INTRODUCTION
Medication abortion (MAB) is a safe and effective means of ending intrauterine pregnancy at ≤10 weeks gestation and can safely be performed in the primary care setting1. The FDA approved mifepristone for use in combination with misoprostol for MAB in 2000, and as of 2015, 35.8% of eligible abortions were completed using MAB.2 Patients want access to MAB through their primary care physician, citing improved privacy, convenience, and continuity of care as potential benefits3–5. Nonetheless, the majority of women seeking MAB in the USA attend abortion clinics6. This study aimed to understand internal medicine physician attitudes regarding training and provision of MAB.
METHODS
A unique link to a self-administered survey (see Table 1) was emailed to all residents (N=30) and attendings (N=22) in a primary care and social medicine internal medicine program using key survey, a secure on-line survey platform. All resident and attending physicians in this residency program practice in the same federally qualified health center in the South Bronx. Up to 3 reminder emails were sent to participants. Deidentified data were directly exported to Excel and analyzed manually. Qualitative data from the open-ended questions were analyzed using a grounded theory approach. Two authors independently used inductive coding to generate themes; there was no discordance between the themes identified by each author.
Table 1.
Survey Questions
| Resident questions | Answers | Attending questions | Answers |
|---|---|---|---|
| Do you think your patients would like to be able to access abortion medication in your continuity clinic? | Yes/no | Do you think your patients would like to be able to access abortion medication in your continuity clinic? | Yes/no |
| Would you like clinical experience in counseling patients on the options for terminating a pregnancy? | Yes/no | Are you interested in receiving clinical experience in medical abortion? | Yes/no/already trained |
| Are you interested in receiving clinical experience in medical abortion? | Yes/no | Once trained, would you be interested in providing medical abortion? | Yes/no |
| If trained, would you be interested inproviding medical abortion to your continuity patients? | Yes/no | Once trained, would you be interested in precepting residents in the provision of medical abortion? | Yes/no |
| How comfortable are you in determining gestational age less than or equal to 10 weeks by any method? | Very comfortable/somewhat comfortable/somewhat uncomfortable/very uncomfortable | How comfortable are you in determining gestational age less than or equal to 10 weeks by any method? | Very comfortable/somewhat comfortable/somewhat uncomfortable/very uncomfortable |
| If trained, do you intend to provide medical abortion in your post-residency practice? | Yes/no | ||
| If you have concerns about providing medical abortion at your continuity clinic, what are they? | Open-ended | If you have concerns about providing medical abortion at your continuity clinic, what are they? | Open-ended |
This study was approved by the Albert Einstein College of Medicine Institutional Review Board.
RESULTS
The resident response rate was 83.2% (n=25) and the attending response rate was 72.7% (n=16). All residents (100%) and most attendings (96%) believed that patients would like to be able to access MAB in their primary care clinic. All residents reported a desire to be trained in pregnancy options counseling, and all but one reported a desire to obtain clinical training in the provision of MAB (96%). 88% of residents intended to provide MAB after training. The majority of attendings (82%, n=13) also reported a desire to be trained. A majority (87.5%) of the attendings said that they would provide MAB if trained, and 75% would precept residents in MAB cases. Importantly, the majority of attendings (62.5%) and residents (68%) reported being either very or somewhat uncomfortable with determining gestational age by any method; this skill is required for the provision of medication abortion and traditionally is lacking in internal medicine curriculae.
Less than half of the respondents (43.8% of attendings and 32% of residents) answered the open-ended question exploring concerns about MAB provision at the clinic. Responses fell into the following themes: clinical competency (n=10), systems issues (n=10), individual workload (n=3), and legal (n=3) (see Table 2). Clinical competency concerns included determining gestational age and pregnancy location, providing comprehensive anticipatory guidance to patients, and identifying and managing complications. Residents’ systems-related concerns included low patient volumes as a potential barrier to achieving clinical competency. Residents and attendings had concerns about adequate follow-up. One attending noted the importance of obtaining buy-in from other staff such as nurses, front desk staff, and administrators. Residents and attendings expressed workload concerns, noting their doubts about being allotted sufficient time to provide MAB. Finally, both residents and attendings expressed concerns about legal ramifications for providing this service.
Table 2.
Thematic Analysis of Concerns
| Codes | Themes |
|---|---|
|
- Ability to appropriately date pregnancies (2) - Ability to determine intrauterine pregnancy (2) - Ability to provide comprehensive anticipatory guidance (1) - Ability to identify and manage complications (3) - Ability to gain experience to feel comfortable providing MAB (2) |
Clinical competency (10) |
|
- Ensuring adequate training and patient volume (2) - Ensuring supervision (1) - Uncertainty about demand (1) - Ensuring appropriate follow-up, including access to OB if needed and ability of patients to reliably contact MD/RN with questions (5) - Achieving buy-in from clinic administrators/staff (1) |
Systems issues (10) |
|
- Ensuring enough time allotted in the schedule (2) - Taking on too many responsibilities (1) |
Individual workload (3) |
|
- Losing federal funding (2) - Compliance with regulations (1) |
Legal (3) |
DISCUSSION
Reproductive health is a component of US internal medicine residency training. With mounting evidence that MAB is a safe, effective, and desired form of terminating a pregnancy in the primary care setting, it is important to explore internist interest in providing this service. This study offers evidence that some primary care internists feel that the provision of MAB is within the scope of their practice and are interested in receiving MAB training. This study also highlights that internists have some specific concerns about MAB provision, which may represent barriers to MAB training uptake in internal medicine programs and merit further evaluation.
This small study was performed in a primary care internal medicine residency program committed to social medicine. Interest in training and provision of MAB may be higher among this group than in other internal medicine programs, and some concerns described in this study may be practice site specific. Larger studies are needed to see if these findings are generalizable to other internal medicine programs.
Declarations
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.National Academies of Sciences, Engineering, and Medicine. 2018. The Safety and Quality of Abortion Care in the United States. Washington, DC: The National Academies Press. 10.17226/24950 Last accessed 12/30/2020. [PubMed]
- 2.Jatlaoui TC, Boutot ME, Mandel MG, Whiteman MK, Ti A, Peterson E, et al. Abortion Surveillance — United States, 2015. MMWR Surveill Summ. 2018;67(SS-13):1–45. doi: 10.15585/mmwr.ss6713a1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Wu JP, Godfrey EM, Prine L, Andersen KL, MacNaughton H, Gold M. Women’s satisfaction with abortion care in academic family medicine centers. Fam Med. 2015;47(2):98–106. [PubMed] [Google Scholar]
- 4.Summit AK, Casey LM, Bennett AH, Karasz A, Gold M. “I Don’t Want to Go Anywhere Else”: Patient Experiences of Abortion in Family Medicine. Fam Med. 2016;48(1):30–34. [PubMed] [Google Scholar]
- 5.Page C, Stumbar S, Gold M. Attitudes and preferences toward the provision of medication abortion in an urban academic internal medicine practice. J Gen Intern Med. 2012;27(6):647–652. doi: 10.1007/s11606-011-1956-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Jones RK, Jerman J. Abortion incidence and service availability in the United States, 2011. Perspectives on Sexual and Reproductive Health. 2014;46(1):3–14. doi: 10.1363/psrh.12015. [DOI] [PubMed] [Google Scholar]