Every year, more than 100 new obstetrician-gynecologists graduate from a Texas residency program and enter the medical workforce. Theoretically, all have had the opportunity during their four years of residency to learn about what's called "induced abortion" — named that to distinguish it from a miscarriage. But the closure of abortion clinics in Texas — more than 20 since 2013 — has made that training increasingly difficult.
Texas has 18 residency programs in the field of obstetrics and gynecology, but only one allowed me to observe how abortion is taught. Because of the political pressures facing abortion providers, NPR agreed not to reveal the doctors' full names or the clinic's location. The resident agreed to be identified by her middle name, Jane.
Medical residents can opt out of abortion training for religious or moral reasons, but Jane felt a professional obligation to learn the procedure.
"This is part of OB-GYN — it's not an optional part, per se," Jane said. "Women can choose if they want an abortion or not, but you as their doctor need to be able to provide them with all the choices available."
Jane spent that morning performing ultrasounds on pregnant women, working alongside a senior doctor who supervised.
Together, the two women examined a printout from a fetal ultrasound, and the senior doctor offered some feedback.
"On this image here, you want it more of a plane, as if you were opening it like this, so that you have the hypothalamus in your picture," the senior doctor advised Jane. "That's going to give you a better measurement."
Doctors do ultrasounds before abortions in order to date the pregnancy, which helps determine which technique will be used to terminate it. In some states, including Texas, an ultrasound is also mandated by state law.
Jane spent about a month at this family planning clinic during the third year of her residency. Being able to perform the abortion is just one set of skills she learned. She also learned to counsel patients about abortion, contraception and sexually transmitted diseases, and learned techniques for pain management and dilation of the cervix.
The rotation taught her things that will be useful in other practice areas, Jane said. For instance, OB-GYNs use ultrasounds for many different reasons.
"Before in residency, we were doing ultrasounds maybe once during a clinic afternoon, or a few ultrasounds in the OB triage area," Jane said. "But here we do 30 ultrasounds in a morning, so it's a lot of good learning about how to do ultrasounds."
It may be good learning, but in Texas this training happens quietly, almost in secret.
"Doctors working in these institutions are walking a very delicate line," said Carole Joffe, a medical sociologist at the University of California, San Francisco. Joffe studies doctors who do abortions.
"Some of them want very much to be able to train residents," she said. "But they are fearful of the other sectors of the university coming down on them and saying, 'You're threatening our funding.'"
Academic medical centers in Texas receive tens of millions of dollars a year in state funding. Many of those centers sponsor residencies, which are the training programs that come after medical school. They last four or more years and allow doctors to focus on a specialty.
It's understandable why an OB-GYN resident in Texas might think twice about providing abortions. Doctors who provide the service must think about security issues for themselves and their staff. They also have to deal with the scrutiny of state inspectors as well as anti-abortion protesters.
Last summer, hundreds demonstrated outside the Planned Parenthood affiliate in Houston after an anti-abortion group released a series of undercover videos purporting to shed light on problems with fetal tissue research. (Planned Parenthood maintains that the videos are deceptively edited and denies wrongdoing. Meanwhile, two people involved in making the videos have been indicted.)
"Aren't you glad you're from Texas, a pro-life state?" a man shouted into a microphone. "We've got great, pro-life leaders, like Sen. Ted Cruz," he added, as the crowd burst into cheers. Later, they prayed and sang "The Battle Hymn of the Republic."
Surveys and other research show that doctors who do abortions may have fewer job opportunities. That's because many hospitals and group practices refuse to employ doctors who do abortions, even if they do so during evenings or weekends, on their own time.
A few years ago, 48 doctors in Texas did abortions, but a recent study shows it's now down to 28. And some of the remaining doctors are nearing retirement.
Bernard Rosenfeld, 74, hasn't been able to line up a successor to lead his medical practice. He says he understands — he's been dogged by protesters for years.
"They've picketed my house where I live," he said. "They put bullets in our parking lot."
Rosenfeld has two medical offices but provides abortions at only one, a modest brick building in Houston's museum district. He bought the clinic from other doctors in 1982, but now he can't find anyone to buy it from him.
"I've talked to some doctors, but none of them are interested in the political consequences of providing abortions," he said.
As the number of doctors in Texas dwindles, medical educators have raised the alarm about the need to train the next generation.
To find out how much abortion training was going on, I contacted all 18 OB-GYN residency programs in Texas. Although abortion is legal, and these programs are expected to provide some access to abortion training, my queries were frequently met with fear, evasion or even outright hostility.
One OB-GYN professor in Dallas hung up on me. Another agreed to an interview, then canceled.
Six of the programs, a third of the total, simply refused to answer questions about how the training takes place.
"UT Health does not want to participate in that story," said a spokeswoman for the University of Texas Health Science Center in Houston. "It's not a story that benefits us."
UT Health sponsors two OB-GYN residency programs, both at Houston hospitals.
In the end, I could only confirm that three out of the 18 programs in Texas had made arrangements for residents to spend time learning at an outpatient family planning clinic. Those types of clinics are where most abortions in Texas take place.
It's unclear how some of the residency programs are handling the training requirement. Some directors point to the difficult fact that the nearest abortion clinic is now closed. Other directors may be providing some options for training but wouldn't talk about it publicly.
One doctor who would was Robert Casanova, who was recently the residency director at Texas Tech University Health Sciences Center in Lubbock. The last clinic that provided abortions in Lubbock closed in 2013.
"As of now, there's really nothing in a close radius to us," Casanova said. "Our patients will go to Albuquerque; they'll go to Dallas; they'll go to Denver."
Casanova was left in a similar bind, with no local clinic where the OB-GYN residents could learn.
To compensate, Casanova created special seminars that cover elective abortion. He even arranged for guest speakers to fly down from Denver.
Since 1996, all OB-GYN programs in the U.S. must offer the residents at least the option to learn abortion techniques, even if the training happens elsewhere. If the residency programs don't do so, it can affect their accreditation.
In Texas, all 18 programs are currently accredited — even in places like Lubbock, where there are no longer any clinics that perform the procedure.
Given the political climate in Texas, and the dwindling number of such clinics, residency directors have had to scramble to find other ways to fulfill the curricular requirement.
Tony Wen, the residency director at the University of Texas Medical Branch, in Galveston, said it's one of the thorniest logistical problems he has encountered. His OB-GYN residency program is a large one, with slots for 32 residents.
"We cannot teach them the procedure itself," Wen said. "Can we teach them the concept, and describe the procedure and that sort of thing? Yes, we can do all that."
Wen explained he is hampered by three factors:
- Like most hospitals in Texas, UTMB does not allow elective abortions. Doctors must obtain special approval to do abortions for other reasons, such as severe abnormalities in the fetus, or a threat to the mother's life.
- Galveston does not have an outpatient abortion clinic. Wen has arranged for his residents to be able to travel for training to a clinic in Houston, an hour's drive away, but almost none have gone.
- The faculty physicians at UTMB accept reimbursement from the Texas Women's Health Program, a state-funded program for the medical treatment of low-income patients. The doctors cannot be paid if they perform elective abortions or affiliate with an organization that does. The upshot is that Wen and his colleagues cannot teach the procedure, even at an off-site clinic.
Most of his residents don't seem bothered by the situation, Wen said.
"If this part of the training is very important to them, more likely they will probably rank and choose another residency program to go to, instead of come to Texas," he said.
That's not to say the politics haven't affected the curriculum in other ways, explained Wen.
Because getting an abortion has become more difficult in Texas, more patients may be purchasing abortion drugs in Mexico to try to induce a miscarriage, and those pills don't always come with clear instructions.
"Here in Texas, they could easily cross the border and get that medication," Wen says. "A lot of people's thinking process is, 'If five tablets [are] good, 10 must be better!' "
Wen has started teaching the residents how to diagnose a woman who has overdosed on abortion drugs, and what to do to save her life.
This story is part of a reporting partnership with NPR, Houston Public Media and Kaiser Health News.
Disclosure: Planned Parenthood and the University of Texas Medical Branch have been financial supporters of The Texas Tribune. Find a full list of donors and sponsors here.