The perfect time to discuss ways in which your program integrates abortion training is when applicants come to interview. Introduce the abortion and contraception component of residency as part of the essential education your program offers, and discuss the benefits of family planning training.  Some things to consider as you introduce potential residents to the training:

Who should introduce abortion training?

You – as the faculty member responsible for training – or the residency program leadership can present it to the applicants as a group.

Where does training happen?

Often applicants tour the clinical care facilities, and many programs include a tour of the family planning clinic as part of their tour.  It can be helpful if you or another team member is there to lead the tour and answer questions.

What does training include?

Provide potential residents in your program a brief introduction of the family planning training. We have found it is important to explicitly mention that abortion training is expected and that you offer partial participation. Some residents will want to opt-out of certain parts of the rotation, but all are expected to participate to the extent they feel comfortable.

Why present abortion training during the interview?

It is important that applicants know ahead of time about these options so they can include this in their decision-making about residency program.  In addition, including it in the interview lets applicants know that the department supports the training. [2]

You can suggest to residents that if they train at your program, they will have multiple points of access to increase their knowledge in abortion, contraception and sterilization. Training may include:

Didactic lectures on abortion and contraception

Participation in contraception care which can include:

• counseling women about contraceptive options
• managing side effects of methods
• prescribing methods
• placing intrauterine devices or contraceptive implants
• doing sterilization procedures

Participation in abortion care which may include:

• counseling women seeking termination about their options
• doing ultrasounds to assess gestational duration
• providing medical abortion regimens
• managing analgesia/anesthesia and supporting women who are undergoing uterine evacuation or induction procedures
• performing uterine aspiration, D&E and induction termination

Experiences with family planning outside of a dedicated clinic:

• counseling women regarding pregnancy options
• making appropriate referrals
• managing post-abortion complications during care of patients in the ER and in clinics associated with the Gynecology, Obstetrics, Maternal Fetal Medicine, and Family Planning Services

Be up front about the benefits of abortion training and the expectations for participation at your program.

“Participation is expected. Partial participation is possible, beneficial and expected.”

This may be the first time residents will hear about a partial participation ‘protocol’ or even that partial participation is possible. Residents who feel strongly about abortion training will select residency programs according to their values.  Many will have not thought about abortion and the extent to which they want to participate. Your institution should have a protocol for working with partially-participating residents that describes what the program expects of all residents. Here is an example of a protocol, and the ACOG Committee opinions on abortion training and conscientious refusal.

ACOG Committee Opinion on Abortion Training

ACOG Committee Opinion on Conscientious Refusal

Sample Partial Participation Protocol

Orientation provides a good opportunity to review and orient learners to the clinic, to review the objectives of the rotation, and to once again describe expectations of participation in the rotation.  Remind the learners that family planning is a routine part of ob-gyn training.  Frame the abortion conversation within its public health importance. Be ready to discuss any hospital-specific or state regulations that are pertinent to your program.

Discuss with individual learners the extent to which they plan to participate and give them examples of how they might maximize learning even if they choose not to fully participate. Use the partial participation policies and checklists below to guide these conversations.

It might be helpful to provide a Values Clarification Workshop or similar opportunity to discuss feelings about abortion to all residents, regardless of participation intentions. Review the resources below for more information.

Do not ask residents to commit to a participation level

It’s important to not force residents to commit to a participation level—it should be a fluid discussion over the course of the rotation. We know that some residents decide to do more than they thought they would during the rotation and some residents decide to do less. It is important to be available to them as they make these decisions.

Partial Participation Policy

Present the option to partially participate and be explicit in expectations of minimal participation. Here is our recommended policy for partial participation in abortion training, as well as examples from two other Ryan Programs sites.

Partial Participation Recommended Policy Template

Sample Partial Participation Policy 1

Sample Partial Participation Policy 2

Sample Partial Participation Policy 3

Partial Participation Checklist

Many programs have chosen to create or use checklists to visually explain what procedures and activities are expected, and which are optional. Checklists should be very clear (but not binding.) Here are a check-list template and a few examples. As you will see, there are very few parts of the rotation in which a resident can completely opt out.

Partial Participation Recommended Checklist Template

Sample Partial Participation Checklist 1

Sample Partial Participation Checklist 2

Values Clarification Exercises

Caring For Challenging Patients Workshop

Video Lecture: Teaching Professionalism in Abortion Care Video Companion Guide

Physicians’ Professional Responsibilities in Abortion Care Video Companion Guide

Teaching Professionalism through a Case-based Values Clarification

Resources to inspire discussion about participation in abortion training:

Videos

12th and Delaware

The Fake Abortion Clinics Of America: Misconception

Motherless: A Legacy of Loss from Illegal Abortion

Readings

In Photos: The Journey to Get an Abortion From Texas’ Rio Grande Valley

The New Abortion Providers

Where are the Doctors?

What Happens to Women Who are Denied Abortions?

The week or two preceding the rotation is a critical time in the process, as the resident will need to develop a clear idea of how much or little they will participate in the rotation. The resident should know that they have flexibility to change their participation level during the rotation. At the same time, however, you need to have time to create alternate plans for the resident if they will have free time due to limited participation.

Individual meetings

Checking in one-on-one is the best way to help a resident develop expectations for the rotation, and to gauge his or her intended participation level. While they may have seen a checklist at orientation, this is a time to walk through it with them. Let residents know about the benefits of participating, and the skills they can develop on the rotation.

Explain details of rotation

If the resident is an intern, they may not know the full scope of abortion care. Go through the details (below) with them well before the rotation so that it has time to sink in.

If this resident plans to partially participate, let them know how this will affect their rotation and that you two can/ will meet regularly to re-evaluate participation level. Discussing this ahead of time helps avoid the feeling that partial participators are being “singled out”. 

Communicate with other trainers

It is important to consider other team members / clinic personnel when integrating partial participators into the schedule, but also be sensitive to the resident who is opting out of an aspect of or an entire procedure. Try to prevent the resident being asked to do an abortion by a different faculty member on the family planning or other rotation. Describe in very concrete terms what the trainee is willing to do and not do, and provide a timeline for when things might change. Ask your colleagues to gentle handle discussions around participation with care to not pressure the learner. Avoid whispering about the trainee and other behaviors that might make him or her feel judged.

 

Clarify in what activities the resident is willing to engage, exploring:

• Gestational age limits
• Indications for the abortion
• Examination of the products of conception
• Osmotic dilator placement
• Local anesthetic block placement
• Use of mechanical dilators
• Assisting with the procedure (setting up the equipment, providing ultrasound guidance)
• Being present in the room during an abortion

Emphasize and remind them that their level of participation can change over the course of the rotation.

The first day of the rotation should be educational and not hold any surprises for you or the learner. Check in with residents who are/ were considering partial participation and remind them of your support.

Consider providing a Values Clarification exercise at or after the first day of the rotation to connect with residents about any issues they are having.

If a resident chooses to opt out of abortions, be ready to provide educational and non-punitive alternatives. (see list of alternative activities)

Early check-in

Check in with the learner early in the day to ensure s/he is comfortable with the activities.

Debrief at end of day

Connect with the learner at the end of the first day and get a sense of how she/he is feeling about the rotation.

 

Educational alternatives to clinic participation

• Increase participation in other aspects of care such as counseling, ultrasound, IV line placements
• Make a learning plan about how to gain the skills the resident is missing from limited participation. For example, she or he could plan to practice local anesthetic blocks in other GYN cases, like before LEEP/cone biopsies or hysteroscopy. S/he could increase arrange to be assigned more uterine aspiration cases in the setting of early pregnancy loss from the OR, ER, or outpatient clinics. S/he could spend extra time doing simulation.
• Facilitate online learning – resources are provided on this site
• Do a project. These include an evidence-based review of a family planning topic, a patient handout about an aspect of care, or a hospital or clinic protocol. Consider asking the resident to teach the clinic staff about a topic.
• Participate in or organize an opportunity to educate legislators in your state

Connect with the learner throughout the rotation about his/her comfort level and participation.  Emphasize the fluidity of participation level. Give them the opportunity to initiate discussion or to request a check in about any discomfort.

Regular check-ins without pressure

Schedule check-ins with your partially-participating resident at intervals that seem appropriate for the individual resident.

“When would you like to check in again?”

We have found that a routine check-in works well for some residents and some facilitators, but for others, it might be beneficial to ask the resident when they would like to check in about partial participation, rather than ask too often or too rarely.

Case discussions

Consider discussing atypical cases with the resident as they come up. These include women who are presenting later in pregnancy, complicated cases, or emotionally challenge cases, such as young teens. These types of cases sometimes cause more stress in the learner.

If a learner’s partial participation makes space for additional learners to care for patients consider inviting other learners (e.g. residents who want to refresh skills, MFM fellows) to join you.

Video interview with Dr. Deborah Bartz on incorporating partial participants in abortion training.