Proceedings of a Workshop—in Brief

Physician Perspectives and Workforce Implications Following the Repeal of Roe v. Wade

Proceedings of a Workshop—in Brief

In June 2022, the U.S. Supreme Court’s Dobbs v. Jackson Women’s Health Organization¹ ruling overturned the January 1973 Roe v. Wade² decision, which ruled state law banning abortion unconstitutional. The Dobbs decision resulted in new limitations on the provision of reproductive health care. New legal restrictions have impacted clinicians across the nation, including obstetrician gynecologists (OB/GYNs), maternal-fetal medicine specialists, family physicians, emergency medicine specialists, oncologists, and more.

On May 25, 2023, the National Academies of Sciences, Engineering, and Medicine Standing Committee on Reproductive Health, Equity, and Society held a virtual public workshop to consider the current impacts of the Dobbs ruling on practicing physicians and potential workforce implications. During the workshop, four physicians shared their experiences navigating changes to laws related to abortion care while practicing in Arizona, Georgia, Ohio, and Tennessee, including effects on their work with their patients, colleagues, and institutions. The workshop also featured perspectives of national-level implications for the future of the physician workforce and closed with a discussion session. This workshop was the first in the “After Roe” Webinar Series organized by the Standing Committee on Reproductive Health, Equity, and Society.³ The series is designed to examine society-wide impacts of limits on access to reproductive health care in order to elevate challenges and strategies to protect health and well-being.

This Proceedings of a Workshop—in Brief is a high-level summary of the topics and discussions that occurred during the workshop. It should not be viewed as providing consensus conclusions or recommendations of the National Academies.

CHANGES IN EXPERIENCES PRACTICING SINCE OVERTURN OF ROE V. WADE

Victor J. Dzau, president of the National Academy of Medicine, opened the virtual workshop by reflecting on the implications for patients’ access to care because of the Dobbs decision. He explained that the decision has made accessing high-quality reproductive health care more difficult in the United States and that the effects were inequitable, with “particular risks for women of

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color, women from low-income backgrounds, and those in rural areas.”

Claire Brindis, workshop moderator, began by acknowledging that some physicians affiliated with clinics that provide abortion care are feeling concerns for their personal safety and well-being, and that the physicians sharing their experiences during the webinar practice in different states where different restrictions on abortion access are in place.

The speakers began by sharing how state-level restrictions to access to abortion care have affected their subsequent experiences practicing medicine in their respective states. Several speakers described uncertainty navigating the new restrictions and finding that the legislative language was unclear and not inclusive of all possible medical circumstances.

Ivana Thompson (OB/GYN, University of Washington School of Medicine)—who currently practices in Seattle, Washington, but explained that she would be providing perspectives from her time at an academic institution in Tennessee—described how, following the Dobbs ruling, she was unsure how to counsel patients because the implications for medical practice in Tennessee were unclear as was the timeline for when changes would go into effect. Possible legal risks and penalties were also unclear, adding further complexity and uncertainty.

David Hackney (OB/GYN & Maternal-Fetal Medicine Specialist, University Hospitals Cleveland Medical Center and Case Western Reserve University) explained that Ohio Senate Bill 23 prohibiting abortion after fetal cardiac activity is detected—which is usually about 6 weeks from the last menstrual period—was enforced in Ohio for 3 months but is no longer in effect. He added that an abortion access measure will be on the ballot in the state in 2023.

Atsuko Koyama (pediatrician, University of Arizona College of Medicine) described how, in the weeks immediately after the Dobbs ruling, “abortion stopped happening for several weeks in the state of Arizona” because “vague laws” made it difficult to navigate what was legal and not legal. The state ultimately enacted a law dating from prior to Arizona’s statehood that prohibits physicians from providing abortions after 15 weeks except in cases of medical emergency. Koyama added that, due to a small number of abortion providers in Arizona, it is not easy to spread information about navigating the restrictions.

Nisha Verma (OB/GYN, Emory University) shared concerns that the physician shortage in Georgia will become worse. She added that, although there are exceptions to the state’s law prohibiting abortion after fetal cardiac activity is detected, which is usually about 6 weeks from the last menstrual period, navigating them often creates more confusion and these exceptions do not necessarily align with what is happening “on the ground.” Verma stated that the exceptions do not take into account all complexities inherent in each individual case and, as a result, many physicians feel concern about caring for pregnant people.

IMPACTS ON FIELDS BEYOND OBSTETRICS AND GYNECOLOGY

Brindis noted that much of the attention surrounding the impacts of the Dobbs decision has been focused on the obstetrics and gynecology fields, but that many of the changes in state laws related to abortion care and the challenges navigating those changes are also relevant to other areas of medicine—cardiology, for example—and asked the speakers whether they have heard from providers in other fields about the issue.

Many speakers shared that physicians in other specialties have reached out to them. Hackney said that he receives questions about the impacts of the Dobbs decision from colleagues in other fields “all the time” and that there is an increasing recognition of the interconnection between abortion access and different types of care, suggesting that it is not feasible to silo abortion care or pregnant patients. Thompson agreed that it is important to talk about how abortion care is essential and has impacts across specialties. The impacts of the Dobbs ruling also reach into adolescent medicine, said Koyama. She described how there were barriers to minors accessing reproductive care even before the ruling, and now this group is even more negatively impacted. Verma added

that she was hearing of cases around the country in which pregnant people were unable to get treatments or medications for care unrelated to their pregnancy, including autoimmune disorders or “women being delayed in getting cancer care because they might be pregnant.”

HOW MEDICAL INSTITUTIONS ARE RESPONDING

The speakers explained the different ways their and other institutions are responding and addressing emerging challenges.

Verma explained that her institution in Georgia created a taskforce to help address the confusion and uncertainty surrounding the changing landscape of restrictions in Georgia. Verma said that clinicians at the institution can go to the taskforce to have a case reviewed and receive guidance about how—or if—care can be provided. She added that it is important to ensure that laws are not being interpreted more strictly than is appropriate.

Thompson agreed with Verma’s point, describing leaning on a similar interdisciplinary taskforce and legal experts in Tennessee to provide care that was in line with and not more restrictive than the laws at the time. Thompson went on to explain that the need for clinicians to focus time on gaining legal expertise was sometimes frustrating.

Hackney raised the issue of communication, noting a “chilling effect” on physicians speaking out about challenges. He explained that this was not always necessarily due to formal institutional policies, but also informal power structures.

Koyama shared that some institutions are giving their physicians guidance about what information they can provide to patients about abortion care. She noted her appreciation that President Biden directed the Department of Health and Human Services to reaffirm that the Emergency Medical Treatment and Labor Act (EMTALA) requires emergency medicine departments to stabilize patients even if the treatment includes abortion care. However, Koyama explained that EMTALA does not stand in Texas due to a lawsuit, which means many emergency medicine physicians in the state are “caught in a bind” because they may have a patient for whom they cannot legally provide care. She explained that despite EMTALA requiring emergency medicine physicians to provide emergency and stabilizing care and despite there being OBs and Family Medicine physicians who are trained to perform abortions or reproductive healthcare to manage patients with ectopic or pregnancy related emergencies, due to confusing laws or restrictive laws in some states, patient lives and healthcare have been compromised.

Thompson added that communication between institutions could also create challenges. She shared that, in Tennessee, a lack of communication between institutions about how they were interpreting abortion care laws created inconsistencies in treatment around the state.

Taskforce Operations

Verma and Thompson expanded on the operations of the respective taskforces they described earlier in the discussion and provided insight into challenges they have experienced. Verma described a recent difficult case in which a patient was carrying a fetus with a condition called holoprosencephaly, meaning that the “brain hadn’t formed properly.” Verma could have provided abortion care pre-Dobbs, but, under current restrictions, she instead needed to create a case summary to present to the taskforce and wait for input. The taskforce ultimately recommended that an abortion should not be provided under Georgia law because the fetus, once born, could potentially live for a few months and it was unclear if this fit criteria for medically futile pregnancy under the law, at which point Verma informed the patient. Verma explained that the need for taking cases to a taskforce to attempt to interpret what medical care can be provided under state law poses a significant logistical and time burden.

Thompson emphasized that the taskforce, known as a committee at her Tennessee institution, was actually in place before the Dobbs ruling, so its operations had been refined over time. The committee created a framework based on their understanding of the limitations in the

state to make quick decisions about next steps in care, typically within 24 hours. Despite this, Thompson emphasized the logistical challenge of summarizing and presenting the case to the committee, keeping the patient informed, waiting for a decision, and then coordinating care. Still, Thompson noted the value of having a committee review cases because it offered a feeling of safety for physicians providing abortion care and reduced the likelihood of pushback from other clinicians.

Verma added that there is not a standard way of interpreting state laws and their exceptions. She noted that the laws are not written by medical experts and do not use medical terminology.

NATIONAL TRENDS AND IMPLICATIONS

Jack Resneck, Jr. (American Medical Association) provided an overview of the trends and potential effects of the Dobbs ruling on the physician workforce. Resneck said that state laws restricting access to abortion care have put physicians in an “impossible position” because they are attempting to provide care and comply with often vague laws. He stated that the laws intrude on the physician-patient relationship and have the heaviest impact on marginalized and minoritized communities.

Resneck said that the fallout from the ruling is not what the health field needed at a time when clinician burnout is high. “I’ve seen data in the last several months that 1 in 5 doctors say they will leave practice in the next 2 years. This is at a time where patients are already struggling to get access to care with long wait times,” he said. Resneck described some downstream consequences on the physician workforce, noting that there have been news reports that two hospitals in Idaho that provide care rural communities are closing their labor and delivery units. He explained that medical students are making decisions about where they choose to train and practice on the basis of states’ legal environments, adding that programs in states with restrictive abortion access laws saw a decrease in residency applicants in 2023. Resneck said this means that patients in states with restrictive abortion access laws may ultimately experience interference in care and physician shortages.

The potential for interference in access to prescription medication is also an issue, Resneck said, noting that access to the drug mifepristone—which is approved by the U.S. Food and Drug Administration as part of two-drug regimen for abortion—is the subject of a federal court case. He elaborated that this kind of interference in access to tested and approved treatment options could affect patient access to many medications, including those unrelated to abortion care, down the road.

DISCUSSION

To close the workshop, speakers responded to questions posed by audience members. Speakers were asked to comment on exceptions to restrictive laws—e.g., allowance of abortion in cases of life-threatening illness—and how they may often be viewed by physicians. Verma responded that any kind of legislative interference affects the ability to provide timely care, explaining that she may not be allowed to provide care in certain situations because the patient’s condition is not considered serious enough, but that it can develop into a more complicated and dangerous situation. Thompson added that the exceptions and associated requirements can lead to an inappropriate value judgment about who deserves access to care and who does not. She described caring for a patient in Tennessee “who was unable to speak, who was assaulted by their brother, and was 20 weeks pregnant. I was able to provide them care pre-Dobbs; I would not be able to provide that same person care now in that state post-Dobbs.”

Touching on the future of the physician workforce, the speakers were asked to reflect on how their mentoring strategies have changed since the Dobbs ruling. Several of the speakers emphasized fostering trust in the physician-patient relationship. Koyama described giving a lecture to medical residents about the importance of maintaining the trust that they have with their patients. Hackney added that his understanding of mentoring is now much broader and that he has received questions from trainees about engaging with the media. In closing, Resneck offered that he is optimistic about the future because of passionate physicians and medical students.

DISCLAIMER This Proceedings of a Workshop—in Brief has been prepared by Jamie Durana as a factual summary of what occurred at the meeting. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

COMMITTEE MEMBERS Claire Brindis (Chair), University of California, San Francisco; Andreia Alexander, Indiana University School of Medicine; Elizabeth Ananat, Barnard College, Columbia University; Corale L. Brierley, Brierley Consultancy, LLC; Ned Calonge, Colorado School of Public Health; Judy Chang, University of Pittsburgh School of Medicine; Ellen Wright Clayton, Vanderbilt University; Cat Dymond, Atlanta Birth Center; Michelle Bratcher Goodwin, Georgetown University Law Center; Barbara Grosz, Harvard University; Vincent Guilamo-Ramos, Duke University School of Nursing; Lisa Harris, University of Michigan; Paula Johnson, Wellesley College; Justin R. Lappen, Case Western Reserve University School of Medicine; Monica McLemore, University of Washington Schools of Nursing and Public Health; Robert Moffitt, Johns Hopkins University; Rebecca R. Richards-Kortum, Rice University; Sara Rosenbaum, George Washington University; Yvette Roubideaux, Colorado School of Public Health; Alina Salganicoff, KFF; Susan Scrimshaw, University of Illinois at Chicago; LeKara Simmons, AMAZE; Melissa Simon, Northwestern University; Lisa Simpson, AcademyHealth; Tracy A Weitz, American University; Katherine L Wisner, Northwestern University.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Nisha Verma, Emory University; Anna Legreid Dopp, American Society of Health System Pharmacists (ASHP); and Danielle Turnipseed, Association of American Medical Colleges (AAMC). Leslie Sim, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

STAFF Julie Pavlin, Senior Board Director; Ashley Bear, Board Director; Natacha Blain, Senior Board Director; Priyanka Nalamada, Program Officer; Laura Destefano, Director of Strategic Communications & Engagement; Melissa Laitner, Senior Program Officer, Special Assistant to the President; Adaeze Okoroajuzie, Senior Program Assistant; Kavita Shah Arora, National Academy of Medicine Fellow.

SPONSOR This workshop was supported by the National Academy of Sciences W. K. Kellogg Foundation Fund.

For additional information regarding the workshop, visit http://www.nationalacademies.org/our-work/standing-committee-on-reproductive-health-equity-and-society.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2023. Physician perspectives and workforce implications following the repeal of Roe v. Wade: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/27211.

Health and Medicine Division Copyright 2023 by the National Academy of Sciences. All rights reserved.