Abortion 101

After decades of being ignored by medical schools, abortion is back by student demand.

Phoenix Ho (far right) and other Medical Students - for Choice members with a statue of Hippocrates. - Jacqueline  Marino
Phoenix Ho (far right) and other Medical Students for Choice members with a statue of Hippocrates.
One week before finals, two medical students are cutting class to talk about abortion. Their knowledge of the subject is impressive, considering it won't be on their exams. In fact, the extent to which abortion has been covered in their coursework can be summed up in three sentences.

"This is a new drug," says Binit Shah, quoting his pharmacology instructor. "It's called mifepristone. It's a glucocorticoid antagonist."

That was it, the students say. There was no discussion about what the drug, also known as RU486, means to women's reproductive health. No mention of how it should be administered. No discussion of how it altered one of the most controversial medical ethics debates in America.

Abortion's conspicuous absence from the curriculum at the Northeastern Ohio Universities College of Medicine (NEOUCOM) isn't unusual. With the legalization of abortion in 1973, its teaching became more politicized and faded from medical school curricula nationwide. The Alan Guttmacher Institute, which researches reproductive health, says 43 percent of women will have an abortion by age 45. Still, the majority of medical schools simply ignore the subject.

"We learn about all these crazy diseases you'll see once in your life, yet we're not learning about a procedure that half the women in the country are at least going to want to know about," says Amy, a student who offers only her first name.

Patrick Crowley, NEOUCOM's director of public relations, says the school won't comment on why abortion isn't taught, but he doesn't think it's ever been part of the curriculum. That may change if Amy and other students get their way. They want abortion discussed in lectures. They want to learn about it in their third-year obstetrics and gynecology rotation. They want it incorporated into a family planning elective.

They're members of Medical Students for Choice, a 7,000-member national movement credited with bringing abortion education to one-third of U.S. medical schools. And they want NEOUCOM to get with the program.

At first glance, the school seems an unlikely hotbed of activism. Situated 18 miles east of Akron, it's the only reason besides an empty gas tank to exit Route 76 in Rootstown. All brick and windows and sprawling parking lot, the school draws students for a six-year accelerated program from Kent State, Youngstown State, and the University of Akron. Yet there are few signs of student life, save for Phoenix Ho, the president of Medical Students for Choice. His backpack is heavy with books and activist pins, making him look as though he belongs in Berkeley rather than the Ohio boondocks.

But when one takes into account NEOUCOM's mission -- to train family-care physicians -- the activism doesn't seem so out of place. Many women's health advocates want abortion to become a regular part of family medicine. If abortions were performed in doctors' offices instead of in freestanding clinics, the procedure would be somewhat destigmatized. Patients wouldn't have to pass through throngs of protesters, and abortion providers wouldn't feel so ostracized.

Ho helped start the MSFC chapter last year. Soon, students set up an informational bulletin board and were discussing reproductive health in the hallways. Twenty-nine students, including one-fifth of the second-year class, are members.

"The purpose of the group has always been getting discussion out there," Ho says. "Even if you're not going to be an abortion provider, or even if you're not going to be a pro-choice physician, you still need to know the issue."

A five-page, single-spaced e-mail message chronicles the chapter's activities and accomplishments. Members set up a shadowing program at an Akron clinic, and they have developed a month-long family planning elective that would include a week of abortion training for fourth-year students. But the subject still hasn't made the official curriculum. Crowley says the school is considering the students' request. Calls to John D. Engel, vice president of academic affairs, were diverted to the press office.

NEOUCOM's reasons for ignoring the procedure range from the pragmatic to the political.

"It's a can of worms," says one professor, who asked to remain nameless. "It's nothing more complicated than that. We're a state institution funded by tax dollars, and to address something like that in a roomful of people, it's probably one of the most incendiary topics you can bring up."

Of course, learning about abortion is one thing. Actually performing one is entirely different. Of the four students who eventually join Ho's visit with a reporter, only two say they might perform abortions. Amy wants to become a gynecologist; Ho, a pediatrician.

For these students, the ethical question isn't How could you perform abortions? It's How could you not? They believe women will always find a way to abort their pregnancies, and as future physicians, it is their responsibility to help them do it safely. "If abortion was illegal, then millions of women would die from illegal abortions," says Ho.

He observed the process while shadowing a doctor. Once, he got to hold the ultrasound. He was moved by the doctor's compassion and the emotion in the room. "You can see the struggle on the faces of the patients. To think they'd have to go through something like that in a back alley somewhere is terrifying."

Ho worries, however, that performing abortions might not jibe with his goal of becoming a pediatrician. Even though many teenagers get abortions, the procedure is "against the culture of pediatrics." He wants to be a doctor first and an abortion provider second. If being a provider posed a significant threat to his career, he might not do it.

In the ivory tower of academia, students feel fairly safe -- at least physically. But they do fear career damage. "For me, it's sort of like, do I want to say anything or not?" says Matt Chase, a future surgeon. "Some of the big boys might keep me out because they know my views."

Most physicians choose career safety over the risks of becoming a provider. There are so few providers in Ohio that 91 percent of women must travel outside their county to terminate a pregnancy, according to the National Abortion and Reproductive Rights Action League (NARAL).

In fact, many advocates believe the biggest threat to abortion is not the legislature or the Supreme Court; it's the shortage of doctors willing to do the job. In Ohio, the number of providers fell from 45 to 37 between 1992 and 1996, says Mary Brigid, executive director of NARAL Ohio. A majority are older than 50. When they began practicing medicine, it was still common to see women suffering from raging infections and other ill effects of back-alley abortions. After Roe v. Wade, however, militant groups made abortion more dangerous for doctors than patients. The ranks began to thin, and the lack of medical school instruction only exacerbated the problem.

What drove one generation away, however, has emboldened the next. MSFC's first chapter was started in 1993 on the University of California's San Francisco campus -- spurred, ironically, by a threatening mailing titled "Bottomfeeder," meant to scare future physicians away from performing abortions. By then, abortion training had been on the decline for two decades. In 1978, 26 percent of ob/gyn residency programs required residents to perform first-trimester abortions. By 1995, only 12 percent required routine training. Those findings, coupled with a push by advocacy groups including MSFC, prompted the Accreditation Council for Graduate Medical Education to institute new guidelines requiring that residency programs provide access to training.

It worked. Last November, the National Abortion Federation noted that 46 percent of schools responding to a 1998 survey said they now offered first-trimester abortion training. Even more notable is the increase in schools offering second-trimester training -- up from 7 percent in 1991-'92 to 44 percent in 1998.

Even though abortion has been legal longer than students from NEOUCOM's pro-choice group have been alive, they don't take it for granted, perhaps because violence against providers has also been a constant. While these students were in high school, abortion workers were murdered in Boston and Florida. In 1998, as they prepared to enter medical school, clinics were bombed in Birmingham and Atlanta, and a New York gynecologist was assassinated in his kitchen.

Because of the inherent danger, some of the students' strongest supporters are puzzled by their fearlessness. One NEOUCOM faculty member even started a research project examining, among other things, why some students are so avidly pro-choice.

Binit Shah, a future psychiatrist who grew up in Mentor, says the answer is as old as the Hippocratic oath. "The issue of pro-choice goes to the larger issue of what it means to me to be a doctor. I don't want religious organizations or political organizations or anyone else imposing on my right to do what's best for my patients."