Nina Nguyen, a third-year medical student at Quebec’s Université de Sherbrooke, has spent precisely 35 minutes learning about abortion in school — and all from a single case study she read in an ethics class. “It was about a 32-year-old woman who comes in to your office. She’s six weeks pregnant, she’s really nervous, and she wants an abortion because she’s in an abusive relationship,” Nguyen says. Students were asked a series of questions: What concerns you about the patient? What are the ethical values and principles in conflict? And what’s your personal stand on abortion? “That’s it,” she says. “Some groups only talked for 20 minutes.” Her class did, however, devote six hours of their obstetrics-gynecology unit to male anatomy and erectile dysfunction, working diligently through the physiology, statistics and potential treatments for the condition.
During Anjali Kulkarni’s second year of medical school at the University of Toronto (U of T), she also met once with a small group of classmates to discuss the ethics surrounding abortion. “We’d had a talk from a lawyer who gave a good history of abortion law in Canada,” she says, but the hypothetical cases they were then asked to review all concerned pregnant women suffering from rare diseases or issues of fetal anomalies. “There was nothing in it that was ‘A woman is pregnant and doesn’t want to be; what do you do?’ ” she says, nor was there any medical information.
Since 1988, when the Supreme Court struck down Canada’s abortion law — calling it a violation of a woman’s right to “life, liberty and security of the person” — abortion has, on paper at least, been governed by the same regulations as any other medical procedure in this country. Yet more than 25 years later, medical schools still tiptoe around the subject in the classroom. Despite the Supreme Court’s ruling, abortion remains a polarizing issue in the medical community; providers fear for their safety, and students struggle to find out where faculty members stand. Too often, it’s easier to simply avoid the subject altogether. Because there is no standardized curriculum for any medical discipline, by the mid-2000s, only half of Canada’s 17 medical schools offered some discussion about first-trimester surgical-abortion techniques. A recent study published in the journal Contraception found that in a third of schools, abortion isn’t raised in mandatory lectures at all.
That’s a patchwork approach to educating medical students about an enormously common procedure: Thirty-one percent of Canadian women under the age of 45 have terminated a pregnancy. In 2011 alone, the most recent year for which data is available, 92,524 abortions were reported. It’s safe to expect, then, that every physician in every discipline will encounter a patient who has had or is seeking an abortion. Women’s health specialists shouldn’t be the only ones getting training — all physicians ought to have a basic understanding of the procedure and its implications. This wouldn’t mean they’d have to perform one, since the Canadian Medical Association allows for conscientious objection. But the choice to terminate an unwanted pregnancy belongs to a woman alone. Once she makes that choice, she is entitled to a safe, timely and confidential abortion. That’s not a question of values: In Canada, it is a matter of law.
Still, the distribution of providers across this country is abysmal, especially outside our largest urban centres, where free-standing clinics — which perform some 57 percent of abortions — are predominantly located. Roughly one in six hospitals offers abortion services, nearly all of them concentrated within 150 km of the U.S. border. In July, New Brunswick’s sole private clinic closed, leaving two hospitals, and no more than four gynecologists, to provide all the province’s abortions. (Last Friday, however, it was announced that a new medical centre offering abortions would open in the old Fredericton clinic, after a crowdfunding campaign raised more than $125,000.) Women in the Yukon, Northwest Territories and Nunavut can have the procedure in just three hospitals. While Quebec has 46 abortion facilities, the Prairies combined have eight. Prince Edward Island has no provider at all. As a result, Canadian women in rural or remote areas often must travel great distances, out of pocket, to access an essential element of their reproductive care.
In many cases, medical schools have done little to help normalize what is, in this country, a very normal procedure. “Schools are not keen to court anything they perceive as controversial,” says Dr. Mei-Ling Wiedmeyer, a Vancouver-based family physician who graduated from Montreal’s McGill University in 2008 and completed a women’s health fellowship at U of T. “Medical schools as institutions are not typically brave. And it shouldn’t require any bravery, because abortion is a legal medical procedure that is clearly within their purview.”
When formal instruction falls short, it’s left to small groups of self-motivated students to educate themselves. An organization called Medical Students for Choice, which was founded in the U.S. in 1993 and now has chapters in 10 of Canada’s 17 schools, has been instrumental in pushing for curriculum reform, clinical electives and apprenticeships. Individual young men and women are also finding ways to arm themselves with knowledge, coordinating lunchtime lectures with abortion providers and arranging volunteer work in family-planning centres. “There are a lot of myths and misinformation about abortion and its complications out there,” says Kulkarni. “We need the raw data.”
Over the past year, pro-choice advocates have celebrated a string of victories in Canada. In September, Brian Gallant became the premier of New Brunswick after campaigning in part on the repeal of a bill that restricted access to abortion in the province. Less than two months later, he lifted a regulation mandating that two doctors had to certify the procedure as medically necessary, which had been in place for 30 years. In December, the College of Physicians and Surgeons of Ontario proposed a new policy that requires anti-abortion doctors to refer patients to another physician or they could face disciplinary action. And last spring, Liberal leader Justin Trudeau pledged that his incoming MPs would all vote in favour of a woman’s fundamental right to choose.
Another potential milestone is slated for later this year. Health Canada will finally decide on the approval of mifepristone, a pill that ends pregnancy in its early stages. Called an “essential medicine” by the World Health Organization, mifepristone is available in nearly 60 countries and used in roughly 60 percent of abortions in Europe, but has been languishing in Canada’s drug-approval bureaucracy since October 2012. Earlier last week, the Society for Obstetricians and Gynaecologists of Canada urged the federal regulator to approve the drug, although Health Canada, which had been set to rule in mid-January, has now deferred its decision until at least the fall, pending more information from the drug company.
One might imagine that medical schools would be on the front lines of these conversations, but students say the opposite is true. When Nguyen approached the Université de Sherbrooke faculty about increasing the breadth of information delivered about abortion — in particular, counselling and technique — she was told the curriculum was packed solid. “The reproductive unit is where students learn the essentials of women’s health,” says Dr. Guy Waddell, director of Sherbrooke’s obstetrics and gynecology department. “There are many subjects to cover during a month, so choices had to be made according to the learning objectives.” Classes delve into anatomy, puberty, menstrual problems, normal and abnormal pregnancies, pelvic pain, contraception, sexually transmitted infections, miscarriage, gynecologic cancer and menopause, but, he says, “We don’t talk about induced abortion.”
Faculty across Canada note that it isn’t the job of the schools to teach students every possible aspect of medicine, but instead to ensure they know how to find the information they need. “I have 28 days to teach these guys about the basics,” says Dr. Melissa Mirosh, an assistant professor at Saskatoon’s University of Saskatchewan who coordinates the female reproductive system unit. She acknowledges that abortion is a sensitive subject in medical school, “in the way that the breast, rectal and erectile exam is a sensitive subject.” But she emphasizes that the purpose of all curriculum is to give students “the taste of the tip of the spoon. When I talk about abortion, I try to keep it pretty crisp and to the point: Here it is, it’s out there, and if you’re interested, come talk to me because we can talk about it for a really long time. But I don’t know if chatting to the whole group is reasonable given the volume of material I’ve got to cover.”
For a young medical student, showing a curiosity in abortion isn’t always so simple. Particularly in smaller cities, they often worry about the personal implications of asking for instruction. When the doctor in a fertility clinic where Nguyen worked bristled at the mention of abortion, the student never raised the topic again. “Of course — she’s grading me,” Nguyen says. “I don’t want to make her angry.”
“Even though I was very interested,” says a fourth-year student at the University of Saskatchewan, “it wasn’t until I started my obstetrics internship that I knew who the abortion providers were in the area, because it’s not discussed — there’s absolutely a fear of stigma.” Her only classroom exposure consisted of a slide outlining termination options and referral obligations, as well as one ethics discussion so tense that students asked to drop the subject. “I was nervous to approach faculty because I never knew where they stood on the issue, and you wonder if it’s going to follow you when you’re trying to get accepted into a competitive residency.” (The student asked to remain anonymous after a guidance counsellor expressed concerns that an association with abortion provision might compromise her chance at a residency spot after graduation.)
Even in a major urban centre like Toronto, where U of T third- and fourth-year students receive a handbook indicating that abortions are happening in local hospitals and clinics and inviting them to learn about the procedure, few students show interest in the training. The faculty member and doctor responsible for that elective explained that while “the people who are keen seek it out,” most medical students “are busy; they have a lot of other things to do, and it’s not mandatory.” Mirosh agrees, “I can’t say I have people banging down my door.”
“You have to be so self-motivated to go through the training process in the first place,” says Wiedmeyer, who provides abortions as part of her practice in Vancouver. “Unless you specifically decide, ‘I’m going to take all the steps; I’m just going to persist’ — which is essentially what I did — there are so many levels at which you could drop out.”
When medical students do learn about abortion, though, it can have a measurable effect on their view of the procedure. Studies on abortion curricula are rare, but in 2008, Contraception found that after ob-gyn residents attended programs with integrated abortion training, they were not only more supportive of abortion and more likely to include it in their practice, but twice as likely to feel comfortable counselling patients about their options. Of course, for some, that is precisely the problem. “We have many people in positions of authority in medical schools and the community who are anti-choice,” says Joyce Arthur, executive director of the Abortion Rights Coalition of Canada. “They want to maintain the silence and stigma around abortion.”
It’s no small feat to bring change to a medical-school curriculum: It requires dedication, coordinated efforts, a network of support and unflagging patience when confronted with bureaucracy. But it can be done.
In her first week of medical school, Kulkarni received an email from the U of T chapter of Medical Students for Choice, introducing her to the club and its work. By second year, she and classmate Jillian Bardsley had become co-presidents, looking to add some medical information to their class’ ethical discussion on abortion. The pair organized meetings with school faculty, the course director and the pre-clerkship director. They were precise with their requests: statistics on the frequency of abortion in Canada, surgical and medical abortion techniques and an overview of the actual risks. They referred to more substantial lectures at other medical schools; Western University in London, Ont., which offers a two-hour pre-clerkship lecture on the medical and surgical aspects of abortion, was a touchstone. To counter any potential concerns from faculty about the material’s sensitivity, Kulkarni and Bardsley consulted with representatives from the women’s health elective, the developmental disability elective, and the respective associations for Jewish, Muslim and Christian medical students.
“Faculty first said, ‘Well, we don’t give a play-by-play of how to do an appendectomy,’ ” Bardsley says. “But abortion is something women ask about, and I don’t think you get the same questions with an appendectomy.” (Not to mention that roughly three times as many abortions are performed each year.) She adds that, yes, surgical abortion is very similar to the procedure involved during a miscarriage, and the drugs for medical abortion can be used elsewhere, but there are social and psychological issues unique to abortion that doctors must address.
Bardsley also notes that, in 2012, there was a U of T exam question about abortion and parental consent that baffled most students (in Canada, no law sets out the age of consent for the procedure, though most facilities have internal rules). She thinks the incident began to persuade faculty more information was required, so the following year, the school introduced an hour-long lecture on the basics of abortion and counselling as part of its second-year obstetrics and gynecology unit.
In 2008, Tara Cessford, then a medical student at Vancouver’s University of British Columbia (UBC), conducted a formal survey assessing her classmates’ understanding of abortion. At the time, the school offered a single third-year lecture, which she worried wasn’t enough to equip students to counsel patients about abortion. “Without skilled, experienced providers, women would not be able to access the full spectrum of reproductive health services they are entitled to in Canada,” Cessford says. “If medical students performed poorly [in the survey], I thought this might compel the school to reform their reproductive health training.” The medical students bombed.
Confronted with the results — as well as specific suggestions for incorporating training into the course load — UBC administrators added a session on abortion epidemiology to the school’s second-year curriculum in 2010. But family-planning faculty are still looking to add depth to their program. They have proposed that all medical students be required to spend a week in a women’s clinic, where they will learn about contraception, pregnancy options, counselling, abortion, ectopic pregnancy and miscarriage. The training should be implemented within the next few years.
In 2013, at the annual general meeting for the Canadian Federation of Medical Students (CFMS) in Quebec City, a small group broke off to create a position paper on abortion, in order to provide direction to the organization’s 8,000 members. Among its suggestions: that all students receive mandatory training in abortion (with exemptions for conscientious objection); that all students be tested on abortion in their licensing exams; and that the Committee on Accreditation of Canadian Medical Schools only accredit those universities that include training in abortion and counselling. “Ultimately, these are recommendations: The CFMS doesn’t exactly have any authoritative power,” says Kulkarni, who became the CFMS’s national officer of reproductive and sexual health last November. But there is momentum for change.
The possibility of prescribing mifepristone in the near future is further incentive to reexamine how physicians are trained, because the drug would put family doctors squarely at the centre of how abortion is carried out in this country. Mifepristone wouldn’t negate the need, or even the desire, for surgical abortion — some women would rather undergo a simple procedure under professional supervision than take a pill that produces a miscarriage at home. But once women are able to access highly effective medical abortion, they are no longer tied to a surgical facility, or to a specific doctor working within that facility.
Should Health Canada approve the use of mifepristone, the roughly 100,000 women who terminate an unwanted pregnancy each year would be able to turn to their physicians instead of designated abortion providers. That offers a substantial shift in access, particularly in rural or remote areas, and it opens up an opportunity for a new national conversation. Medical schools are uniquely positioned to educate this country on the facts of abortion and set the tone of the discourse. But they have to educate their students first.