Jennifer was one of my first patients as a new doctor, and she came to see me about an unintended pregnancy. A single mom to a rambunctious 5-year-old girl, Jennifer was struggling economically and battling depression. We talked about the options available to her: continuing the pregnancy and preparing to parent another child, offering the baby for adoption or having an abortion. She chose to continue with the pregnancy, and I worked with her over the following months as she struggled with the discomforts of pregnancy, excessive weight gain and the anxiety of having to raise two small children on her own.
Seven months later, I delivered Jennifer’s beautiful baby boy. Six weeks after that, I saw Jennifer, her new baby and her 5-year-old for a joint checkup. We discussed colic, diet and exercise, her daughter’s ADHD and birth control. During Jennifer’s visit, I placed an IUD, a long-acting intrauterine contraceptive device, so that her next pregnancy could be by choice and not by chance.
These are the types of relationships that inspired me to become a family doctor: intergenerational, continuous care for patients of all ages, inclusive of all healthcare needs.
New policies proposed in April by the Residency Review Committee for Family Medicine, or RRC, the group that outlines requirements for physician training programs nationwide, threaten to interfere with that comprehensive care and to decrease reproductive health access for women like Jennifer.
The proposed RRC changes would eliminate the current requirement that family medicine residents learn full-scope reproductive healthcare. Instead, the decision to teach these skills would be up to the discretion of individual residency programs. Family doctors would no longer be required to learn how to prescribe birth control, place intrauterine devices or contraceptive implants, provide options counseling for women with unintended pregnancies or diagnose and manage miscarriages.
The RRC, composed of 11 men and three women, finds the current guidelines too onerous. The committee’s proposal aims for more flexibility and creativity by making the requirements more general and less restrictive.
Although the RRC has the right idea (the requirements for family medicine training are notoriously cumbersome), its choices are misguided. Family medicine residents, for example, are required to complete two months of surgical training. It could eliminate that requirement instead, given that the number of family doctors practicing general surgery is infinitesimal.
Unintended pregnancies account for nearly 50% of U.S. pregnancies and lead to healthcare costs of more than $12 billion annually. If we stop training family physicians in reproductive health skills, the result will be many more unintended pregnancies, particularly in the medically underserved poor urban and rural communities where family physicians tend to work. These communities often lack access to specialty care. If we place these medical services solely in the domain of costly specialists, reproductive healthcare will become even more unobtainable.
As a general practitioner, I have tremendous respect for my specialist colleagues. I refer patients to them often to help with cases that are out of my scope of practice. Comprehensive contraceptive care, however, is relevant to about 75 million women in this country and should fall within the scope of primary care.
The Affordable Care Act intends to expand women’s access to reproductive healthcare by requiring health insurance programs to cover the cost of birth control. The law also addresses the enormous primary-care shortage by offering incentives to physicians to enter primary-care fields. To expand our primary-care resources but opt out of training these new doctors in the most current and effective reproductive health skills would be like investing in a sailboat, hiring an inexperienced crew and refusing to teach them how to sail.
Physicians should be allowed to choose what type of medicine they practice and what procedures they perform. Residents currently can opt out of reproductive health training on moral or religious grounds, just as they can opt out of abortion training.
But if the proposed changes go through, a substantial number of residency programs, particularly those affiliated with religious institutions, are likely to stop teaching these skills altogether. Residency program directors who have personal objections to contraception and abortion could decide not to train any of their residents in these essential tools of reproductive healthcare. Many family doctors interested in learning full-spectrum women’s healthcare would have difficulty finding the programs invested in teaching the necessary skills.
Almost weekly, another state or institution attempts to restrict women’s rights to reproductive freedom. I am deeply disturbed that my own profession, the one I chose for its emphasis on continuity of patient care and its foundation of social justice, seems to have joined the fray.
Alison Block is a family medicine resident.