Steinauer, Jody MD, MAS*; Drey, Eleanor A. MD, EdM*; Lewis, Rebekah MPH†; Landy, Uta PhD†; Learman, Lee A. MD, PhD*
Abortion is one of the most common surgical procedures in the United States, more common than hysterectomy, sterilization, or cesarean delivery.1 In 1996, 1.4 million abortions were performed in the U.S.,2 and one half of all unintended pregnancies ended in abortion.3 Several studies have established that access to abortion has decreased over the last 15 years. This decrease has been partly attributed to a shortage of providers.4,5 As of 1996, only 14% of U.S. counties had an abortion provider, representing a decline of 85 providers per year from 1992 through 1996.2 Lack of access causes women to delay abortions, potentially forcing them into the even more difficult task of finding a second-trimester provider and increasing their surgical risk.6
The number of obstetrics and gynecology residency programs that routinely included abortion training declined from 24% in 1986 to 12% in 1991,7 and a 1993 study found that 46% of graduating residents had performed no more than 10 elective first-trimester abortions during their residencies.8 In 1995, responding to the decline of training and providers, the Residency Review Committee for Obstetrics and Gynecology added the requirement that abortion training be offered in all residency programs. In a survey administered since the Residency Review Committee for Obstetrics and Gynecology requirement changed, 46% of program directors stated that routine first-trimester training was included in their residency programs.9 Although this indicates an improvement in training availability, it may overestimate the number of residents who receive training.10
Since 1980, the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco has included routine abortion training in its residency program. The rotation is a 6-week PGY-3 family planning rotation at an in-hospital abortion clinic, modeled after an outpatient abortion service, where medical and surgical pregnancy termination is provided up to 23 weeks gestation. On average, residents perform 90 second-trimester surgical abortions and 50 first-trimester abortions during this rotation. The rotation is administered by a faculty member who completed a family planning fellowship. We evaluated resident satisfaction with abortion training during and after residency.
MATERIALS AND METHODS
The objective of the rotation is to teach residents the knowledge and skills for providing comprehensive, evidence-based abortion and postabortion contraception care. This includes preoperative and postoperative care, gestational dating, ultrasound, pain control, medication abortion for early gestations, aspiration abortion (manual and electric), dilation and evacuation (D&E), diagnosis and management of abortion complications, and counseling about pregnancy and contraceptive options. On one of the preoperative care days an advanced practice clinician staffs the clinic while the resident spends the morning in didactic education and the afternoon in continuity clinic. The resident spends the other 4 days in the clinic. The rotation takes place during the third year of residency, a year spent at a variety of University of California, San Francisco and other hospitals, including community and health maintenance organization hospitals with high surgical and obstetric volume.
Residents are able to opt out of the training by meeting with the program director and arranging an alternative clinical experience. In addition, residents who want to limit training to earlier gestations are allowed to do so. However, because the clinic depends on resident staffing, if a resident opts out entirely, arrangements are made for a different resident to cover the service.
The training site, the Women's Options Center at San Francisco General Hospital, is an abortion clinic set within the county's public hospital. The Women's Options Center is the only clinic in northern California that provides abortions after 18 weeks for women with state-funded insurance; therefore, it provides a high proportion of second-trimester abortions. In addition, it is a referral center for women with medical problems that limit care in other outpatient sites. The clinic provides more than 2,000 abortions annually, of which approximately 50% are first-trimester abortions, 20% are abortions between 14 and 19 weeks, and 30% are abortions between 19 and 23 weeks. The majority of these abortions are done with a local anesthetic and under moderate sedation.
In a given week, 1 day is dedicated to first-trimester care. The remaining 4 days are primarily used for second-trimester abortions, alternating 1 day for preoperative care followed by a procedure day. On staff, there are approximately 15 faculty obstetrician–gynecologists who work in the abortion clinic; however, the director of the clinic, an expert in abortion and family planning, serves as the primary mentor and is responsible for the clinic and training protocols.
At the beginning of the rotation residents are asked to review the syllabus for the rotation. The main textbook used is A Clinician's Guide to Medical and Surgical Abortion.11 They are also expected to read relevant chapters,12 relevant articles,13 and clinic consent forms and protocols. On their first day, they observe a counseling session conducted by a trained counselor. During the first week 2 faculty are scheduled in the clinic. One does procedures separately from the resident to maintain clinic flow and to work with a medical student, and 1 works with the resident. After observing abortions at a variety of gestational durations by the faculty preceptor, the resident is observed doing first-trimester procedures and, when judged competent, begins learning second-trimester procedures, slowly increasing to later gestational durations. During subsequent weeks, 1 attending in clinic works in parallel with the resident, doing procedures separately, and being immediately available to observe or assist the resident if needed.
Residents rate the educational value of all clinical rotations anonymously at the end of each year of training by completing comprehensive evaluations. They are asked to rate each rotation on a 5-point Likert scale, with 5 indicating “maximum value,” 4 “great value,” 3 “some value,” 2 “little value,” and 1 “no value.” In addition, they are asked which 3 rotations and clinical experiences were of most and least value in the previous year of residency.
Using PGY-3 residents’ evaluations during a 5-year period, from 1998–2003, we compared ratings of the family planning rotation with all rotations individually, all inpatient rotations and inpatient gynecology rotations combined, and outpatient rotations and experiences combined. We also surveyed those trained between 1998–2001 1 to 3 years after their graduation by mail to assess the rotation's value after graduation. In the follow-up survey using a 5-point Likert scale (ranging from 1 = far lesser value to 5 = far greater value), we asked them to rate the value of the family planning rotation compared with the other PGY-3 rotations and all rotations of residency. To identify the rotation elements contributing to the perceived value, we asked graduates to rate to what extent each element (on 4-point Likert scales from “no contribution” to “significant contribution”) contributes to positive or negative aspects of the rotation. Finally, we asked them open-ended questions about their experience of the rotation and its effect on their current practice. Because of privacy concerns, we intentionally did not directly ask graduates whether they currently provide abortions.
The Wilcoxon rank-sum test was used to compare mean scores, and χ2 tests were used to compare the proportion of residents who rated the rotations a “5.” We considered differences with a probability level of less than .05 to be statistically significant. The study was approved by the University of California, San Francisco institutional review board and was given exempt status.
Forty residents completed the third year of residency over the 5 years, none opted out of abortion training, and 100% completed the evaluations. Of all third-year rotations, the family planning rotation was the highest rated, with an overall score of 4.70, indicating extremely high educational value (Table 1). In statistical comparisons with other rotations, the family planning rotation was valued similarly to the Bay Area health maintenance organization experience and the elective rotation (P > .05). The family planning rotation was ranked more highly than all inpatient rotations, inpatient gynecology rotations, and outpatient clinical experiences, all of which scored well. The family planning rotation received a higher proportion of “maximum learning experience” or “5” ratings (75%) compared with all inpatient rotations (17%, P < .001), outpatient clinics (20%, P < .001), continuity clinic (54%, P = .05), and the elective rotation (54%, P = .1). Sixty-six percent of residents rated the family planning rotation as 1 of the top 3 clinical experiences of the third year, surpassing all other rotations.
We were able to contact 23 of 24 graduated residents who participated in the rotation from 1998–2001. Of these, 83% (19) returned the mailed survey. The average rating of the family planning rotation was 4.8, and 85% of respondents rated it of “maximum learning value.” Compared with all rotations of residency, where 5 indicates “far greater value” and 1 “far lesser value,” the family planning rotation received an average rating of 4.3 (standard deviation ± 0.56).
Overall, positive aspects of the rotation contributed strongly whereas negative aspects contributed relatively little to the overall rotation experience (Table 2). Factors that were cited as contributing to the rotation's popularity included the opportunity to master surgical skills, repetition of cases, the balance of autonomy and supervision in training, and a positive work environment. Respondents reported that their least favorite aspects of the rotation were diversity of trainers and techniques, high volume of second-trimester procedures in the service, and emotional discomfort during the procedure. However, no residents scored any of the negative factors a 4, or as significantly contributing to the negative, and very few residents gave negative contribution scores of 3 to “diversity of trainers and techniques” (n = 2), “repetition of cases” (n = 2), “high number of second-trimester procedures” (n = 2), and “emotional discomfort during the procedure” (n = 3). The respondents who gave at least 1 negative factor a score of 3 still gave the overall rotation a very high average score of 4.7. The 1 resident who gave “personal feelings about abortion” a score of 3 as contributing to the negative chose to be trained up to the clinic's gestational limit, and ranked the overall rotation a 5.
Several themes emerged from open-ended comments of residency graduates. Respondents reported that the rotation affirmed their commitment to provide abortions, that they have continued to use the skills learned in the rotation, and that the ability to perform first- and second-trimester abortions has been valuable in their postresidency practices. Eleven respondents volunteered that they currently provide elective abortions. One graduate said they liked “feeling capable of safely providing/performing a procedure/service that could be needed in both elective and emergent situations.” When asked about negative aspects of the rotation one graduate listed “[the] emotional impact of complex lives of women presenting for late abortions. I sometimes felt drained, but I never doubted the importance of the work.”
Our findings, based on a 5-year review of residency and 3 years of postresidency evaluations, support the value of a dedicated 6-week family planning rotation for PGY-3 residents in obstetrics and gynecology. Several characteristics of our residents and of the rotation may have set the stage for success.
Many of our residents are motivated to learn how to do abortions and provide postabortion contraceptive care. The national leadership of the faculty and the department's support of abortion services and training attract interested residents. When applicants visit University of California, San Francisco to interview for a position in our residency, we discuss the integrated nature of the family planning rotation, the department's commitment to service, training, and research in reproductive health, and the process by which one can opt out of training, including the necessary schedule changes. Since 1998 1 resident has restricted training to earlier gestations and none have opted out.
In the PGY-3 year residents are making a transition from close supervision to autonomy in their clinical decision-making, which may developmentally prime them to value the responsibility of a precepted but highly independent practice in abortion care. Individual faculty–resident precepting is rare during most rotations in our residency program. The apprenticeship model of the family planning rotation provides direct one-on-one supervision with the feedback and repetition necessary to optimize procedural learning.14 Other rotations exposing resident teams to a variety of procedures as well as clinic-based care may lack the repetition and/or feedback.
The high satisfaction rating of the rotation relative to other educational experiences is noteworthy, given the context of the PGY-3 year. During that year the residents train at community hospitals where they have the opportunity to do a high volume of gynecologic surgery with significant autonomy. The elective rotation is free of clinical and call duties, allowing residents to travel to extramural and often international sites for research or clinical experiences. That our residents value the abortion rotation more than the others adds validity to our conclusion that aspects of the rotation itself are responsible. These include its placement in an academic environment that accepts abortion, in which the majority of faculty participate in the abortion service, and that the clinic itself is run by supportive, highly skilled staff. Furthermore, it is noteworthy that residents so highly value the training given that the clinic's patients include some of the most psychologically and medically challenging of their residency.
Graduates indicate that they apply many of the skills learned during their family planning rotation to other clinical situations. Eleven of the graduates spontaneously mentioned that they currently provide elective abortions. Others who did not volunteer whether they provide abortions also rated the rotation highly and indicated that the skills learned during the rotation could be applied to their current gynecologic practice. In a previous study of graduates of University of California, San Francisco and 4 other residency programs from 1989–1998, 70% of University of California, San Francisco graduates and 58% of all respondents reported providing elective abortions at some point since residency (University of California, San Francisco data not published separately.).15 Other studies show that access to abortion training in residency makes it more likely that obstetrics and gynecology physicians will provide abortion, even while controlling for abortion attitudes and intention to provide before residency.16–18
There is no specific didactic program within the rotation that focuses on the ethical or political issues involved in abortion work, except for a small amount of information about public health in the required readings. Residents are encouraged to discuss any personal concerns about abortion with the attendings and the director as they arise. Within our department approximately 1 grand rounds lecturer per year touches on political aspects of abortion, and there are a variety of seminars related to abortion and contraception within the broader university. During the rotation residents gain insight into the reasons women choose to have abortions, as well as the lengths to which they will go to obtain our services, sometimes traveling hundreds of miles from rural areas of California. In addition, there are opportunities for interested residents to do international work in countries in which abortion is illegal to experience the public health implications firsthand.
The strengths of our study include the use of data provided by residents over 5 academic years and the addition of data obtained from residency graduates who can better evaluate the relevance of their training in abortion to their current practice. The response rates were extremely high for all of our evaluation data, minimizing the potential impact of differential response rates by only the most supportive residents and former residents.
The anonymous, mailed follow-up survey was focused on abortion training and was conducted by investigators the residents know to be particularly interested in abortion training, raising the possibility of response bias and Hawthorne effects. In contrast, the anonymous, annual evaluations of all rotations are not biased toward any individual rotation. The agreement between residency graduates and residents under our supervision confirm the convergent validity of these findings. Finally, the cross-sectional study design does not permit us to attribute the rotation's perceived value to any individual or subset of aspects of the rotation itself. To do so we would need to conduct a trial comparing the aspects we hypothesize to be the most important, including the balance of autonomy and supervision and a positive work environment.
University of California, San Francisco as an institution and the Department of Obstetrics, Gynecology and Reproductive Sciences offer a supportive environment for abortion training. All obstetrics and gynecology faculty at San Francisco General Hospital do abortions, and many of the faculty are nationally and internationally recognized for their family planning work. While these resources are not easily duplicated at other residency programs, many lessons can be learned from our model. In terms of training aspects, the rotation is one in which the residents have a highly focused task set, including much repetition, and supervised progression in responsibilities. This can be translated into many areas of skill acquisition in obstetrics and gynecology and also to a less intensive abortion training program. A similarly supervised training method can be devised for programs which offer only first-trimester abortions. Although our training program involves more than a dozen trained attendings, its success hinges on the dedication of the medical director to provide continuity in training and evaluation. Finally, regarding surgical volume, we estimate that our residents are adequately trained in first-trimester procedures after approximately 40 procedures, which can be achieved in a rotation that incorporates abortion training 1 day per week for 4 to 8 weeks, depending on patient volume.
In conclusion, a comprehensive, integrated rotation in family planning can be highly satisfying during residency and relevant for subsequent clinical practice. Understanding the reasons for the rotation's success can help other residency programs develop educational experiences of similar value. As obstetrics and gynecology residency programs develop opportunities for abortion training to comply with the requirements of the Residency Review Committee for Obstetrics and Gynecology, the outpatient service at the San Francisco General Hospital may be a useful model.
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