How the Dobbs decision and abortion restrictions changed where medical students apply to residency programs

(Press-News.org) In the three-and-a-half years since the U.S. Supreme Court overturned the constitutional right to an abortion in Dobbs v. Jackson Women’s Health Organization, the fragmented state of abortion access has put medical professionals in a precarious position. Many states have tightened abortion restrictions, with some enacting criminal penalties up to life in prison for physicians who perform abortions. Medical schools have curtailed abortion-related curricula.

New research led in part by the University of Washington found that the new restrictions are not only affecting the current medical workforce — they may be shaping the next generation of physicians. The study, published March 2 in JAMA Network Open, found that applications to medical residency programs in states that enacted new abortion restrictions dropped sharply following the Dobbs ruling.

The decrease occurred among both male and female applicants. Applications to specialities related to reproductive health — obstetrics and gynecology, family medicine, internal medicine and emergency medicine — saw the largest decreases.

The new study builds on previous research that had shown decreased application rates to residency programs in states with abortion restrictions by applying causal methodologies to understand the impact of the Supreme Court decision and isolating results from male and female applicants.

“This research provides important empirical evidence about how state-level policy changes following Dobbs may influence decisions made by medical trainees about where to pursue their graduate medical education,” said co-author Anirban Basu, a UW professor of health economics and director of the Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute.

To learn more about the research, UW News sat down the paper’s three authors: Basu; lead author Dr. Anisha Ganguly, assistant professor of medicine at the University of North Carolina at Chapel Hill; and co-author Dr. Anna Morenz, assistant clinical professor of internal medicine at the University of Arizona. Both Ganguly and Morenz completed their internal medicine residencies at the UW School of Medicine.

The medical residency match process is quite different from traditional higher-ed applications. Can you explain how that works, and how it relates to your study’s findings?

Dr. Anna Morenz: Applicants may apply to as many programs as they want, with some applying to dozens of programs. At the end of interviews, they’ll rank those programs based on their preferred landing spots. The programs, in turn, will rank all the applicants that they received. A computer algorithm then matches everyone with the goal of filling all the residency slots, and it’s very good at that. We know that almost all open residency slots in the U.S. are filled. So programs are still filling their residency slots even in states with restrictions.

What concerns us about these findings is that there’s an early signal of people avoiding applications to these states. That has potential implications for the quality of the applicants to restricted states, which could not be assessed in our data. There’s typically a high likelihood that people stay where they train for their residency, but if you landed in a restricted state that was low on your rank list, you may be more likely to complete your training and then leave to a non-restricted state. We aim to look at this very important question in projects to come.

Anisha and Anna, you’re both practicing primary care physicians. How big a part of a physician’s training is abortion and other pregnancy-related care? 

Dr. Anisha Ganguly: It’s not a big part of our training traditionally, though there has been a movement to integrate more abortion care into primary care residencies. That’s more the case in family medicine rather than internal medicine, because medication abortion has now become the most common means for abortion care. As internists, we commonly diagnose pregnancies and care for women with medical conditions as they consider family planning.

AM: I do think it’s important to note that a huge percentage of primary care physicians are trained in family medicine. And family medicine physicians are trained in delivery of babies, management of prenatal care, miscarriage management, contraception and abortion. Anisha and I trained in internal medicine, and there is increasing interest to include medication abortion training in internal medicine, as it is fully within our scope of practice.

The effects of the Dobbs decision have been well-documented, and previous work on this topic highlighted changes in OB/GYN residency applications. What’s new in your study specifically? 

Anirban Basu: We had a much longer pre-period than previous studies. We looked back to 2019 to see what had been happening to application rates in these two kinds of states — those that eventually restricted abortion access and those that didn’t — and we showed that these rates had been moving similarly until the ruling. That gives a little more weight to the evidence to say the change is due to the ruling. 

The second big thing is that previous studies did not distinguish whether men and women were changing their behavior similarly. I think that’s a very important finding in our study, that male applicants are changing their behavior at an even higher rate. 

AG: I agree that the gender stratification was an important contribution. The other stratified analysis that we explored was about how specialty type may be driving some of the effects that we saw. A lot of people can reason that OB/GYN applicants would be affected by this directly, and there’s a lot of literature to support that. But what we’re showing is that it’s not just the OB/GYN workforce that’s going to be impacted. It’s the primary care workforce and the emergency medicine workforce. 

We’re hoping that message spreads a little more broadly. This is not just about women’s health. It’s about the future of primary care and the person who’s going to save you from your heart attack in the future.

Let’s talk a little more about that gender stratification. You found that male applicants changed their application preferences at a greater rate than female applicants, which looks like a surprising result. What’s going on there? 

AG: When we generated our original hypotheses, we thought we were going to see increased effects among women applying to residency, but we actually ended up seeing that there were long-term disparities that existed pre-Dobbs between restricted and non-restricted states. This was likely because of the laws targeting abortion providers and other state-level laws that were affecting women’s behavior. What we’re seeing is that women had been reading the tea leaves about access to reproductive health care prior to the Dobbs decision, but the decision did unmask a wider problem that drove a lot of new behavior among men.

One of the messages that we are getting from this paper is this is an “all of us” problem. It’s not just about women physicians. It’s about men who are also making choices about their professional autonomy and also about access to reproductive health care for their families. Women have been and will be considering their personal access to care and autonomy before this decision, but perhaps these state restrictions after Dobbs may have newly increased awareness among men. 

Among all these shifts, you found one group whose application rates didn’t change significantly: people applying to highly competitive medical specialities. What do you think explains that stickiness? 

AG: Anna and I had brainstormed about this being a potential effect modifier, because people who are applying in highly competitive specialties like orthopedic surgery or dermatology apply very broadly and don’t get to exercise a lot of choice about where to go. Whereas for large specialities like internal medicine, family medicine or pediatrics, there are a lot of programs in a lot of places, so applicants have more options. In those cases, state-level policies like abortion restrictions can factor more into people’s decision-making.

At an institutional level, what changes could be made to address these trends? 

AG: Institutions can make choices to mitigate some of these effects by supporting candidates with access to reproductive care within the scope of the restrictions that exist. Other industries are building in travel benefits for women who may need to travel to access these services. 

It’s not this aspect of a decision alone that shapes a residency applicant’s choice to go to a specific place or program. But there are other things that institutions can do to make trainees, particularly women, feel supported and valued. If you’re existing in an environment where state policies make women feel a lack of autonomy, then there are workforce policies that can be in place to bolster that sense of autonomy. That could take the shape of parental leave policies, lactation policies, other things that institutions can do to make women feel like, even if this part of your voice has been taken away, we’ll help you with the rest.

AB: One policy that has a long history of literature supporting it is financial incentives. Physicians do respond to financial incentives, but in many cases those incentives need to be quite steep to get people to change their decisions. 

AM: The other option is training opportunities. A lot of programs in states that had laws or restrictions that preceded the Dobbs decision would set up partnerships with organizations in another state where they could send their trainees to learn about pregnancy termination and miscarriage management. That’s a burden on residency programs and residents both. You have to set up housing and travel agreements. But that’s another key thing that programs need to keep in mind in order to recruit applicants. 

For more information or to contact the researchers, contact Alden Woods at acwoods@uw.edu.

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