When Rose Al Abosy began weighing which obstetrics and gynecology residencies to apply to, she spoke to advisers, considered programs’ academics and evaluated how state laws would affect her ability to train in providing abortions.
The Boston University Medical School graduate narrowed down the options to 80 programs in states that had not enacted restrictions on abortion care.
“For me just kind of looking for residency programs, it was like a nonnegotiable,” said Al Abosy, who was matched at the University of Washington. “I needed to learn how to do this training.”
The Supreme Court’s 2022 decision overturning the constitutional right to an abortion caused a cascade of changes to state policies affecting those seeking or providing abortions.
But it also appears to have become a factor in how medical students choose their specialty as they match with residency programs, with early data indicating a drop in those choosing obstetrics and gynecology residency programs from last year—before the Dobbs v. Jackson Women’s Health Organization decision.
A CQ Roll Call analysis of yearly resident applicant data provided by the Association of American Medical Colleges found a 6.75 percent decrease in medical school and osteopathic medical school applicants to OB-GYN residency programs compared to 2022. Among only osteopathic student applicants, the number of applicants dropped by 8.7 percent.
The drop in applicants to OB-GYN programs is more stark in states with abortion policies considered “most restrictive” or “very restrictive” by the reproductive rights policy organization the Guttmacher Institute, falling 6.29 percent from 2022 to 2023. For states considered “very protective” or “protective,” applicants also dropped 3.16 percent.
Application data alone does not necessarily demonstrate a causal relationship on how medical school graduates chose or were matched to their residency programs, and AAMC could not provide institution-level data. Nor do all states have OB-GYN residency programs.
Still, analysts say the data may be telling.
“There’s more demand for obstetrician and gynecology training and residency programs than there are spots, and so I think it’s more a matter of what’s going to happen to where those trainings are taking place. Are they going to entirely leave hostile states and set up their training programs elsewhere?” asked Suzanne Bell, an assistant professor in the Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.
“I think we have yet to see what those full ramifications are.”
A drop in Texas
Texas, which banned nearly all abortions in September 2021 through a unique citizen enforcement mechanism, is home to 16 OB-GYN residency programs—fewer than only New York and California. Among them: the UT Southwestern Obstetrics and Gynecology Residency, the biggest program nationally, which boasts to have trained 1 in 80 OB-GYNs.
Prior to the law’s implementation, MD applicants to OB-GYN residency programs in Texas remained stable year to year, according to AAMC data. From 2020 to 2021, the number of applicants changed about 0.10 percent.
In 2021, 975 students applied for OB-GYN residency programs in Texas. But in 2022—the first year after the Texas law went into effect—that number had dropped to 872. In 2023, it had dropped to 821—a nearly 19 percent drop in applicants over two years.
David Forstein, president and CEO of the Rocky Vista University College of Osteopathic Medicine and an OB-GYN professor who is studying the transition from medical school to residency with a group of other OB-GYN educators, said the Dobbs decision’s impact remains unclear.
“What we don’t yet know, although we’re trying to gather that data, is if students who would normally go to places like Texas and Florida for their residencies choose not to go there,” he said.
Still, there are indications that restrictive state policies are having an impact.
A survey presented at a May American Congress of Obstetricians and Gynecologists Conference found that 77 percent of third- and fourth-year medical students nationwide across medical specialties said abortion policies will affect the locations of residency programs they plan to apply to.
Fifty-eight percent of the almost 500 students surveyed between August and October last year said they were unlikely to apply to a program in a state with abortion restrictions.
“There are so many factors that medical students think about when they’re deciding where to apply to residency prior to Dobbs,” said Ariana Traub, a third-year at Emory University School of Medicine who led the survey. “Now when you add in Dobbs to this and it kind of adds another layer to that complexity. I think, a lot of times, people forget that doctors are people too and they make these decisions.”
For those considering OB-GYN, Traub said they heard from two camps: individuals who are hesitant because of the political environment surrounding abortion and students emboldened by the decision to go into the specialty.
Kellen Mermin-Bunnell, a co-author and also a third-year at Emory, said going into the study they expected the biggest impact for prospective OB-GYN residents, who would have limited training in abortion care if limited to medical emergency cases.
“If you’re not able to learn and train by doing these procedures on a patient who is medically stable, who is choosing to have this procedure, who is a good learning case, it’s a lot harder to get good at doing it,” she said.
Pamela Merritt, executive director at Medical Students for Choice, said her organization has been trying to seek more clarity from residency programs in writing.
“In the banned states, we have not got the kind of declarative statements that would allow us to say to our members that if you go to a residency program in Florida or Texas you are definitely going to be supported in your training,” she said. “For me, it seems perfectly reasonable to expect them to go on the record.”
That, said Merritt, has left MSC members going into the match with an unclear map of what accommodations will be made.
“I’m not 100 percent certain that the declines that we saw can be totally connected to the Dobbs decision, even though it’s convenient for me,” she said. “I think after this year, what we expect is to see, you know, the proof in the pudding.”
American Medical Association President Jack Resneck Jr. said medical students, residents and fellows are “being robbed of opportunities to train the breadth of basic reproductive health care.”
“They’re learning that it’s now normal to have to pick up the phone and call hospital attorneys all the time on standard of care decisions that used to be uncontroversial and actually starting to make some geographic decisions based on those state laws,” he said at a May National Academy of Medicine event.
Federal and state lawmakers are examining how to reduce any gaps in medical training.
“I think, at the federal level, we should think about how we can allow a trainee in a restrictive state perhaps to go to a state like California,” Rep. Ami Bera, D-Calif., said at a news conference on May 10.
Bera, a physician, said that also involves navigating licensure issues and funding to travel in other states to ensure access beyond simulated care.
“An OB-GYN that trains in one state should have the same training that an OB-GYN in another state has,” he said. “You as a patient aren’t going to be thinking about that. You’re gonna assume that your doctor that’s finished the residency training programs has the same training. That just might not be the case in the future.”
His office is still narrowing down an idea for a specific bill.
Anita Mikkilineni, an OB-GYN and assistant professor at George Washington University, said states have already begun navigating this challenge.
“They piecemeal put together a curriculum so that residents can get that exposure, sometimes crossing state lines, but that’s a very complex process,” she said. “What we think the government could do to help us there is figure out how can we fund those residents without using states’ money or whatever so that they can safely cross state lines to get that rotation.”
Merritt said she has talked to state legislators from Illinois, Colorado, California and New York who are looking for legislative solutions.
“There’s definitely a very real interest in some of those states. I think the devil is going to be in the details of whether or not there’s going to be the freed-up funding,” she said.
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