Safe, legal abortion is an essential part of health care. Nearly one-quarter of American women will have an abortion in their lifetimes, despite barriers such as closed clinics, lack of insurance coverage, and various forms of stigma. Providing abortion care also has its barriers, due in large part to the anti-abortion activism that distorts this basic health service. But there are hidden contributors as well, which pose more insidious risks to abortion access: Aspiring doctors are learning harmful ways of discussing abortion and their medical schools are doing little to stop it.

To understand this, several colleagues and I analyzed interviews with 74 students in their final year of medical school who were planning to specialize in obstetrics and gynecology. We reported our findings in the journal Social Science & Medicine.

During lengthy interviews, more than half of the students used the term “elective” to differentiate some abortions from others. This piqued our interest because “elective” has a very specific — and confusing — medical meaning. Within medicine, “elective” describes procedures that can be scheduled in the future, and differentiates them from procedures that must be performed immediately. “Elective” does not imply anything about the value or importance of the procedure; indeed, a lifesaving surgery should be called elective if it doesn’t need to be done today. Using this framework, the vast majority of abortions performed in the United States are appropriately categorized as elective.

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Outside of medicine, however, “elective” means voluntary or optional.

Almost all of the students who used the term “elective” in their interviews misunderstood the difference, and used its non-medical meaning. They inappropriately juxtaposed “elective” and “medically necessary,” and used “elective” to describe abortions they considered to be sought for “social” or “convenience reasons.” The few who mentioned abortion after rape and incest were careful to clarify that those were unique social situations where abortions were not to be considered elective. In our interviews, students used “elective” to mark abortions sought for what they considered less-acceptable reasons or by what they considered less-acceptable people. Many students conveyed this bias by expressing that they would likely refuse to provide “elective” abortions in their future practice despite being willing to provide others.

Not a single student questioned their non-medical use of the term, and many described this use of “elective” being reinforced by their educational environments. Some noted how teachers ignored or glossed over the topic of elective abortion; others clarified that unless students went to certain clinics on certain days, they would only be exposed to what they were told were medically necessary abortions or, more commonly, no abortions at all.

One student related a story of seeing a patient transferred to an academic center from a freestanding abortion clinic for medical complications of pregnancy, but then having the patient be unable to receive care because no available faculty members would participate in an abortion that was considered elective.

Categorizing any abortion as unnecessary or unacceptable, especially when couched in co-opted medical jargon, is egregiously unprofessional. It places patients at risk of inferior treatment, and is also squarely at odds with standards set by the American College of Obstetricians and Gynecologists and other specialties that provide reproductive health care. But with some medical schools providing no formal education about abortion and the majority offering a single lecture or a non-required rotation, medical students’ hazy or incorrect knowledge about abortion care should not be a surprise.

In a vacuum, medical students get their knowledge from informal systems sometimes referred to as the hidden curriculum. As we describe in our report, misuse of the term “elective” exposes a hidden curriculum for abortion care that teaches students to make medically meaningless distinctions between abortions, to make inappropriate refusals of care, and to judge patients.

This hidden curriculum may make abortion more difficult to access, but it could also create a generation of physicians who are unprepared to even talk with their patients about abortion. At a time when physicians should be speaking out against threats to essential health care services, our research suggests that future obstetricians and gynecologists are ill-equipped to do so. As medical schools ignore the topic, medical trainees learn incorrect information through informal means, and ultimately abortion care becomes more stigmatized and more critically threatened.

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Recent calls to train more abortion providers are timely, but they will founder without sustained institutional support. Medical schools must immediately set formal standards for how to discuss abortion with patients and with colleagues. They must then expand the role of reproductive health experts in developing required classroom and clinical experiences around abortion. And when students’ beliefs require they have no direct role in abortion care, schools must teach them how to mitigate any resulting delays or lapses in care for their patients, and to frame their refusals in a way that does not magnify abortion stigma.

Medical schools have a responsibility to ensure that future physicians appreciate the health impacts of safe and legal abortion care, regardless of political efforts to change its legality. Their future patients’ lives depend on it.

Benjamin E.Y. Smith, M.D., is a faculty member at the Fort Collins Family Medicine Residency at Poudre Valley Hospital.

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  • I was waiting for the portion of the article in which you propose an alternative term instead of “elective”. I think it is unfair to question medical students about terms they were taught in the curriculum. You should question the faculty which teach these courses instead.

  • I wholeheartedly agree with the author. These medical services are essential, and a thorough understanding of the guidelines should be required in the curriculum. As a pharmacist, I also take exception to policy of the State Boards of Pharmacy to allow a pharmacist to refuse to dispense medication prescribed for abortion and related procedures. These procedures are fully legal and should be available to any woman who desires them.

  • I find it ironic that the author suggests that “their future patients lives depend” on providing abortion services when an abortion is terminating the life of the fetus. An abortion terminates that future life!

    • The role of a physician is to provide safe care. There is no reality in pretending a physician should value a “potential life” over improving an actual one. Many women choosing abortion already have a child or several. These women know exactly what it takes to carry through a pregnancy, and what it takes to raise a child. You don’t get to butt with your naive equivalencies just because you have a belief in the moral superiority of some “potential life” over existing lives. No, not unless you’ll take the aborted embryos or fetuses and raise those cells to reach a state of actual life, maybe in your own body, please. Oh, and then raise it well for another 18-22 years.

    • Jennae, Adoption of children, through discarded frozen embryos is a real thing and we can be against rape and call it out as an immoral abuse, without running a woman’s shelter.

    • I find it ironic that a person who claims they are pro life, cheered on cost cutting at schools and state agencies. I also find it ironic that anyone educated would say such a thing. Back in the good old days when abortion was illegal a lot of women died in back alley abortions. It was only legalized to prevent these brutal senseless deaths. Again i find it ironic that physicians refuse to do D and Cs on women whose fetus has died already, exposing that woman to pain, infection and possible death. The children these woman already have suffer too, left motherless after the mother dies after an illegal abortion.
      Right to Lifers in my state cut funding to food stamps, schools and social workers. A nine year old boy was locked in a dog kennel and tortured to death. Child Protective Services was “Saving money” by not keeping track of any of these children. There have been a lot of horrific child abuse cases, all of them could have been prevented it these Right To Lifers actually cared about the children already born.
      I think is ironic that the same people who claim they are “Right to Life” are silent when it comes to those poor children at our Border, or the children hungry or dying right now in Yemen.
      Here is what happens when religious zealots and hypocrites are in charge of women’s reproductive health. These babies were born and left to starve and die of disease. https://www.theglobeandmail.com/news/world/tuam-ireland-house-of-tears/article36431106/
      We have not heard of any Physicians speaking out about the Infant and Maternal Death Rate here in the US either. Our media does not cover the dangers of childbirth, and how Abortion is so much safer. The facts have been effectively censored. An ethical physician would be asking why, instead of posting nasty comments on here.

      Shame on you!

  • Big people and governments BELIEVING they can attain benefits by spilling the blood of little ones in the womb is demonic, a belief system similar to that of an ancient culture committing human sacrifice to attain better crops of corn. If a doctor is doing such things or connected in some way, I would never trust them to work on me or anyone in my family.

  • This really should be a red flag. The Bias against women in healthcare is already well documented. One in six hospital beds in the US is in a religious hospital anyway. Apparently leaving a dead fetus to rot inside a woman’s uterus, is standard operating procedure. The media does not cover the number of mishaps and deaths associated with giving birth, in order to stoke fears about abortion. The rising death rates of Mothers and Infants in US Hospitals might give us a clue to how bad this really is. If anyone wants to promote anti Abortion rhetoric, perhaps they should inform themselves on how woman died in the good old days.

    • This isn’t the good old days. Abortion is the murder of children to turn women into pornography and emasculate men, feigning the removal of man duty to protect his children from conception to death.

    • B Delaney,
      I’m saying the first lady being made into pornography was about what men want, just like abortion is about what men want. Wicked men will keep abortion around for the same reason they keep pornography around.

      As for the surviving children being made fatherless and women being given power to separate children from their fathers, that is where another form of societal self destruction comes in. These policies separate the most vulnerable(children and women) from the basic protections of a father.
      Human rights cease to exist, when you remove the teeth from the men who have the power/ability to protect. Human rights do not exist without duty and enforcers of such duties.
      “God never calls the orphan motherless, stateless or churchless. He always calls them fatherless. God has appointed men to protect and provide for women and children. Abortion IS a man’s issue!” quote from Rusty Thomas

      Sorry for my poor writing skills. Thanks for trying to see my perspective.

    • Jeriah: “Abortion IS a man’s issue!”

      You are simply wrong. “The ENTIRE biological/gestational male contribution to an offspring is ONE microscopic set of the DNA comprising 23 chromosomes. EVERYTHING that happens thereafter obstetrically is solely that the the effort and risk borne by the woman. Men have no standing. Neither do non-pregnant WOMEN where it comes to the 14th Amendment Equal Protection of a woman who IS gestating.”

      – Quote by me. Backed by science.

    • Bobby, I agree with your analysis of the current belief systems in power and that is exactly why men get to pretend it’s none of their responsibility. They use women with impunity. Abortion makes women cheap, accessible, and exchangeable with no commitments, no responsibilities, and no bother to be considerate of her physiology.

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