This Doctor Had To Leave Her State To Learn How To Perform Abortions
WILMINGTON, Delaware — The doctor was about midway through her month of training, her head swimming with the new skills she was learning, when a heavy, tattooed patient in her 20s walked into the clinic to terminate an early pregnancy.
In the cramped exam room, closely supervised by the abortion provider who would perform the procedure itself, the doctor began running through the setup tasks she had observed and practiced over the previous weeks: injecting the painkiller lidocaine into multiple spots around the patient’s cervix and inserting a speculum into her vagina.
On that last step, the doctor began to struggle. She had only done this a few times before, and never on a patient with a larger body.
“All this extra tissue was collapsing around my speculum, and I could not see the cervix very well,” she said. “There are tricks for things like that, but I am not yet at a skill level where I have the ability to troubleshoot.”
As she tried to reposition the metal device, the patient’s anxious voice floated down from the other end of the table. “Is everything OK?”
After all her years of medical education, it was humbling for the doctor to feel like a beginner again. She would repeatedly experience, even sometimes embrace, that feeling during her brief stint in Delaware — each struggle a warning that the month of training, as rigorous as it was and as difficult as it was for her to obtain, would likely not be enough.
The doctor, who specializes in internal medicine and pediatrics, came to be in that exam room thousands of miles from home because in 2022, the Supreme Court ruling overturning Roe v. Wade had rolled back access to abortion in her state. Though abortion training was not required in her specialties, she had long wanted to learn how to perform the procedure. But the new rules in her state — which went through years of litigation — dramatically reduced access to that training. Also, because abortions and miscarriages often require identical surgical procedures and drugs, the doctor would have fewer opportunities to practice the skills needed to treat a wide range of pregnancy complications and obstetric emergencies.
The doctor didn’t want to accept that gap in her training. So she threw herself into the growing pool of doctors scrambling to find a clinic in another state willing to offer a few weeks of hands-on abortion instruction. It would take her two years to find, apply for and raise the funds to afford the month-long crash course she eventually secured in Delaware. Once there, she lived out of a Staybridge Suites while still paying rent back home, fueled herself with granola bars and frozen veggie burgers she cooked in a thrifted toaster oven, drove hundreds of miles in a rented Ford sedan back and forth across the state to train at each of Planned Parenthood’s four clinics and spent her off-hours studying for her board exams and managing her own patients on the other side of the country. It was a far cry from the comprehensive, yearslong abortion training doctors could receive before the Supreme Court overturned Roe v. Wade, but it was much better than nothing.
The doctor is one of many residents across the country who have gone out of state for training in abortion since Dobbs. Most of them are OBGYN residents who are required to have that experience but are unable to get it in their home states. A smaller group are those, like the doctor, who have opted to do so in addition to their required medical training. Her experience is just one glimpse into the challenges these residents encounter as they try to cover as much as ground as possible on an expedited timeline out of state — and supports medical experts’ fears that shortcomings in post-Dobbs training alternatives could affect the skills of many doctors.
The doctor, to whom POLITICO granted anonymity due to her fear of professional repercussions and the threat of physical violence for seeking abortion training, was not exactly sure when or how she would use what she learned in her future career. Maybe she would move to a blue state after completing her residency and offer abortions as part of a private practice. Maybe she would join the cadre of doctors who parachute into abortion clinics a few days a month to help meet rising demand. In any case, she never wanted to be in a situation where a patient needed help ending a pregnancy and she didn’t know how to treat her.
“It felt like a moral imperative,” she said. “I don’t want my kids, my pediatric patients, having babies of their own before they’re able to do the things that they tell me they want to do at each clinic visit — graduate high school, graduate college, find a partner, do all of these things.”
Back in that narrow Delaware exam room, afraid of exacerbating and prolonging her patient’s discomfort, the doctor asked the attending physician training her to take over. And with skills acquired through performing abortions over many years, the attending physician quickly completed the procedure, operating by feel when the tiny window to the patient’s cervix was obscured.
The doctor knew she would need more than this bare-bones training to be able to handle situations like these, but she didn’t know how she could obtain it after returning home.
“I feel like I’ve gotten a little taste,” she later told me, “but I know it takes doing it day in and day out to really gain that proficiency.”
Had the doctor known when she was applying for residencies around the country in 2019 what she knows today, she never would have picked the conservative-leaning state that became her temporary home.
After the Supreme Court overturned Roe v. Wade, clearing the way for abortion bans to take effect in much of the country, including her state, her medical school put together virtual town halls on what the new legal landscape meant for patients and providers. But the PowerPoint decks and lectures from hospital attorneys did little to clarify when doctors could provide abortions — even ones they deemed medically necessary — or how the ban would affect residents’ training.
As a popular backlash to the bans mounted nationwide, the doctor started writing to her members of Congress asking them to restore federal protections for the procedure. And when protesters gathered outside her state capitol, she joined them, wearing her white lab coat but covering up the embroidered name of her institution to avoid trouble. The thought gnawed away at her that she could and should do more.
“I realized there was no reason why I couldn’t actually be at the forefront of this and actually perform abortions myself,” she said. “And I might have a much more significant impact doing that, because so few residents, so few medical personnel, are able to do that specific role.”
But in order to become an abortion provider, she needed to get trained. Before Roe the doctor could have done rotations at a local clinic to gain that experience. Now, her opportunities for such training in-state had all but vanished — as they had for medical students and residents in roughly a third of the country — raising fears that women having miscarriages and other obstetric emergencies in the future will encounter doctors ill-prepared to care for them.
Even those required by their specialty to have such training are facing difficulties post-Roe. Abortion training has long been mandatory for board-certified OBGYNs, though anyone with a religious or moral objection may opt out. While those requirements still stand, researchers estimate that about 44 percent of all U.S. OBGYN residents — more than 2,000 per year — have lost access to that training in the states where they’re practicing, forcing them to scramble to find out-of-state placements. And it’s even harder for those like the doctor, who aren’t required to have such training but want it anyway.
So in August of 2022, as she worked upwards of 80 hours a week in her residency, she started searching for abortion training out-of-state. Her program gave her permission to pursue it but offered no resources or guidance.
Scrappy networks of philanthropic, medical and activist groups sprang up in the wake of Dobbs to help residents in restrictive states secure temporary placements at hospitals, universities or clinics where abortion remains legal. Dozens of institutions in red states have also forged direct partnerships with sites in blue states — for example, a private university in Texas has been sending its residents to train for a few weeks at UCLA. But the doctor’s medical school told her they had no such arrangement.
“I didn’t even know if I was eligible for any of this,” she said. “I just applied anyway.”
After reading news articles about residents traveling to California for abortion training, she reached out to a few universities there, but they had no capacity to host her. She then spent months pursuing an opportunity with a national network of clinics that ultimately couldn’t find a spot for her because of overwhelming demand. Her search finally led her to the Midwest Access Project, a non-profit that has helped hundreds of medical workers find abortion training opportunities over the past two decades — training that was often hard to come by even with Roe still in place due to state restrictions and stigma.
The group cast around for a clinic willing to work with the doctor, finding their way to the Delaware Planned Parenthood chapter through a friend of a friend.
It can slow a clinic down to host a resident, especially a non-OBGYN like the doctor, limiting the number of patients it can serve. But for Kelly Nichols, the associate medical director for Planned Parenthood of Delaware who helped train the doctor, the short-term inconvenience is worth the long-term benefit for the national workforce.
“It’s really important that we have a diversity of different specialties,” she said. “A lot of people who are working in primary care, gynecology and emergency medicine are going to come in contact with people who have had an abortion or are seeking abortion care or need help with miscarriage management or early pregnancy complications. So it’s really important that the full scope of people and providers are familiar with these services, even if they don’t provide it themselves.”
There is considerable agreement among leading medical groups, including the American College of Obstetricians and Gynecologists and the Association of American Medical Colleges that the overturning of Roe has adversely affected medical education. A 2024 investigation by the House Energy and Commerce Committee, which examined 20 residency programs across 15 states, found that medical residents in states with abortion bans are receiving inadequate training on many core components of obstetrics and gynecology, from surgical skills to options counseling.
One midwestern residency director told the House investigators that their residents, compared to those trained before Roe fell, are less proficient in basic skills like dilating a cervix — necessary for intrauterine device (IUD) insertion and hysteroscopy procedures — due to the lack of abortion training.
“You can tell who has done it and who has learned it from a book,” said another residency director who assists in conducting the annual exams that determine whether OBGYN residents are awarded board certification. “There is a gap in how they’d manage patients, and you can already see it.”
But some anti-abortion voices in medicine dispute the idea that abortion training is essential.
Dr. Christina Francis, the CEO of the American Association of Pro-Life OB-GYNs, said that while doctors should be free to cross state lines for abortion training if they want it, it should not be required of aspiring OBGYNs and no taxpayer funding should support such instruction.
“Specific training in induced abortion is not necessary for OBGYNs to have full training and know how to provide excellent care to women,” she said.
Francis recalled her own residency at a Catholic hospital that did not provide abortions. She said she practiced enough on miscarriages, learning both surgical techniques and medication management, that she “could have finished my residency training and gone down the street and gotten me a job at Planned Parenthood the next day doing abortions, if I had chosen to do so.”
Still, there’s no question that abortion bans have limited what procedures much of the nation’s future medical workforce are able to observe and practice, a gap the doctor and other residents have tried to fill with training in blue states.
In the doctor’s case, Delaware Planned Parenthood agreed to provide the training. The costs for the trip — flight, hotel, rental car, medical licensing fees, malpractice insurance, background check — would be the doctor’s responsibility, but she pulled together several grants and scholarships to cover the nearly $8,000 cost.
In April, nearly two years after she began her search, she boarded a plane to Delaware.
She was eager for training she was sure would make her a better doctor, but she also felt like she was stepping into “a political minefield” with no room for error — and no certainty about what would await her when she returned. Would she have any ability to practice the skills she learned? Though her direct supervisors had approved her participation in the program, would other leaders at her conservative-leaning institution refuse to give her recommendations because of her pursuit of abortion training? Would this help or hurt her job search down the road, or even make her a target of violence?
“You’re just very vulnerable as a resident,” she said. “Despite being so passionate about this, I don’t want to jeopardize my career.”
Before she arrived in Delaware, the doctor had never even seen an abortion depicted in a textbook or training video, let alone observed one in-person. About half of the nation’s medical schools — including the one she attended in a blue state before beginning her residency — offer no instruction on how to terminate a pregnancy. So her trepidation and curiosity ran high when, on her third day, she peered over the shoulder of one of Planned Parenthood’s attending physicians as he examined the patient’s cervix, applied numbing medication and used metal tools and a small suction device to remove the fetus in less than 10 minutes.
Her overwhelming thought: “That’s it?”
She was struck by how straightforward and safe it seemed — far easier than the complex medical procedures she’d been doing for years.
“I’ve placed giant central intravenous catheters in the veins of people’s necks using an ultrasound, where there is a risk of puncture or collapsing a lung,” she said. “Although training is required, abortion seems much less technically complex.”
Learning to prescribe abortion pills — which the FDA has deemed safe and effective for nearly a quarter century — was even simpler, a baffling discovery to her given that only 14 percent of gynecologists and vanishingly few other doctors offered that service even when Roe was in place.
She was shocked, then angry: Why had these basic skills been walled off from her general medical education? Why was she led to believe they were so difficult and specialized that only a select few could provide them? Why was seeking out the training so much harder than the training itself?
“I’m just so frustrated with the institution of medicine,” she said, her voice rising. “All week I kept thinking, maybe there’s some part of it that is so challenging, and that’s why no one learns how to do it.” Particularly after learning how to dispense the pills, she thought: “Why the heck couldn’t more residents and attending physicians be providing this care?”
For most of that first week, the doctor mainly watched. Sometimes the clinician training her would invite her to look in between the patient’s legs or direct her attention to something on the ultrasound screen. Other times she’d be handed an instrument so she could feel the difference between the slick, viscous lining of a uterus with a fetus still inside and the grittier texture after it was removed.
She also observed the subtle things clinic staff did to put patients at ease — protocol shaped by the awareness that many have survived rape or other trauma. When they invited patients to lay back on the exam room’s elevated platform, for example, they called it a table instead of a bed in order to avoid any sexual connotation. They sat on a low stool when talking to the patient before the procedure to create a more equal power dynamic. If a transvaginal ultrasound was needed, they offered the patient the option of inserting the device herself.
More than anything else, the doctor’s first exposure to the procedure cemented in her mind that abortion is — and should be taught as — a normal health care service, something all kinds of medical providers should know how to do.
“I always had the idea that someone else could do this but now I think: we are the someone else,” she said.
One morning, when the doctor pulled into the parking lot, a gaggle of anti-abortion protesters stood between her and the clinic’s front entrance — some waving signs featuring enlarged photos of fetal parts, and some urging the patients and staff trying to reach the doors to turn back.
A group of clergy who support abortion rights — imams, priests, rabbis — were there escorting patients and providers into the clinic, and they swooped to her side, opened a rainbow striped umbrella to shield her, and kept up a loud patter of small talk to drown out the demonstrators.
Before that day, the doctor had only seen anti-abortion protesters from afar and had never been one of their targets. But as she entered the second week of her training, she began assisting in what their chants and signs called murder.
When a patient came in to terminate a pregnancy about 12 weeks along, she performed the set-up tasks, then held the ultrasound device steady on the patient’s abdomen while the attending physician turned on a vacuum device. Once the machine had sucked the fetus out of the uterus, the doctor was directed to take its contents into an adjoining room and examine them to make sure every piece was cleanly removed and no traces were left behind that could cause an infection.
Peering into a little tray at what clinics call the “products of conception,” the doctor was taken aback. Parts of the fetus were clearly identifiable — little nascent organs and limbs, a partially-formed skull.
The experience hung over her for days.
“I was thinking very deeply about ethics and morality,” she said. “Even if people don’t view a fetus as life, I can see why people struggle with abortion. What is the potential for life?”
Ultimately, she said, despite her initial discomfort, the experience strengthened her belief that people should have the right to end a pregnancy. Before, she had supported abortion rights in the abstract. Now she knew — intimately — what she was supporting.
“My commitment is to the patient in front of me,” she said. “And if that patient is asking me to perform an abortion, my duty is to do no harm, and to not perform the abortion is causing harm by limiting patient autonomy.”
Still, the next time she steeled herself to walk through the crowd of protesters shouting and waving signs outside the clinic, she saw them in a new, more empathetic light.
“I better appreciate why it is such a complicated and intense issue for so many people,” she said. “And honestly, if you truly believe this is murder, you should be out protesting. Just like I believe in abortion rights so vehemently that I pursued this training for two years. My actions are consistent with my beliefs, and while that looks very different from the person protesting, we are parallel.”
By her third week, the doctor had gained more confidence, hopping between clinics in Wilmington, Dover, Newark and Seaford.
Abortion pills, the most common method of ending a pregnancy, she found relatively simple to prescribe. But surgical abortions proved more challenging, and it became clear that while four weeks could prepare the doctor to terminate a pregnancy when everything goes by the book — it would not prepare her to manage everything that can go wrong.
Because the rate of complications from abortion is low — about 2 percent — medical experts stress that it’s crucial for residents to observe and participate in a lot of them. Yet it’s common for those like the doctor doing brief, out-of-state rotations post-Roe to never see a complication.
“You can’t predict when they’ll happen and they’re so time sensitive that you can’t save those cases for when trainees are there,” explained Pratima Gupta, an OBGYN and complex family planning specialist in San Diego who has been training red-state residents. The crash course residents like the doctor are getting, she said, pales in comparison to her own training many years ago, in which she assisted in several abortions every day for multiple years.
“I saw a patient who had an amniotic fluid embolism in the middle of her procedure. I saw patients who had a perforation,” she recalled. “I wanted to have exposure to those really rare complications during my training so that now that I’m an attending [physician], I’ve already seen it and I’m unfazed. I’m not going to lie: my heart rate is still through the roof. But I know how to deal with it.”
And sometimes, the doctor discovered, the complications aren’t strictly medical.
One day in her third week of training, she was called to perform an abortion for a patient in her late teens, who came unaccompanied to the clinic with a first-trimester pregnancy. (Delaware law only requires patients younger than 16 to inform their parents they are having an abortion.)
The teenager had never had a pelvic exam, let alone an abortion. So when the procedure started, the doctor said, she began “totally wigging out.”
She yelled. She thrashed around. She gave conflicting signals.
“In one breath, the patient was saying, ‘I want you to do this, just do it,’ and the next breath, they said, ‘No, I can’t take the pain,’ and then we pause and they’re like, ‘No, just do it,’” the doctor recalled. “We said, ‘Let us know when you’re ready for us to begin again.’ We just emphasized, ‘You’re safe, and you’re in control of this.’”
The patient repeatedly insisted that she wanted the abortion, but the doctor knew the patient’s anxiety and discomfort meant she also needed the procedure done as quickly and smoothly as possible. That was not something the doctor was ready to do as a beginner. So she moved from between the patient’s splayed legs to her side, letting the more experienced physician take over as she led her in a guided meditation to help her get through the procedure.
Staying in a cheap hotel was starting to grate on the doctor. In her first room, the front door fell off its hinges. In the second, the door wouldn’t lock. In the third, the fridge let out high-pitched screeches in the middle of the night.
Being away meant missing professional opportunities, including her residency program’s annual retreat. The time difference also had made it hard to schedule calls with her boyfriend. When they did connect, she learned that their poodle had taken over her spot in bed.
Still, she wished she could stay longer, and was grateful that Planned Parenthood’s Wilmington clinic, which usually doesn’t see patients on Fridays, made an exception to give her one final day of experience before she flew home.
Doctors who trained pre-Dobbs say there is no set number of procedures one needs to observe or practice on a dummy before being ready to operate on a patient, and no exact number of procedures on patients to achieve competency.
“Just like the fact that not everybody passes their driving test the first time around, it varies from individual to individual,” said Gupta, the San Diego-based OBGYN who oversees residents’ training. “Somebody might be competent after 10, and somebody might need 50.”
Still, the crash courses red-state residents like the doctor are receiving post-Dobbs force them to move much more quickly from observing to assisting to performing the procedure, leaving them less prepared than those in blue states who have the training woven in throughout the course of their three- or four-year residencies. Red-state providers now fear the next generation won’t know how to provide abortions in the rare instances they are allowed — such as when a patient’s life is in jeopardy.
“Will they develop those skills eventually? Maybe,” said Anitra Beasley, the president-elect of the Society of Family Planning and an OBGYN based in Texas who has helped residents secure training in California. “But will they have those skills when somebody needs them? Maybe not. And I do think patients will suffer because of it.”
In the end, the doctor assisted in about a dozen surgical abortions — performing a few completely on her own — and dispensed several dozen medication abortions over the month. Each one provided a brief glimpse into a patient’s life.
There was the woman who asked again and again if her partner would be able to tell that she had an abortion — a red flag for domestic violence that prompted the clinic to offer a hotline and other resources.
There was the woman who, when handed an abortion pill, swallowed it and then stuck out her tongue to prove she had done so — as people are ordered to do when they take medications in prisons and mental institutions.
Other patients tried to justify their decision, telling the doctor about financial woes and pressure at school even as she told them that she supported their choice no matter the reason.
In her final night in Delaware, she folded her scrubs into neat piles and stuffed them into her luggage — alternately fretting about going over the airline’s weight limit for her flight home and brainstorming ways she could help other doctors to pursue abortion training. Early the next morning, she set off for the airport, eager to return home but more convinced than ever that she cannot stay there and practice long-term.
“Obviously I can’t go back and change where I applied,” she said. “But I can decide where I will take my expertise in the future.”
Upon her return, even as her board exams loomed, the doctor put together a presentation to share some of what she learned and encouraged her fellow internal medicine and pediatrics residents to pursue their own out-of-state abortion training.
None, so far, have taken her up on it.
