaching Moral Courage & Rights-Based Leadership in Medicine: A Cross-Disciplinary Exploration

Clinical medicine's complexities and demands often surpass the scope of formal ethics and leadership training that medical schools and residency programs provide. The discrepancy between medical education and the realities of clinical work may contribute to ethical erosion among learners, namely, medical students and residents. Unlike traditional approaches to teaching professional ethics and leadership in medicine, rights-based (aspirational) pedagogies approach trainees as autonomous moral agents, whose work has moral value to themselves and others, who live with the ethical consequences of their professional choices, and whose work shapes their individual moral character. By incorporating teaching strategies that intentionally build learners' rights-based leadership through the development of moral courage, medical educators may counter important aspects of ethical erosion while promoting learner preparedness, outcomes, and well-being. Military teaching approaches offer a valuable example to medical educators seeking to create structured curricula that foster moral courage to promote rights-based leadership, given the high level of moral and managerial complexity present in both medicine and the military. Through a comparative analysis of professional ethics in the medical and military disciplines, this Observation article explores the validity of applying precedents from military ethics and leadership education to medical training. Through arguments rooted in moral philosophy, military history, and military organizational research, we explore the expansion of rights-based teaching methods within the predominantly traditional and rules-based norms of medical education. In relating these findings to real-life clinical scenarios, we offer six specific, rights-based modifications to medical ethics curricula that have potential to promote morally courageous leadership and counteract the ethical erosion medical students and residents face.

"I Went Into This Field to Empower Other People, and I Feel Like I Failed": Residents Experience Moral Distress Post-Dobbs

Background The 2022 Supreme Court ruling in Dobbs v Jackson Women's Health Organization nullified the constitutional right to abortion, which led to effective bans in at least 14 US states and placed obstetrics and gynecology (OB/GYN) residents in dilemmas where they may have to withhold care, potentially causing moral distress-a health care workforce phenomenon less understood among resident physicians. Objective To identify and explore moral distress experienced by OB/GYN residents due to care restrictions post-Dobbs. Methods In 2023, we invited OB/GYN residents, identified by their program directors, training in states with restricted abortion access, to participate in one-on-one, semi-structured interviews via Zoom about their experiences caring for patients post-Dobbs. We used thematic analysis to analyze interview data. Results Twenty-one residents described their experiences of moral distress due to restrictions. We report on 3 themes in their accounts related to moral distress (and 4 subthemes): (1) challenges to their physician identity (inability to do the job, internalized distress, and reconsidering career choices); (2) participating in care that exacerbates inequities (and erodes patient trust); and (3) determination to advocate for and provide abortion care in the future. Conclusions OB/GYN residents grappled with moral distress and identified challenges from abortion restrictions.

Addressing Moral Distress After Dobbs v. Jackson Women's Health Organization : A Professional Virtues-Based Approach

ABSTRACT

The June 2022 U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization abolished federal protections for reproductive choice. In states where subsequent legislation has restricted or banned access to abortion services, physicians and trainees are prevented from providing ethically justified evidence-based care when patients with previable pregnancies are seeking an abortion. Pregnant patients' vulnerabilities, stress, and the undue burden that they experience when prevented from acting in accordance with their reproductive decision-making can evoke negative emotional consequences, including moral distress in clinicians. Moral distress occurs when clinicians feel a moral compulsion to act a certain way but cannot do so because of external constraints, including being hindered by state laws that curtail practicing in line with professional standards on reproductive health care. Moral distress has the potential to subvert prudent clinical judgment. The authors provide recommendations for managing moral distress in these circumstances based on the professional virtues. The fundamental professional virtues of integrity, compassion, self-effacement, self-sacrifice, and humility inform the management of moral distress and how to respond thoughtfully and compassionately, without over-identification or indifference to the plight of patients denied abortions. The authors also discuss the role of academic leaders and medical educators in cultivating a virtue-based professional culture at the forefront of clinical and educational processes in a post- Dobbs world.

An online alternative: a qualitative study of virtual abortion values clarification workshops

BACKGROUND

Following the U.S. Supreme Court Dobbs decision, access to abortion education is increasingly regionally dependent. Participation in values clarification workshops on abortion can improve abortion knowledge and reduce stigma. Traditionally, values clarification workshops occur in person, yet medical education increasingly utilizes online learning. We sought to understand how a virtual platform impacted medical students and Obstetrics and Gynecology (ObGyn) residents' experience with a values clarification workshop on abortion.

METHODS

We conducted values clarification workshops over Zoom with medical students and ObGyn residents at four midwestern teaching hospitals from January 2021-December 2021 during the COVID-19 pandemic. We held semi-structured interviews with participants and facilitators to learn about how the virtual format impacted their experience with the workshop. Four researchers analyzed transcripts using an inductive approach to generate codes then themes.

RESULTS

We interviewed 24 medical students, 13 ObGyn residents, and five workshop facilitators. Participants and facilitators found the virtual platform to have both unique advantages and disadvantages. Four central themes were identified: 1) Screen as a barrier: participants noted obstacles to conversation and intimacy. 2) Emotional safety: participants felt comfortable discussing sensitive topics. 3) Ease of access: participants could access virtual workshops regardless of location. 4) Technology-specific features: Zoom features streamlined aspects of the workshop and allowed for anonymous contributions to discussion.

CONCLUSIONS

Our findings suggest that a virtual platform can be a convenient and effective way to deliver values clarification workshops on abortion, and this technology could be leveraged to expand access to this training in areas without trained facilitators.

Abortion Policy: Legal, Clinical, and Medical Education Considerations

Abortion is a frequent topic of policy debate in America and a central issue in politics since the Dobbs v Jackson Women's Health Supreme Court decision. A number of states have completely or nearly completely banned abortion and criminalized health care providers. People seeking abortion care are turning to alternatives outside the formal health care system or traveling to states that have preserved access. Approximately half of US Obstetrics/Gynecology residents will train in a state where abortion is illegal, lending to a frightening future where Obstetrics/Gynecologists are not trained to provide this common, sometimes life-saving, health care.

The Impact of the Dobbs Decision on Diagnostic Radiology Applicants, Residents, and Program Directors

In the Dobbs decision the United States Supreme Court overturned Roe v. Wade, returning the issue of abortion to the states. To date, there is little published data on the impact this might have on where future residents choose to pursue graduate medical education. We investigated the potential effects of the resultant varied political landscape of abortion care access laws with respect to influence on the selection of prospective diagnostic radiology training programs by medical students, comparing application rates for the 2022 recruitment cycle to the prior 4 years across a geographically diverse group of 22 academic and community sites across the United States. We provide strategies for program directors to consider in dealing with topics related to this continually evolving issue as it pertains to resident recruitment and retention.

The association between abortion restrictions and patient-centered care for early pregnancy loss at US obstetrics-gynecology residency programs

BACKGROUND

Early pregnancy loss is a common medical problem, and the recommended treatments overlap with those used for induced abortions. The American College of Obstetricians and Gynecologists recommends the incorporation of clinical and patient factors when applying conservative published imaging guidelines to determine the timing of intervention for early pregnancy loss. However, in places where abortion is heavily regulated, clinicians who manage early pregnancy loss may cautiously rely on the strictest criteria to differentiate between early pregnancy loss and a potentially viable pregnancy. The American College of Obstetricians and Gynecologists also notes that specific treatment modalities that are frequently used to induce abortion, including the use of mifepristone in medical therapy and surgical aspiration in an office setting, are cost-effective and beneficial for patients with early pregnancy loss.

OBJECTIVE

This study aimed to determine how US-based obstetrics and gynecology residency training institutions adhere to the American College of Obstetricians and Gynecologists recommendations for early pregnancy loss management, including the timing and types of interventions, and to evaluate the relationship with institutional and state abortion restrictions.

STUDY DESIGN

From November 2021 to January 2022, we conducted a cross-sectional study of all 296 US-based obstetrics and gynecology residency programs by emailing them and requesting that a faculty member complete a survey about early pregnancy loss practices at their institution. We asked about location of diagnosis, use of imaging guidelines before offering intervention, treatment options available at their institution, and program and personal characteristics. We used chi-square tests and logistic regressions to compare the availability of early pregnancy loss care based on institutional indication-based abortion restrictions and state legislative hostility to abortion care.

RESULTS

Of the 149 programs that responded (50.3% response rate), 74 (49.7%) reported that they did not offer any intervention for suspected early pregnancy loss unless rigid imaging criteria were met, whereas the remaining 75 (50.3%) programs reported that they incorporated imaging guidelines with other factors. In an unadjusted analysis, programs were less likely to incorporate other factors with imaging criteria if they were in a state with legislative policies that were hostile toward abortion (33% vs 79%; P<.001) or if the institution restricted abortion by indication (27% vs 88%; P<.001). Mifepristone was used less often in programs located in hostile states (32% vs 75%; P<.001) or in institutions with abortion restrictions (25% vs 86%; P<.001). Similarly, office-based suction aspiration use was lower in hostile states (48% vs 68%; P=.014) and in institutions with restrictions (40% vs 81%; P<.001). After controlling for program characteristics, including state policies and affiliation with family planning training programs or religious entities, institutional abortion restrictions were the only significant predictor of rigid reliance on imaging guidelines (odds ratio, 12.3; 95% confidence interval, 3.2-47.9).

CONCLUSION

In training institutions that restrict access to induced abortion based on indication for care, residency programs are less likely to holistically incorporate clinical evidence and patient priorities in determining when to intervene in early pregnancy loss as recommended by the American College of Obstetricians and Gynecologists. Programs in restrictive institutional and state environments are also less likely to offer the full range of early pregnancy loss treatment options. With state abortion bans proliferating nationwide, evidence-based education and patient-centered care for early pregnancy loss may also be hindered.

Anticipated Impact of Dobbs v Jackson Women's Health Organization on Training of Residents in Obstetrics and Gynecology: A Qualitative Analysis

Background

On June 24, 2022, the Supreme Court of the United States in the case of Dobbs v Jackson Women's Health Organization ended constitutional protection for abortion, thus severely restricting access to reproductive health care for millions of individuals. Concerns have arisen about the potential impact on medical students, residents, and fellows training in restricted areas and the effect on gynecologic training and the future provision of competent comprehensive women's health care in the United States.

Objective

To qualitatively explore the anticipated impacts of the Dobbs ruling on training in obstetrics and gynecology (OB/GYN).

Methods

A participatory action research approach employing methods of qualitative analysis was used. Trainees and leaders in national OB/GYN professional and academic organizations with missions related to clinical care and training of medical students, residents, and fellows in OB/GYN participated. Two focus groups were held via Zoom in July 2022. Using an iterative process, transcripts underwent coding by 2 independent researchers to identify categories and common themes. Themes were organized into categories and subcategories. An additional reviewer resolved discrepancies.

Results

Twenty-six OB/GYN leaders/stakeholders representing 14 OB/GYN societies along with 4 trainees participated. Eight thematic categories were identified: competency, provision of reproductive health care, residency selection, inequity in training, alternative training, law-based vs evidence-based medicine, morality and ethics, and uncertainty about next steps.

Conclusions

This qualitative study of leaders and learners in OB/GYN identified 8 themes of potential impacts of the Dobbs ruling on current and future training in OB/GYN.

Abortion Care in the United States - Current Evidence and Future Directions

Abortion Care in the United StatesAbortion services are a vital component of reproductive health care. Jung and colleagues review medication abortion and procedural abortion as well as implications of increasing restrictions on access in the United States.

"They were there because they were pregnant. Which is a really apolitical thing"-Medical student discussions of politics in abortion care in the United States

OBJECTIVES

State abortion policies can vary widely. Geographic location and political climate could influence a medical student's abortion education experience. We compared how medical students training in one permissive and one restrictive state discussed politics in abortion care.

STUDY DESIGN

From 2018 to 2019, we interviewed US medical students during their Obstetrics and Gynecology rotation from two Midwestern academic centers with differing state abortion policies-one in Ohio (restrictive) and one in Illinois (permissive). In-depth interviews occurred following an abortion shadowing experience and included questions about politics in abortion care. We sorted data using flexible coding, with index codes around "politics," followed by specific analytic coding. We compared codes by medical school using NVIVO software.

RESULTS

We interviewed 28 students (50% in Ohio). Students in Ohio discussed specific barriers to patient care and how politics infringed upon the quality of medical care, describing abortion as stigmatized care. Students in Illinois described abortion as high-quality medical care, delivered without the infringement of restrictive laws. Students at both schools described their medical school climates as supportive to abortion, yet in Ohio, students described exposure to more diverse abortion views than Illinois students. Ohio students also described engaging in abortion advocacy work, while Illinois students felt more politically disconnected.

CONCLUSIONS

Even as clinical training opportunities decline, restrictive states may hold unique advocacy opportunities. Educators should tailor abortion curricula to address state level differences, as disparities in abortion access and student learning opportunities widen.

IMPLICATIONS

Students training in permissive states see abortion as routine health care, occurring without political interference. Students in restrictive states see abortion as hindered by politics and stigmatized, which may encourage advocacy. Educators should tailor curricula to address state level differences as disparities in abortion access and student learning opportunities widen.