Part Two: Residency programs and medical practices drew them to Tennessee. Then came Dobbs.
A looming shortage of OB-GYN physicians comes as Tennessee faces maternal health challenges
“I don’t want to abandon women who are in need,” says Dr. Jessie Rizzuto. (Photo: John Partipilo)
(This is the second in a two part series on how Tennessee’s abortion ban has affected the training, recruitment and retention of OB-GYN doctors in Tennessee. This story was originally published on April 26.)
Boosting the doctor supply in Tennessee
Recruiting residents to Tennessee is critical to the state’s health care workforce. In Tennessee, 46% of residents training in the state stayed to practice in the decade through 2021, according to the Association of American Medical Colleges. That’s below the 55% overall state retention rate seen nationally.
“We are an exporter of physicians,” Miller said. “We are a growing state. We should be growing the number of physicians, but we are not.”
University of Tennessee Health Science Center has developed programs to encourage retention by offering medical school tracts that lead to residency placements. Of the students who do both medical school and residency in Tennessee, about 60% stay and practice in the state, Strome said.
“We want our students to go back and, ideally, be able to practice in every single county of the state so that we can make sure that folks, rural and folks who live in urban settings, have coverage,” Strome said.
He described “unbelievable” results for the recent OB-GYN match day for UTHSC, reflected in geographic diversity, the schools represented and the applicants themselves.
“The laws don’t make it more attractive to come, but, in spite of that, we have been able to recruit great people to regions where our primary OB-GYN programs are based because of a desire to serve and care about humanity,” Strome said.
In a national survey of more than 2,000 medical students, residents, fellows and practicing physicians through social media, three-fourths of respondents said they would not apply to states with legal consequences for providing abortion care and more than 80% would prefer to train or practice in states with preserved abortion access, according to a study published in February in the Journal of General Internal Medicine.
Dr. Simone Bernstein, a resident physician in psychiatry at Washington University in St. Louis and one of the study’s authors, said restrictive abortion laws affected not just preferences for those within OB-GYN, but also other specialties, including dermatologists prescribing treatment or pediatricians working with teenage patients. Students and doctors also considered the impact of abortion restrictions on themselves and their family members as patients.
“If they follow through on these preferences, those states may have an exacerbation of the existing physician shortages that are in place,” Bernstein said. “Ultimately this could lead to worsening health outcomes for those that do live in those states.”
For many residents seeking to gain abortion training, the solution is not as easy as just excluding programs in more restrictive states, said Pamela Merritt, executive director of nonprofit Medical Students for Choice who is based in Illinois. Students must strategize to avoid not matching at all in what is a highly competitive process. And, some OB-GYN students are drawn to where the need for maternal care is greatest, which often overlaps with where abortion is most restricted.
- 43 of 95 counties had no OB-GYN doctors in 2022
- Tennessee has a projected shortage of 170 OB-GYN doctors in 2030
- Only Arkansas and Mississippi have. worse maternal death rates than Tennessee
“If you are in obstetrics and gynecology and you want to do good and provide care, there is an emotional and ethical pull there,” Merritt said.
In Tennessee, 43 of 95 counties had no OB-GYN physicians in 2022, according to the Health Resources and Services Administration. Tennessee has a projected shortage of 170 OB-GYN doctors in 2030 and is forecast to meet 84% of OB-GYN demand, below the 90% expected nationally.
The looming shortage comes as Tennessee faces significant maternal health challenges.
There were nearly 42 maternal deaths per 100,000 live births between 2018 and 2021 in Tennessee, according to the Centers for Disease Control and Prevention. Only two states, Arkansas and Mississippi, ranked higher.
Accreditation requirements for Tennessee’s OB-GYN programs is another challenge medical training leaders are navigating. In September, the Accreditation Council for Graduate Medical Education reaffirmed the need for clinical experience in induced abortion to fulfill OB-GYN requirements, except for those who opt-out for moral or religious reasons. Programs that don’t provide that clinical experience could be cited, but their accreditation is unlikely to be affected as long as they show they are addressing the issue, the ACGME said.
The board “recognizes the legal restrictions on abortions in some areas of the country will make meeting the requirement challenging,” an ACGME spokesperson said in a statement. “However, clinical experience in performing induced abortions is essential to the evidence-based practice of obstetrics and gynecology.”
While elective abortion training is no longer allowed in Tennessee, residents still gain experience in miscarriage management and they will be “competent and confident” if they move to an area where abortion is legal, said Dr. Edward Hills, Meharry Medical College Interim Chairman of the Department of Obstetrics and Gynecology in Nashville.
“I do think the more training you have and the more exposure you have, the probability is that you are going to be better qualified to take care of the serious problems,” Hills said.
More high-risk pregnancies anticipated
For Dr. Jessie Rizzuto, a fourth-year OB-GYN resident at a major medical center in Nashville, the Dobbs ruling came as she was interviewing for high-risk obstetrics fellowships. What would have been an easy decision to pursue a Nashville fellowship as a top choice became very difficult.
“It made a really big difference for me,” said Rizzuto, who is from Baltimore. “I talked about the pros and cons ad-nauseum.”
Patients with high-risk pregnancies often see a specialist early in their pregnancy. Some women may have pulmonary hypertension, cystic fibrosis or conditions that pose high risks of death when pregnant. Some women could develop cancer while pregnant, or fetal anomalies might be detected. Prior to Tennessee’s trigger ban, termination would be among options for those patients to consider. Without that option, Tennessee’s abortion laws are likely to yield more high-risk pregnancies, Rizzuto said.
“I didn’t want to abandon women here who are going to be in need,” Rizzuto said. “I do feel that urge to continue to serve the women of this community.”
Rizzuto ultimately committed to a fellowship in Nashville. The presence of local friends, mentors and family factored into her decision to stay and she also found inspiration in the doctors training her who continue to serve patients to the best of their ability within the law’s constraints.
After her three-year fellowship, Rizzuto will have to make another decision on where to build a practice. She envisions wanting to stay in Nashville but she will need to see how the laws play out and how they affect her work with high-risk patients.
“It can be really hard to see these patients not able to get certain care that they would have somewhere else,” she said. “And then, to see bad things happen to them. So, I don’t know.”
For Dr. Leilah Zahedi-Spung, high-risk obstetrics became untenable in Tennessee within months of the trigger ban. In her first job after a fellowship, she was the only doctor in her Chattanooga practice trained for evacuating a uterus in the second trimester and could not risk a career-ending felony charge that could come from saving lives. She was recruited by a Colorado practice and in January, she and her family moved to Denver where abortion is allowed at each stage of pregnancy.
“I was happy to be there, taking care of patients and providing a service that was very important,” she said. “But, when this trigger ban hit, it became abundantly clear I had a giant target on my back as the only person doing this kind of care. There was nothing that anyone, including the hospital, could do to protect me from criminal prosecution.”
Sending patients out of state for care that she could provide took an emotional toll, as did waiting hours to treat a woman in pain because she did not yet show infection after her water broke and because her fetus still had a heartbeat. But leaving her community, colleagues, patients and the region she grew up in was also hard.
“I made the decision that was best for me and for my family,” she said. “That doesn’t mean I don’t feel guilty over the fact that now I’m not there to take care of people.”
The recent changes to the Tennessee law do little to assuage her concerns.
“This doesn’t change the equation for anybody in that state,” she said. “It’s the same standard we were using before, where we still have to wait until someone is so sick to intervene.”
It can be really hard to see these patients not able to get certain care that they would have somewhere else. And then, to see bad things happen to them.
– Dr. Jessie Rizzuto
Zahedi-Spung also cautioned Tennessee lawmakers against taking relief in the recent OB-GYN match percentages. At some point, “there is going to be a vacuum effect,” she said. “People are not going to apply to these states.”
Finding rotations outside of Tennessee
Oregon Health and Science University in Portland, where abortion is allowed in each stage of pregnancy, saw a 15% increase in applicants for its OB-GYN residency program this year, said Dr. Alyssa Colwill, assistant professor in obstetrics and gynecology at OHSU. Dobbs was referenced as a reason for ranking OHSU at the top of their list among the program’s current intern class.
“I do think it is largely impacting residents’ decisions about where they are applying and what that means for their career trajectory,” Colwill said.
Oregon Health and Science University began offering month-long rotations for residents in states with more restrictive abortion bans in October in response to the training limitations programs in those states were facing. Within 10 days of posting what could be a dozen new rotation positions in March, OHSU received 23 applications, three of which were from Tennessee residents. Several residency programs have asked about partnering with the university so that each of their residents could rotate there. While rotations help some residents access needed training, they are not an adequate fix, Colwill said. She estimates about 1,100 residents across the U.S. will have more limited training under the more restrictive abortion laws.
There is just a lot of moral distress that comes from working in a restricted state. Most people who are going into residency are not considering whether or not the care they want to provide will be made illegal or whether they might go to jail for providing that care.
– Hannah Light-Olson, Tennessee medical student
“The amount of training that you would get over the course of four years at your home program really is going to be more comprehensive than what we can offer in this very kind of shortened elective rotation,” Colwill said.
Training in another state also means logistical and financial hurdles, such as finding and paying for housing and transportation. At OHSU, private donors have contributed funding to help out-of-state residents cover those costs and make it more accessible to physicians regardless of their means, Colwill said.
Rizzuto’s medical center is sending OB-GYN residents to New York City for month-long rotations to meet abortion care requirements and they will need to find housing. “Many people have families and it’s not easy for them to leave,” Rizzuto said.
Abortion laws and out-of-state training options will be among considerations for Nashville medical student Hannah Light-Olson as she ranks OB-GYN residency programs next year.
“Obviously, I would prefer to have the maximum ability to train,” Light-Olson said. “There is just a lot of moral distress that comes from working in a restricted state.” She added, “Most people who are going into residency are not considering whether or not the care they want to provide will be made illegal or whether they might go to jail for providing that care.”
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