Integrating abortion training into family medicine residency programs.

Abstract

Family physicians provide many office-based procedures in primary care settings. While first-trimester abortion is a procedure appropriate for and performed by family physicians, few residency programs offer routine training in this skill. This study explored the experience of residency programs that have initiated or are in the process of initiating required abortion training.
Faculty members responsible for abortion training curricula in identified programs completed questionnaires and semi-structured interviews.
Faculty members from nine programs with required training and seven programs interested in initiating this training were included in the study. Factors that assisted in curriculum development included the support of family medicine and obstetrician-gynecologist faculty. Commonly encountered challenges included the need for dedicated resources, inter-specialty conflict, and limited access to training sites.
Family medicine programs can be successful at developing required abortion training. Collaboration with colleagues inside and outside the family medicine department and with receptive training sites will benefit programs interested in such.

Full text

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337Vol. 39, No. 5
Residency Education
Providing comprehensive care across the life cycle is a
core value in family medicine. The benefits of family
physicians providing a broad range of services in the
primary care setting include continuity and coordina-
tion of care, access for patients, enhanced physician-
patient relationships, and patient satisfaction.1-4 One
element of comprehensive care is office-based proce-
dures, such as colposcopy, vasectomy, and endoscopy
procedures. Both research and training guidelines have
examined and encouraged the integration of these skills
into family medicine residency training.5-8
Early abortion is another skill suited to the strengths
of family physicians. The non-procedural aspects of
abortion care, including counseling and the ability to
provide contraceptive information, are standard in the
practice of family medicine. With respect to aspiration
abortion, procedures such as endometrial biopsies and
IUD insertions are commonly performed by family
physicians,9-12 and limited additional training is needed
to perform first-trimester abortions for those proficient
in these skills. Aspiration abortion is recognized as
within the scope of practice for family physicians,
with terminations up to 10 weeks gestation listed as
an advanced skill by the American Academy of Family
Physicians.12 Medication abortion using mifepristone
and misoprostol is also well documented to be in the
scope of practice for family physicians.13,14
In contrast to the procedures mentioned above,
however, aspiration and medication abortion training
in family medicine residency programs has received
limited attention, and few programs offer routine train-
ing (with opt-out provisions and alternative curricula for
those residents who do not wish to participate). A 2003
survey by the Society of Teachers of Family Medicine
(STFM) Group on Abortion Training and Access found
that only 11 of the 480 residency programs in existence
Integrating Abortion Training Into Family
Medicine Residency Programs
Christine Dehlendorf, MD; Dalia Brahmi, MD; David Engel, MD;
Kevin Grumbach, MD; Carole Joffe, PhD; Marji Gold, MD
From the Department of Family and Community Medicine, University of
California, San Francisco (Drs Dehlendorf, Engel, Grumbach, and Joffe);
and Department of Family and Social Medicine, Montefiore Medical Center,
Bronx, NY (Drs Brahmi and Gold). Dr Engel is now with the Department
of Family Medicine, University of Washington.
Background and Objectives: Family physicians provide many office-based procedures in primary
care settings. While first-trimester abortion is a procedure appropriate for and performed by fam-
ily physicians, few residency programs offer routine training in this skill. This study explored the
experience of residency programs that have initiated or are in the process of initiating required
abortion training. Methods: Faculty members responsible for abortion training curricula in identi-
fied programs completed questionnaires and semi-structured interviews. Results: Faculty members
from nine programs with required training and seven programs interested in initiating this training
were included in the study. Factors that assisted in curriculum development included the support of
family medicine and obstetrician-gynecologist faculty. Commonly encountered challenges included
the need for dedicated resources, inter-specialty conflict, and limited access to training sites.
Conclusions: Family medicine programs can be successful at developing required abortion training.
Collaboration with colleagues inside and outside the family medicine department and with receptive
training sites will benefit programs interested in such training.
(Fam Med 2007;39(5):337-42.)

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May 2007Family Medicine
at that time were willing to be identified as offering
abortion training as a routine part of the curriculum.15
This relative neglect of training is likely related to
several factors. First, procedural training in family
medicine residency programs generally presents a range
of challenges, including the availability of trained fac-
ulty, limited procedural volume, competition with other
specialties, and the need for expensive equipment.16 In
addition, training in abortion likely presents unique
challenges due to its politically charged nature. Little
research, however, has examined the specific experi-
ences of residency programs in abortion training.
Two recent articles have described the experience in
individual institutions in initiating training for medica-
tion abortion.17,18 Both programs described challenges
in the process, including resistance from staff, the need
for equipment such as ultrasound units, and the need
for surgical back-up. Ultimately, both programs were
successful in integrating medication abortions, and
their reports present strategies they used to overcome
challenges, including collaboration with other depart-
ments and values clarification sessions with staff. An-
other recent paper explored the experiences of seven
urban programs in establishing abortion training and
services in primary care residency clinics.19 Identified
themes included the importance of institutional support,
back-up agreements with obstetrician-gynecologists,
and ensuring patient volume.
While these initiatives are important first steps, the
aforementioned papers only describe the experience of
two individual programs and a local consortium and
only explore training within residency continuity clin-
ics. Our study was designed to identify the challenges
and facilitators to establishing routine abortion training
across a national sample of family medicine residency
programs, including programs that trained both within
and outside the residency continuity clinic. To explore
a diversity of experiences, we studied both programs
that have already been successful at implementing
abortion training and programs that are in the process
of developing this training.
Methods
This study was approved by the University of Cali-
fornia, San Francisco Committee on Human Research
and conducted between August 2004 and June 2005.
All of the 16 residency programs across the United
States believed to have a required abortion curriculum
(with an opt-out provision) and seven US programs in
the process of developing this training were contacted.
Eleven of the programs with required training had
previously been identified in a survey performed by
the STFM Group on Abortion Training and Access,15
and the other programs were identified by experts in
the field.
Program directors in these 23 programs were invited
to participate and asked to identify key faculty mem-
bers in this curricular area. Consent forms and e-mail
questionnaires were then sent to these faculty members.
The questionnaires took approximately 5–10 minutes to
complete and included general information on abortion
curricula, including the specialty of abortion trainers.
All identified faculty were then contacted for telephone
interviews. Interviews were semi-structured, lasted
20–60 minutes, and were tape-recorded with the con-
sent of the participant. The interview tapes were coded
with a confidential identifier and transcribed.
Our study sample ultimately consisted of 16 of the
23 programs contacted. Of the 16 programs initially
categorized as having required training, three pro-
grams either declined to participate or did not reply
to the initial mailing and multiple follow-up telephone
contacts, and four programs were determined to not
have required training, leaving nine for analysis. All
of the seven programs without required training agreed
to participate.
Qualitative analyses of the semi-structured inter-
views began with determination of the initial themes
by the two interviewers. A sample of interviews was
then coded by three researchers with NVIVO software,
using these themes as initial codes and developing ad-
ditional coding. This coding schema was discussed,
and consensus codes were developed. All interviews
were coded using the consensus codes. Data analysis
of the quantitative survey data was conducted using
Microsoft Excel and chi-square statistics.
Results
Characteristics of programs in the study sample are
described in Table 1. All programs had routine aspira-
tion abortion training, and eight of the nine had routine
medication abortion training. Three programs reported
having required abortion training for 2 years or less, and
six programs reported training for 5 to 20 years.
Curriculum Development in Programs
With Required Training
Several factors were noted to influence the process of
developing required abortion curricula (Table 2).
Intradepartmental Factors. All of the nine programs
with required training had faculty “champions” who
were influential in the development of the abortion
training curriculum. All were motivated by a com-
mitment to improve both the training of residents and
access to abortion services for patients. In addition to
spearheading curriculum development, they provided
abortion services and functioned as trainers. These key
faculty members also noted the importance of having
support from other family medicine colleagues:

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Residency Education
I think that the strong commitment of a couple faculty
members is critical . . . a couple of very strongly sup-
portive, committed people . . . who are actually willing
to put time, and energy . . . is real, real critical.
This intradepartmental faculty support was espe-
cially important because in several programs the faculty
champions encountered resistance from a minority of
other faculty members:
Other obstacles . . . were individual faculty members
who were resistant to the idea of providing abortion
care. We had by far, you know, support. It was only
really two people . . . But the chair was very support-
ive, and a number of other vocal advocates…really
helped us.
Residents were also influential in the process
of developing several programs. One faculty
member described their involvement:
They were involved from an advocacy perspec-
tive, saying they wanted this to happen, they
wanted the [abortion] training.
In programs where residents were less uni-
formly supportive, actively including residents
in curriculum development was noted to be
important in fostering their ownership of and
participation in the training:
I think if we had to do it all over again, we
would have included the residents earlier in
our discussions . . . eventually everything
worked out well, but if I were counseling any
residency about taking this on, it would be with
complete openness and transparency from the
very beginning.
The majority of respondents stressed the importance
of resources and time allocated to support the develop-
ment of abortion training. These resources, from the
department and/or outside organizations, were critical
to defray both initial and ongoing costs of training.
Initial costs included the purchasing of supplies for
providing abortions at residency continuity clinics, such
as ultrasound machines and manual vacuum aspirators,
and financial support of faculty time. Compensating
high-volume sites for the costs of providing training
was the most frequently mentioned ongoing cost.
All programs in the process of including abortion
training within residency continuity clinics noted that
clinic staff buy-in was extremely important. Involving
clinic staff in the process of developing the curriculum
helped to engage them. Faculty in programs where
members of the support staff were not initially support-
ive noted that workshops for “values clarification,” in
which participants explore their personal values about
abortion training, were helpful in improving support
and interest.
Interdepartmental/Hospital Factors. The major-
ity of faculty members stated that their relationship
with colleagues in the departments of obstetrics and
gynecology had facilitated their efforts to expand
abortion training, and several described this assistance
as critical to their success. Ways in which obstetrician-
gynecologists improved the process included assisting
with logistics, such as clinical protocols and medication
ordering, training family medicine faculty, offering
political support within the community and/or hospital,
and providing aspiration or surgical back-up.
Table 1
Characteristics of Programs
Characteristic
Programs With
Required Training
(n=9)
Programs Without
Required Training
(n=7)
Programs That
Declined to
Participate
(n=3)
Geographic area
West Coast
Southwest/Midwest
Northeast
Type of program
University based
Community based
Location
Rural
Urban
Suburban
Rural and urban
3
1
5
2
2
3
0
0
3
3
6
3
4
1
2
1
7
1
0
0
6
0
1
0
3
0
0
Table 2
Factors Affecting the Development
of Abortion Training
Intradepartmental factors
• Faculty champion
• Family medicine faculty
• Residents
• Dedicated resources
• Support staff
Interdepartmental/hospital factors
• Relationship with obstetrics-gynecology colleagues
• Credentialing
Non-institutional factors
• Accessible high volume abortion clinic for training
• Community reaction

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May 2007 Family Medicine
One faculty member’s relationship with obstetri-
cian-gynecologist colleagues was summarized in this
quote:
We really have to give credit completely to the fact
that we’ve had a long-time OB-GYN on our faculty,
who has a lifelong commitment to reproductive rights.
[He] is really the person who trained me . . . So it re-
ally is [this OB-GYN] who has brought that into the
residency . . . [and] by me becoming trained it really
helped kind of send a message that this isn’t just a thing
an OB-GYN does.
The relationships with obstetrician-gynecology col-
leagues also presented challenges in some programs.
Highlighting the complexity of the relationships with
obstetrician-gynecologists, half of the programs that
reported support from individual obstetrics-gynecol-
ogy colleagues also reported some degree of resistance
from the obstetrics and gynecology department. The
most common source of resistance arose from issues
around surgical back-up.
Requirements for credentialing to provide aspiration
abortions or perform first-trimester ultrasounds within
residency continuity clinics varied across programs. In
a few programs, family medicine department chairs
determined credentialing without involvement of a
hospital credentialing committee, and in one case,
first-trimester abortion was already included in the
core privileging of family medicine faculty. In other
departments, credentialing involved the agreement of
the departments of obstetrics and gynecology and/or
radiology, which created various degrees of difficulty.
Significantly, since all residency programs had preexist-
ing broad malpractice coverage, malpractice insurance
was not noted to be a barrier in any program.
Non-institutional Factors. Most of the programs had
at least some of their training provided at high-vol-
ume abortion sites, which were neither university nor
hospital affiliated. Several faculty members noted that
this relationship was necessary to provide training,
especially when no abortion services were provided
within their hospital or clinic system.
A few programs were located in communities in
which there were objections to the provision of abortion
services. Tension was manifested in a variety of ways,
including protestors outside one hospital and resistance
from the board of one community clinic where residents
provided primary care. The training of residents was not
noted to be a specific source of controversy beyond that
engendered by introducing abortion services. Several
faculty members noted that it was easier to incorporate
abortion services into their clinics when they were
administered by the hospital or university system than
when they were community governed.
Challenges for Programs in the Process
of Developing Required Abortion Training
The experiences of programs not yet successful in
integrating required abortion training were compared
to already successful programs. Of note, integrated and
non-integrated programs were similar in certain key
areas. All programs had a faculty advocate dedicated
to promoting abortion training. In addition, rates of
resistance from obstetrician-gynecology and family
medicine colleagues were no different between the
two types of programs. There were also no specific
concerns about malpractice or credentialing in non-
integrated programs.
Several differences were noted between these two
groups. The percentages of family medicine faculty
providing abortions were markedly different, with an
average of 17% of all faculty providing abortions in
programs with required training, compared to only
4% in programs without required training (P=<.05).
Several of the programs with required training reported
having an obstetrician-gynecologist who played a
crucial role in developing their curricula, while none
of the other programs had this type of an advocate.
Faculty in programs without required training also
reported that a lack of resources, including the funding
necessary to buy an ultrasound machine and to support
faculty time, was a significant challenge. Finally, the
majority of programs not yet successful at initiating
required training reported that lack of access to high-
volume practices was a barrier. In several cases, both
obstetrics-gynecology and family medicine residency
programs depended on a limited number of training
opportunities for residents.
Discussion
The experiences of programs included in this study
may help other programs interested in integrating
abortion training to anticipate and address challenges
in developing their training curricula. Expanding the
number of programs with abortion training is increas-
ingly important, since access to abortion services in
the United States is limited and declining. Between
1996 and 2000 alone, there was an 11% drop in the
number of abortion providers.20 Because an estimated
40% of all women will have at least one abortion,21 this
declining access has the potential to affect women in
every family physician’s practice. Family physicians
are particularly well suited to address this problem,
since they often provide services in geographic areas
with limited access to medical services.22 In addition,
while not all residents who participate in this training
will become abortion providers, being exposed to this
training has the potential to improve both their coun-
seling skills and their facility with other reproductive
health procedures, including ultrasound examinations
and IUD placements.

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Residency Education
Many of the challenges noted by faculty members,
such as access to adequate procedural volume and the
need for dedicated resources, are similar to those de-
scribed previously by others for procedural training in
general.16 As expected, abortion training also presents
unique issues due to its political and social context. To
overcome both the common and unique challenges,
two prominent program features were identified: the
presence of a faculty advocate and an emphasis on col-
laboration, both within family medicine departments
and with outside parties.
The presence of a dedicated faculty champion was
the most universal finding in our study. While most
curricular changes in residency programs require some
advocacy by individuals within the program, the con-
troversial nature of abortion makes the commitment of
these individuals even more important. Previous studies
of abortion training have documented that these faculty
leaders often benefit from protected time and resources
for activities such as educational interventions17,18 and
values clarification discussions with staff, faculty, and
residents.18
With respect to intradepartmental collaboration,
faculty reported that other family medicine faculty who
supported the provision of abortion promoted a positive
environment around these services. While causality
was not determined, the increased number of abortion
providers in family medicine programs with required
training suggests that having other faculty members
committed to providing abortion services furthers the
success of these efforts.
Family physicians and obstetrician-gynecologists
both contribute to the availability of abortion services
in this country, and the interaction between the two de-
partments was noted to be crucial by faculty developing
the training. Family medicine and obstetrics and gyne-
cology departments should work together to maximize
use of available training sites for both specialties and
to facilitate development of training programs. Clearly,
this collaboration is in the interest of both specialties
and the promotion of women’s health.
The relationship between residency programs and
outside training sites is an issue particular to abortion
training, compared to other procedures, because of
the unique manner in which abortion services are de-
livered in this country. Most procedures can be taught
within the institution in which the residency is based.
In contrast, abortions are often provided in freestanding
clinics, with more than 93% of abortions occurring in
such sites in 2002.23 Therefore, many programs may
have difficulty identifying an abortion clinic interested
in training or with time available for training. Because
most freestanding abortion clinics do not have funding
earmarked for training, residency programs should
consider providing incentives for these clinics to train
residents.
Limitations
The limitations of this study include the small num-
ber of programs and individuals included. While we
attempted to survey all programs with required train-
ing, and nine of the 12 programs participated, these
programs may not be representative of the experiences
or barriers faced in other programs, especially those
less interested in abortion training or in geographic
areas less supportive of abortion training. Since the
majority of our programs were based in urban loca-
tions, rural programs specifically may face different
challenges.
Conclusions
Despite encountering challenges, some family
medicine residency programs have successfully imple-
mented required abortion training. Programs interested
in developing this training will benefit from a carefully
planned approach, with attention to collaborating with
family medicine and obstetrician-gynecologist col-
leagues, developing relationships with training sites,
and involving residents and staff in the process.
Acknowledgments: Data included in this paper has been presented in pre-
liminary form at the 2005 Society of Teachers of Family Medicine Annual
Spring Conference in New Orleans, the 2005 Association of Reproductive
Health Professionals Annual Meeting in Tampa, Fla, and the 2005 North
American Primary Care Research Group Annual Meeting in Quebec City,
Quebec.
The authors thank Jody Steinauer, MD, MAS, for her assistance with
review of the manuscript.
Corresponding Author: Address correspondence to Dr Dehlendorf, Univer-
sity of California, San Francisco, Department of Family and Community
Medicine, 995 Potrero Avenue, Ward 83, San Francisco, CA 94110. 415-
206-8712. Fax: 415-206-8387. cdehlendorf@fcm.ucsf.edu.
REFERENCES
1. Schers H, van den Hoogen H, Bor H, Grol R, van den Bosch W. Fa-
miliarity with a GP and patients’ evaluations of care. A cross-sectional
study. Fam Pract 2005;22(1):15-9.
2. Mainous AG III, Goodwin MA, Stange KC. Patient-physician shared
experiences and value patients place on continuity of care. Ann Fam
Med 2004;2(5):452.
3. Saultz JW, Albedaiwi W. Interpersonal continuity of care and patient
satisfaction: a critical review. Ann Fam Med 2004;2(5):445-51.
4. Saultz JW, Lochner J. Interpersonal continuity of care and care out-
comes: a critical review. Ann Fam Med 2005;3(2):159-66.
5. Wilkins T, Gillies RA, Jester DM, Kenrick J. The current state of flexible
sigmoidoscopy training in family medicine residency programs. Fam
Med 2005;37(10):706.
6. Harper MB, Mayeaux EJ Jr, Pope JB, Goel R. Procedural training
in family practice residencies: current status and impact on resident
recruitment. J Am Board Fam Pract 1995;8(3):189-94.
7. Brotzman GL, Mark DH, Wolkomir MS. Influences on teaching colpos-
copy and treatment modalities in family practice programs. Fam Med
1995;27(5):310-3.
8. AAFP colposcopy position paper. Available at www.aafp.org/x6665.
xml. Accessed January 16, 2006.
9. Phillips WR. Diagnostic and screening procedures in family practice.
Past, present, and future use. Arch Fam Med 1993;2(10):1051-7.
10. Wickstrom GC, Kelley DK, Keyserling TC, et al. Confidence of
academic general internists and family physicians to teach ambulatory
procedures. J Gen Intern Med 2000;15:353-60.

Page 6

342
May 2007 Family Medicine
11. American Academy of Family Physicians. Practice Profile II Survey,
May 2005. Available at www.aafp.org/x821.xml. Accessed January 16,
2006.
12. AAFP core curriculum guidelines: maternity and gynecologic care.
Available at www.aafp.org/x16549.xml. Accessed January 16, 2006.
13. Prine L, Lesnewski R, Berley N, Gold M. Medical abortion in family
practice: a case series. J Am Board Fam Pract 2003;16:290-5.
14. Prine L, Lesnewski R. Medication abortion and family physicians’ scope
of practice. J Am Board Fam Pract 2005;18(4):304-6.
15. Lesnewski R, Prine L, Gold M. Abortion training as an integral part of
residency training [letter]. Fam Med 2003;35:386-7.
16. Sierpina VS, Volk RJ. Teaching outpatient procedures: most common
settings, evaluation methods, and training barriers in family practice
residencies. Fam Med 1998;30:421-3.
17. Prine L, Lesnewski R, Bregman R. Integrating medical abortion into a
residency practice. Fam Med 2003;35(7):469-71.
18. Leeman L, Espey E. “You can’t do that ‘round here:” a case study of the
introduction of medical abortion care at a University Medical Center.
Contraception 2005;71(2):84-8.
19. Bennett, I, Aguirre AC, Burg J, et al. Initiating abortion training in
residency programs: issues and obstacles. Fam Med 2006;38:330-5.
20. Finer LB, Henshaw SK. Abortion incidence and services in the United
States in 2000. Perspect Sex Reprod Health 2003;35(1):6-15.
21. Henshaw SK. Unintended pregnancy in the United States. Fam Plann
Perspect 1998;30(1):24-9, 46.
22. Fryer GE, Dovey SM, Green LA. The United States relies on family phy-
sicians, unlike any other specialty. Am Fam Physician 2001;63:1669.
23. Finer LB, Henshaw SK. Abortion incidence and services in the United
States in 2000. Perspect Sex Reprod Health 2003;35(1):6-15.