For the first 57 minutes of the basketball game between two Bend, Oregon, high school rivals, Kyra Rice stood at the edges of the court taking yearbook photos. With just minutes before the end of the game, she was told she had to move.

Kyra pushed back: She had permission to stand near the court. The athletic director got involved, Kyra recalled. She let a swear word or two slip. 

Kyra has anxiety as well as ADHD, which can make her impulsive. Following years of poor  experiences at school, she sometimes became defensive when she felt overwhelmed, said her mom, Jules Rice. 

But at the game, Kyra said she kept her cool overall. Both she and her mother were shocked to learn the next day that she’d been suspended from school. 

“OK, maybe she said some bad words, but it’s not enough to suspend her,” Rice said. 

The incident’s discipline record, provided by Rice, lists a series of categories to explain the suspension: insubordination, disobedience, disrespectful/minor disruption, inappropriate language, non-compliance. 

Broad and subjective categories like these are cited hundreds of thousands of times a year to justify removing students from school, a Hechinger Report investigation found. The data show that students with disabilities, like Kyra, are more likely than their peers to be punished for such violations. In fact, they’re often more likely to be suspended for these reasons than for other infractions.

For example, between 2017-18 and 2021-22, Rhode Island students with disabilities were, on average, two and a half times more likely than their peers to be suspended for any reason, but nearly three times more likely to be suspended for insubordination and almost four times more likely to be suspended for disorderly conduct. Similar patterns played out in other states with available data including Massachusetts, Montana and Vermont. 

Federal law should offer students protections from being suspended for behavior that results from their disability, even if they are being disruptive or insubordinate. But those protections have significant limitations. At the same time, these subjective categories are almost tailor-made to trap students with disabilities, who might have trouble expressing or regulating themselves appropriately.

Districts have wide discretion in setting their own rules and many students with disabilities quickly earn reputations at school as troublemakers. “Unfortunately, who gets caught up in a lot of the vagueness in the codes of conduct are students with disabilities,” said attorney Robert Tudisco, an expert with Understood.org, a nonprofit that provides resources and support to people with learning and attention disabilities.

Related: When your disability gets you sent home from school

Students on the autism spectrum often have a hard time communicating with words and might yell or become aggressive if something upsets them. A student with oppositional defiant disorder is likely to be openly insubordinate to authority, while one with dyslexia might act out when frustrated with schoolwork. Students with ADHD typically have a hard time controlling their impulses.

Kyra’s disability created challenges throughout her school career in the Bend-La Pine School District. “Nobody really understood her,” Rice said. “She’s a big personality and she’s very impulsive. And impulsivity is what gets kids in trouble and gets kids suspended.” 

Kyra, now 17, said that too few teachers cared about her individualized education program, or IEP, a document that details the accommodations a student in special education is granted. She’d regularly butt heads with teachers or skip class altogether to avoid them. Her favorite teacher was her special ed teacher. 

“She understood my ADHD and my other special needs,” Kyra said. “My other teachers didn’t.”

Scott Maben, district spokesperson, said in an email he could not comment on specific disciplinary matters because of privacy concerns, but that the district had a range of responses to deal with student misconduct and that administrators “carefully consider a response that is commensurate with the violation.” 

In Oregon, “disruptive conduct” accounted for more than half of all suspensions from 2017-18 to 2021-22. The state department of education includes in that category insubordination and disorderly conduct, as well as harassment, obscene behavior, minor physical altercations, and “other” rule violations. 

Disruptive behavior is the leading cause of suspensions because of its “inherently subjective nature,” the state department of education’s spokesperson, Marc Siegal, said in an email. He added that the department monitors discipline data for special education disparities and works with school districts on the issue. 

The primary protections for students with disabilities come from the federal government, through the Individuals with Disabilities Education Act, or IDEA. But that law only requires districts to examine whether a student’s behavior stems from their disability after they have missed 10 total days of school through suspension. 

At that point, districts are required to hold a manifestation hearing, in which officials must determine whether a student’s behavior was the result of their disability. “That’s where it gets very gray,” Tudisco said. “What happens in the determination of manifestation is very subjective.”

In his experience, he added, the behavior is almost always connected to a student’s disability, but school districts often don’t see it that way. 

“Manifestation is not about giving Johnny or Susie a free pass because they have a disability,” Tudisco said. “It’s a process to understand why this behavior occurred so we can do something to prevent it tomorrow.” 

Related: Senators call for stronger rules to reduce off-the-books suspensions

The connections are often much clearer to parents. 

A Rhode Island mother, Pearl, said her daughter was easily overwhelmed in her elementary school classroom in the Bristol Warren Regional School District. (Pearl is being referred to by her middle name because she is still a district parent and fears retaliation.) 

Her child has autism and easily experiences a sensory overload. If the classroom was too loud or someone new walked in, she might start screaming and get out of her seat, Pearl said. Teachers struggled to calm her down, as other students were escorted out of the room. 

Sometimes, Pearl was called to pick up her daughter early, in an unrecorded informal removal. A few times, though, she was suspended for disorderly conduct, Pearl recalled. 

Between 2017-18 and 2020-21, students with disabilities in the Bristol Warren Regional School District made up about 13 percent of the student body, but accounted for 21 percent of suspensions for insubordination and 30 percent of all disorderly conduct suspensions. 

The district did not respond to repeated requests for comment. 

The Rhode Island Department of Education collects data on school discipline from districts, but special education and discipline reform advocates in the state say that the agency rarely acts on these numbers. 

Department spokesperson Victor Morente said in an email that the agency monitors discipline data and is “very clear that suspension should be the last option considered.” He added that the department has published resources about alternatives to suspension and discipline specifically for students with disabilities. 

A 2016 state law that limits the overall use of out-of-school suspensions also requires that districts examine their data for inequities. Districts that find such disparities are supposed to submit a report to the department of education, said Hannah Stern, a policy associate at the Rhode Island American Civil Liberties Union.

Her group submits public records requests for copies of their reports every year, but has never received one, she said, “even though almost every single school district exhibits disparities.”

Related: Sent home early: Lost learning in special education

Pearl said that her daughter needed one-on-one support in the classroom instead of punishment. “She’s autistic. She’s not going to learn her lesson by suspending her,” Pearl said. “She actually got more scared to go back. She actually felt very unwelcome and very sad.”

Students with autism often have a hard time connecting their actions to the punishment, said Joanne Quinn, executive director of The Autism Project, a Rhode Island-based group that offers support to family members of people with autism. With suspension, “there’s no learning going on and they’re going to do the same thing incorrectly.”

Quinn’s group provides training for schools throughout Rhode Island and beyond, aimed at helping teachers understand how the brain functions in people with autism and offering strategies on how to effectively respond to behavior challenges that could easily be labeled disobedient or disorderly. 

Federal law provides a road map for schools to improve how they respond to misconduct related to a student’s disability. Schools should identify a student’s triggers and create a behavior intervention plan aimed at preventing problems before they start, it says. 

Related: How a disgraced method of diagnosing learning disabilities persists in our nation’s schools

But, doing these things well requires time, resources and training that can be in short supply, leaving teachers feeling alone, struggling to maintain order in their classrooms, said Christine Levy, a former special education teacher and administrator who works as an advocate for individual special education students in the Northeast, including Rhode Island. 

Levy recently worked with a student with disabilities who was suspended after he tickled a peer at a locker on five straight days. But, she said, the situation should have never reached the point of suspension: Educators should have quickly identified what the boy was struggling with and set a plan in motion to help him, including modeling appropriate locker conduct. 

Had this boy’s teachers done that, the suspension could have been avoided. “The repair of that is so much longer and so much harder to do versus, let’s catch it right away,” she said.

Many parents described similar situations, though, in which a child routinely got in trouble for repeated behavior. When Michelle Gomes’s daughter became upset in her kindergarten classroom, she’d often run out and refuse to come back in. Sometimes, she’d tear things off the walls.

“Whenever she gets like that, it’s hard to see,” Gomes said. “I hurt for her. It’s like she’s not in control.”

Gomes received regular calls from Cranston Public School officials to come pick her daughter up. A couple of times, the child was formally suspended, Gomes said. The school described her as a safety risk, Gomes recalled.

“She obviously doesn’t feel safe herself,” she said. 

Cranston Public Schools did not respond to requests for comment. 

Gomes’s daughter had a speech delay and anxiety and qualified for special education services. A private neurological evaluation concluded that she was compensating for that delay with her physical responses, Gomes said. 

This can be a common cause of behavior challenges for students with disabilities, experts say.

“Behavior is communication,” said Julian Saavedra, an assistant principal and an expert at Understood.org.* “The behavior is trying to tell us something. We as the IEP team, the school team, have to dig deeper.” 

On her own, Gomes found strategies that helped. Gomes’ child struggled with transitions, so they’d go over her day in advance to prepare her for what to expect. A play therapist taught both her and her daughter breathing exercises. 

Her daughter was switched to another district school where a social worker would sometimes walk the girl to class. When the child got worked up, she’d sometimes be allowed to sit with that social worker or in the nurse’s office to calm down. That helped, but sometimes, those staff members weren’t available. 

In the end, Gomes moved her daughter to a school outside the district that was better equipped to help the girl deescalate. Her behavior problems lessened and she started enjoying going to school, Gomes said.

But Gomes still can’t understand why more teachers weren’t able to help her child regulate herself. “Do we need retraining or do we need new training?” she said. “Because this is mindblowing to me, not one of you can do that.”

Note: The Hechinger Report’s Fazil Khan had nearly completed the data analysis and reporting for this project when he died in a fire in his apartment building. USA TODAY Senior Data Editor Doug Caruso completed data visualizations for this project based on Khan’s work.

CORRECTION: This article has been updated with the correct spelling of Julian Saavedra’s name.

This story about suspension of students with disabilities was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger newsletter.

The post Students with disabilities often snared by subjective discipline rules appeared first on The Hechinger Report.

MINERAL WELLS, Texas — On many Friday nights in this rural stretch of north Texas, you can find Judith Echanique working the concession stands, flush with local fans. 

“I’m always here,” said Echanique, whose 10th-grade daughter and fifth-grade son attend the local public schools. On this February night, she was serving hot dogs, nachos, soda and candy to boosters of the JV and varsity soccer teams. “I was telling my daughter, even if you’ve graduated high school, I will still always come and volunteer, because I love being a mom and I love being involved in the community.” 

In Mineral Wells — a town of about 15,000 located 90 minutes west of Dallas — community members come together to cheer on sports teams, celebrate homecoming and applaud the school choir.

They’re familiar rituals in rural communities throughout the state, where public schools can play an outsized role, serving as social and cultural hubs, major employers and sources of collective pride and community identity. 

“I truly believe the school district is the heart of our town,” said Melanie Stubblefield, who teaches music in the fourth, fifth and sixth grades at Travis Elementary School in the Mineral Wells district, which has about 3,230 students spread across its seven schools.  

A slate of defiant Texas Republican lawmakers agreed. Last legislative session, they repeatedly refused to support a school voucher proposal championed by their Republican governor, Greg Abbott. The program would have allowed any Texas student to use public money to offset the cost of private-school tuition, but skeptical lawmakers worried the plan would divert dollars from public schools, tightening district budgets without a proportionate reduction in costs.

Republicans nationwide, many of whom already supported such private school vouchers, seized upon the issue following the pandemic, using parents’ frustration with remote schooling as one reason to expand these options. Abbott pitched his version as an effort to empower parents. 

“Our schools are for education, not indoctrination,” Abbott said at an event at the capital last spring. “The solution to this problem is empowering parents to choose the school that’s right for their child.” His office did not respond to several requests for comment.

Related: Florida just expanded school vouchers — again. What does that really mean?

The governor worked to court support by tying the passage of his voucher plan to a $7.6 billion funding boost for public schools that included teacher pay raises. Still, a stalwart group of 21 House lawmakers, most of whom represent rural areas and fear the measure would pull resources away from their public schools, sided with state Democrats to torpedo the legislation. 

“Abbott wanted them to bend the knee and kiss the ring, and they’re just not going to do it. That ain’t Texas,” said Rev. Charles Johnson, executive director of Pastors for Texas Children, a public-school advocacy group. “It is Texan to vote in the interest of your community and constituents.”

Others insist the governor’s plan would have little impact on high-performing public schools, where parents are satisfied and unlikely to pull their students. For parents who aren’t, vouchers provide an alternative. 

“We cannot ignore these cries from parents who are saying, ‘Can we please acknowledge that there are some kids that could be better served with a different option?’ That’s what empowering parents is all about,” said Mandy Drogin, who directs Texas Public Policy Foundation’s Next Generation Texas campaign. “We trust individuals to make the best choices for their lives and their families.”

Now, Abbott is targeting the holdouts, many of whom he backed in past contests, in a manner similar to what Republican Gov. Kim Reynolds did in Iowa in 2022, when she endorsed challengers during the primary, helping elect lawmakers who would support her school choice bill. Abbott has crisscrossed the state to stump for their challengers and used his own war chest, lined with a $6 million donation from a Pennsylvania billionaire who supports private school vouchers, to help power pro-voucher candidates’ campaigns ahead of the March 5 primary. 

In many of these districts, the primary election will decide the winner of the race, with Democrats or other challengers unlikely to prevail during the general election in deeply conservative regions.  

The fight over vouchers generally divides Democrats and Republicans, but along with rural resistance in Texas, conservative rural lawmakers in Iowa, Oklahoma and Georgia have battled with their Republican counterparts over the issue, too. Last year, Oklahoma passed a measure that finally satisfied House Speaker Charles McCall, who hails from the rural town of Atoka (3,000-plus residents) and had previously rejected private-school subsidies in the deep-red state. Georgia has yet to find a measure that all members of the state GOP will back, although Republican Gov. Brian Kemp is trying again this year. 

For some in Texas, Abbott’s primary endorsements represent a betrayal.  

“It was the rural communities that gave the governor his double-digit win. We are conservative at the very core. That’s just who we are,” said Randy Willis, executive director of the Texas Association of Rural Schools. “That the governor wants to go after our conservative leaders and say they’re not conservative enough. It’s just wrong.”

Related: Arizona gave families public money for private schools. Then private schools raised tuition

At a mid-February campaign event in Springtown, Texas, Republican Rep. Glenn Rogers, a two-term incumbent who represents Parker, Palo Pinto, and Stephens County, was on the defensive. 

“These last two sessions have been the most conservative in Texas history,” Rogers told the crowd. “The governor and I have agreed on every single legislative priority. I have supported 100 percent of his priorities except one, and y’all probably know what that is: vouchers.” 

The sixth-generation rancher has conservative credentials. He’s been endorsed by the NRA and the anti-abortion group Texas Alliance for Life and helped pass bills to ban gender-affirming medical care for minors, severely restrict abortion access, shut down diversity and equity programs at state universities and invest in border security. 

Still, his stance on vouchers cost him the governor’s endorsement. Now, alongside more than a dozen incumbents up for re-election, Rogers finds himself in a tight primary race against the governor’s pick, Mike Olcott. 

According to Rogers, nearly 90 percent of the messages his office received from constituents during the special sessions were to voice opposition to vouchers. 

“We need to get away from this crazy talk that Republicans can’t pay for public schools and it’s not conservative,” Rogers said. “There’s nothing more conservative than supporting our public schools.”

Under the proposed plan, if a parent chose to use the voucher benefit, state funding — once allocated to the student’s public school — would follow the student to their private school. According to an analysis from the nonpartisan public policy nonprofit Every Texan, if just 1 percent of the public-school population in Rogers’ district chose to use school vouchers, schools would stand to lose more than $4 million in state money. At a 5 percent usage rate, that funding loss jumps to more than $21 million.

School administrators say that kind of hit would devastate already tight operating budgets — strained by declining enrollment after the pandemic and evaporating federal relief funding. And in rural communities without comprehensive private-school options, residents feel they have little to gain from a voucher plan. 

“We accept all-comers to our school district,” Mineral Wells Superintendent John Kuhn said. “We don’t turn kids away and say, ‘I’m sorry, we can’t handle your disability, or you don’t belong here.’ That, to me, is the state’s responsibility — not to pick and choose who gets an education.”

Ashley Mooneyham, an instructional coach in the Springtown school system, attended the Rogers event with two district colleagues. Mooneyham said she typically avoids engaging in politics, but the voucher issue motivated her to attend and speak out on social media. 

“I never post anything political at all, and I’ve been posting pretty frequently. I’m just trying to get the word out as much as possible,” Mooneyham said. “It’s really scary to me. I don’t think people understand how close vouchers are to getting passed in Texas and how drastically that’s going to change everything.”

Related: School choice had a big moment in the pandemic. But is it what parents want for the long run?

Calvin Jillson, a professor of political science at Southern Methodist University in Dallas, said while he expects most incumbents to survive their primary challenges, Abbott has gained ground.  

“He’s already been successful in a few cases where a member he would have targeted decided not to run for reelection,” said Jillson. “They may have made that decision for other reasons, but certainly, the idea of running against the governor was unappealing.”

Jillson said Abbott could exert even more influence if he’s able to flip even a few seats through his primary endorsements.

“If the governor were able to dislodge several incumbents, particularly respected incumbents who’ve been around for a while, that would put the fear of God in others,” Jillson said.

Despite their potential political cost, vouchers are not a central talking point in the campaign. Although the issue is divisive among Republicans, it’s not necessarily animating. 

Related: TikTok billionaire spends millions on Texas candidates who support school voucher efforts

A poll in early February from the University of Houston’s Hobby School of Public Affairs found that 60 percent of Republican primary voters would be “less likely” to support an incumbent representative who voted against voucher legislation. Yet another recent poll by the Texas Politics Project at the University of Texas at Austin found that only 2 percent of Republican primary voters listed vouchers as a “most important” issue. 

“The No. 1 issue is the border; No. 2 is property taxes and inflation,” said Rogers. “When we go door to door, rarely do [vouchers] come up, and we don’t lead with it. We lead with the border because that’s what voters care about the most. But boy, if they give us a foot in the door, we’re ready to talk about it.”

Rogers’ challenger, Olcott, has a platform that mirrors his opponent’s on gun rights, abortion and border security. Olcott lists his support for Abbott’s universal school choice plan second-to-last on his website’s list of issues. 

 When it does come up, however, the governor and Olcott pitch the voucher plan as a necessary response to “woke ideology” circulating in public schools, providing parents with freedom to protect their children from indoctrination.  

But rural educators have pushed back on those talking points, insisting their districts operate far from the culture wars of urban centers. 

“That word [indoctrinate] always gets us fired up,” said Mooneyham. “If we could indoctrinate students, we would indoctrinate them to put their names on their paper or turn in their homework, things like that.”

At stake — according to some rural educators — is not just an election result, but the future of conservative, rural life. 

“What are you going to do when that school district that is the main employer of that small town has to shutter its doors, and that little town just disappears? What happens to all of the traditions and all the memories people had of that school district?” said Brandon Dennard, superintendent of the Red Lick school district in Texarkana, Texas.  

“The very thing you profess to love, you’re trying to destroy.”

This story about Texas school vouchers was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger newsletter.

The post The school choice plan that is controversial, even in Texas appeared first on The Hechinger Report.

SIOUX FALLS, S.D. — The journey to Boston was more than 1,500 miles. The plane ticket cost about $500. The hotel: another $400. She felt a little guilty about going, knowing that not everyone could afford this trip. But it was important; she was headed there to learn. 

So, Amrita Bhagia, a second-year medical student from Sioux Falls, South Dakota, caught that flight to Boston to attend a weekend workshop hosted by the American College of Obstetricians and Gynecologists. There, she joined medical students from around the country for a summit on abortion care. She learned about medication abortion, practiced the technique of vacuum aspiration using papayas as a stand-in for a uterus, and sat in on a workshop about physician’s rights. 

“It was the most empowering thing I could have imagined, especially coming from a state where people don’t want to talk about this stuff, ever,” said Bhagia, an aspiring OB-GYN at the University of South Dakota, a state where abortion is banned. “Other than me flying to Boston to go to an ACOG workshop, I have no idea how to get that training.” 

Even before Roe v. Wade was overturned last summer, access to abortion training was uneven. Medical schools are not required to offer instruction on it, and students’ experiences vary wildly based on their institution. 

But for Bhagia and med students like her in states where abortion has been banned or severely restricted, those training opportunities have gone from not great to nonexistent.

As a result of this insufficient gynecological training, experts warn, a generation of doctors will be ill-equipped to meet their patients’ needs. And across the country, maternal-care deserts will likely expand, as graduating medical students and residents avoid abortion-restricted states.

More than 30,000 medical students are training in states with abortion bans. Another 1,400 OB-GYN residents, who are required to receive abortion training as part of their specialty, are studying in states where abortion is banned or severely restricted. 

“There’s a concern that in states with these restrictions, students are simply not getting enough training and exposure,” said Jody Steinauer, an OB-GYN, medical educator and director of the Bixby Center for Global Reproductive Health at the University of California, San Francisco. “There’s really a worry that if this continues, you’re going to be training a large group of OB-GYNs who can’t provide patient-centered, evidence-based care, no matter where they practice.”

“I would love to stay in Texas and train. This is a fantastic institution and I want to serve this community. But if I can’t get the training I need, I will have to leave.”

Chelsea Romero, a third-year medical student at McGovern Medical School in Houston, Texas

A related concern: Fewer medical students will choose to become OB-GYNs at all, fearing lawsuits or criminal prosecution. Figures show that OB-GYN residency applications are down across the country, but programs in states with abortion bans saw the biggest drops. Application rates for family medicine programs experienced a similar decline.

Abortion is currently banned in 14 states. All offer a narrow exception to this blanket prohibition when the mother’s life is at risk and a few of these states allow abortions in cases of rape or incest. But doctors say guidance on maternal health exceptions remains unclear, leaving physicians vulnerable to potential prosecution when treating patients.

“Students are seeing us struggle with this stuff and they’re like, ‘Yeah, why would I stay here for this?’” said Amy Kelley, a Sioux Falls OB-GYN and clinical associate professor at the University of South Dakota, a state where doctors can face up to two years in prison for violating the state’s ban.

These developments are particularly worrisome in South Dakota and other rural states that are already struggling to recruit and retain maternal healthcare providers. More than half of the state’s counties have no OB-GYNs, and rural South Dakotans with high-risk pregnancies often have no choice but travel to Sioux Falls for specialty care.

Limited access to maternal health care is reflected in troubling maternal mortality rates in abortion-restricted states across the country, where mothers are three times as likely to die due to their pregnancy, according to recent research. Barriers to abortion training could amplify physician shortages, increasing the number of maternal-care deserts and posing even greater risk to maternal health.

“We already have a physician shortage in this country,” said Pamela Merritt, a reproductive rights activist and director of Medical Students for Choice. “And we have the maternal health outcomes that come with that shortage. We have the worst pregnancy outcomes in the developed world. The last thing I want to see is people either having an insufficient education yet providing care, or people not even thinking of OB-GYN as a specialty in certain states.”

Although medical schools’ curricula vary, the Accreditation Council for Graduate Medical Education requires OB-GYN residency programs to provide access to abortion training. Residents with moral or religious objections are allowed to opt out. It’s a key component of an OB-GYN’s training, even for doctors who have no plans of becoming abortion providers.

An OB-GYN must be able to evacuate a uterus — whether the skill is used to care for a patient who’s had an incomplete miscarriage, to remove polyps for cancer diagnosis or assist someone who wants to terminate an unwanted pregnancy — and doctors-in-training can develop this ability through clinical abortion training. 

“Such training is directly relevant to preserving the life and health of the pregnant patient in some instances,” ACGME program requirements state.

Yet in states with abortion bans, direct access to that training has vanished. In the past year, program directors in those states have scrambled to find out-of-state training opportunities so their residents can fulfill OB-GYN program accreditation requirements. But identifying and coordinating those training opportunities is no small feat.

“A lot of programs are grappling with the logistics piece of partnering with another institution to send a resident somewhere else,” said Alyssa Colwill, an assistant professor of obstetrics and gynecology at Oregon Health & Science University, who directs the university’s OB-GYN Ryan Residency program. OHSU plans to host a dozen out-of-state learners for four- to six-week clinical rotations during this academic year. 

Programs like these require significant behind-the-scenes orchestration and space is limited. Visiting learners must apply for a medical license in their new state, complete required hospital training, take out new malpractice insurance, and secure housing and transportation.

More than half of South Dakota’s counties have no OB-GYNs; rural South Dakotans with high-risk pregnancies often have no choice but travel to Sioux Falls for specialty care.

In addition, programs in abortion-restricted states must often cope with the loss of a team member while residents travel for training.

“Programs really need their residents for services they provide,” said Colwill. “It’s not the easiest ask, to have a resident be gone from all clinical duties at their site for a month at a time.”

And while the overturn of Roe has had the most profound impact on residency programs, medical students who are not yet in a residency say they’re also feeling its effects. Doctors-in-training spend four years in medical school before beginning a residency in their chosen specialty.

“Bringing abortion up feels like a violation because it’s so taboo now,” said Bhagia. “I don’t know if I can even ask questions, and that’s impeding my learning.”

Chelsea Romero, a third-year medical student at McGovern Medical School in Houston, Texas, where abortion is restricted, said she has never faced repercussions for discussing abortion, but the risk of consequences is always on her mind. 

“As a student, you’re being evaluated constantly, and these evaluations can dictate if you get residency interviews or not,” said Romero, who stressed she spoke only for herself and not as a representative of her university. “If I have those conversations with a wrong person in power, I could face blowback.” 

One year after Roe was overturned, this stifled learning environment appears to be having an influence on where medical students are applying to residencies. One recent survey of medical students found that 58 percent of those responding were unlikely to apply to a residency program in a state with abortion restrictions, regardless of their specialty. 

“I would love to stay in Texas and train. This is a fantastic institution and I want to serve this community,” said Romero. “But if I can’t get the training I need, I will have to leave.”

“Where you train is where you stay. It is rare that a resident will train in California and then move to rural South Dakota; it just doesn’t happen.”

Yalda Jabbarpour, a family physician and director of the Robert Graham Center, the American Academy of Family Physicians’ policy and research center

Decisions like hers will have ripple effects for the physician workforce in the coming years, said Yalda Jabbarpour, a family physician and director of the Robert Graham Center, the American Academy of Family Physicians’ policy and research center. “Where you train is where you stay,” she said. “It is rare that a resident will train in California and then move to rural South Dakota; it just doesn’t happen.”

That’s exactly what worries Erica Schipper, an OB-GYN in Sioux Falls.

South Dakota is one of only six states in the country without an OB-GYN residency program, which means medical students who want to become OB-GYNs must leave the state to receive their training. Schipper, who also teaches medical students at the USD Sanford School of Medicine, said the state’s abortion ban will make recruitment even harder. 

“When I look at some of the brightest, up-and-coming medical students who we’ve sent away for their residency, we’re hoping they’ll come back, but I suspect they’re thinking twice,” said Schipper. 

One of those students is Morgan Schriever, a Sioux Falls native and a graduate of USD’s Sanford School of Medicine. Schriever is a second-year OB-GYN resident at Southern Illinois University who said she always planned to return to her home state. But after training in Illinois, where abortion is protected, she’s having second thoughts. 

Schriever is not only concerned that she would be unable to provide elective abortions in her home state. She’s also worried that South Dakota’s restrictive law would impede her ability to provide medically necessary abortions when treating patients experiencing pregnancy loss.

“Being in practice in Illinois, I come across these scenarios where I picture myself in South Dakota and I’m like, ‘Oh my God. How would I have handled this?’ I’m just not sure I want to put myself in that position where essentially my license is on the line.”

“There’s really a worry that if this continues, you’re going to be training a large group of OB-GYNs who can’t provide patient-centered, evidence-based care, no matter where they practice.”

Jody Steinhauer, director of the Bixby Center for Global Reproductive Health

These latest recruitment challenges particularly affect states already grappling with an OB-GYN shortage and struggling to improve maternal health care.

“Abortion-restrictive states are the same states that are traditionally rural and have a really hard time attracting physicians,” said Jabbarpour, “so any decline in those states is troublesome.”

Heather Spies, an OB-GYN who trains family medicine and general surgeon residents at Sanford Health, a hospital system in Sioux Falls, said the Sanford system is ensuring its residents are trained in basic obstetrics and gynecology care, including labor and delivery and miscarriage care. Even with the state’s abortion ban in place, she said, doctors at Sanford are able to provide miscarriage care and treat most pregnancy complications. 

“I don’t think those learning experiences have changed because the procedures that we do at Sanford haven’t changed,” said Spies. 

Still, there are some healthcare needs that require specialty care, certain medical emergencies that demand the expertise of an OB-GYN. And as abortion bans undermine training and push OB-GYNs out of restricted states, public health experts say they’re worried maternal-care deserts across the country will grow even drier.

“In the dead of a South Dakota winter blizzard, if you can’t get that helicopter to where it needs to go and that mom and that baby are in danger, you’re much more likely to save those lives if you have a doctor nearby,” said Schipper.

This story about OBGYN training was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for the Hechinger newsletter.

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Bridging digital distances

Ayush Agarwal loves speech and debate. When the pandemic forced debate tournaments online during his sophomore year in high school in San Jose, California, he realized what it meant to live on the other side of the digital divide.

Many of Ayush’s friends at other schools across the city didn’t have a computer or a stable internet connection to participate in online tournaments or sessions. Then, on a Reddit debate channel, he saw postings from around the country like, ‘Hey, I need help; I can’t get into these online tournaments,’ or ‘I can’t access Zoom because my internet’s too slow,’ Ayush, 17, said.

“That, to me, was just really disheartening,” he said. “These guys are fantastic debaters. They’re probably better than me, but they simply won’t be able to attend the tournament, not because they didn’t qualify for it, but just because they don’t have the capability resource-wise.”

So Ayush — now a senior at Basis Independent Silicon Valley, a private school in San Jose — decided to do something about it.

In March 2021, he and three other students, from Evergreen Valley High School and Leland High School in San Jose, started a nonprofit called ClosingTheDivide, which collects used electronic devices and refurbishes them, then donates them to low-income families and students.

The group doesn’t stop at giving out devices. “We also focus on other aspects of technological proficiency,” Ayush said, such as helping low-income residents connect to internet discounts through the Affordable Connectivity Program and to digital literacy initiatives like coding classes.

Since its launch, he said, the nonprofit has expanded to 29 chapters in the United States, Asia, Africa and Europe — led entirely by high school students.

The students have managed to donate more than 1,145 devices; received about $32,000 in grants; collaborated with 10 sponsors and 32 corporate partners; and started 12 computer labs — six in Tanzania, one in Cambodia and five in California.

Recently the students applied for and received a $17,500 grant from the San Jose Digital Inclusion Partnership, a project sponsored by the city, to help them combat the digital divide in their own backyard.

JAVERIA SALMAN

Learning from baseball umpires’ errors

Can baseball teach us something about our short attention spans? A study of major league umpires found that they called balls and strikes more accurately during critical moments in a game. Yet immediately after these moments of intense concentration, umpires made notably more errors. (Thanks to video technology called PITCHf/x, we can tell when they get it right and wrong.)

The good news, according to this study, is that humans can quickly reset their attention spans. No increase in errors was detected after the end of each half inning, when umpires take a two-minute break. Results would need to be replicated in classroom settings, but there is reason to think that students’ attention spans similarly deplete during the school day and that well-timed short breaks could help them.

“People’s ability to pay attention is an exhaustible resource,” James E. Archsmith, an economist at the University of Maryland and one of the researchers on the study, said by email.  “We should take that into account when we’re thinking about settings where we make people focus for long periods of time without breaks. This applies both to schoolchildren and their teachers.”

The study, “The Dynamics of Inattention in the (Baseball) Field,” is currently under review for publication in an academic journal. A preliminary draft has been circulated by the National Bureau of Economic Research.

What is clear is that sometimes staring out the window — or zoning out in left field — may just be a good idea.

JILL BARSHAY

Public speaking, now back in public

Peyton Poole knows she wore a maroon suit with bell sleeves to this year’s National Speech and Debate Tournament, in June. She remembers bright lights, a queasy feeling in her stomach and not much else.

“When I tell you I don’t remember anything,” said Poole, whose dramatic interpretation earned her a second-place finish, “I saw blackness. I found my judges’ faces and I was like, ‘OK, this is happening.’ ” 

When high school speech and debate teams from around the country converged in Louisville, Kentucky, it was the first in-person national tournament since the pandemic began. After two years of virtual competitions, students felt both excitement and nerves about the return of live audiences.

“It’s like pulling your heart out of your chest,” said Poole, 18, who is from Lafayette, Louisiana, and now a freshman at Western Kentucky University.  

Across the country, educators report an increase in student hesitation about public speaking, whether in the classroom or onstage. Coaches are re-teaching skills like eye contact and voice projection. 

“With public speaking it’s about ‘How are we relating to others, how are we respectfully disagreeing?’ ” said Kyair Butts, a language arts teacher and debate coach in Baltimore.

Virtual school didn’t help. “The screen was the masquerade party for students,” he said. “It takes some pulling to help students realize their full potential now that we’re back in person.”

Once they were before live audiences again, “There were nerves, of course, but more so there was relief,” said Dan Hodges, who coaches speech and debate at Apple Valley High School in Apple Valley, Minnesota. “They were finally there, and it felt right.”

SARA HUTCHINSON

Mandatory advising can look more like social work

For decades, college advising was considered primarily a way to help students register for classes. Now, it’s often a tool to help students address other aspects of their lives as they navigate college, including housing, transportation, health or family issues and mental well-being.  It’s sometimes called a case management approach — and, increasingly, it’s mandatory.

At San Antonio College in Texas, for example, students are required to meet with an adviser four times during the pursuit of a 60-hour associate degree — when they enroll, and after they complete 15, 30 and 45 hours of credits. If they don’t, they’re barred from registering for classes.

Around the country, other colleges have taken a similar approach, including the University of Utah, the University of Alaska Fairbanks and several community colleges. At regular meetings, counselors check beyond academics to ask about students’ personal needs or barriers they face.

Many such obstacles worsened during the pandemic, and historically marginalized students have been hit the hardest. College leaders say the students who most need advising support often don’t think they do, or don’t realize what resources exist to help them.

Robert Vela Jr., the former president of San Antonio College, and now president of Texas A&M University-Kingsville, said that, traditionally, the mindset has been: “These folks are adults. We have services available here. If they want to participate, they’ll participate.”

Now, he said, there has been a shift to “a parent approach, that we know best for our students,” adding: “Sometimes, because we know best, we need to take the word ‘optional’ out.”

OLIVIA SANCHEZ

Skip the dining hall — summon a robot

Red alert, Trekkies: Starship Technologies’ robots could be delivering your next Java Chip Frappuccino. Their mission: to map out new college campuses; to seek out hangry students and save them from crowded dining halls; to boldly entertain through song and dance.

Starship, an Estonian company with headquarters in San Francisco, deploys fleets of autonomous robots offering contactless food delivery in locations including college campuses, a welcome service during the Covid-19 pandemic. The six-wheeled mini vehicles respond to mobile orders made on the Starship app, where students buy items through meal swipes or points. On 12 campuses at the start of the pandemic, Starship robots grew popular quickly.

“Robots will be active on 30 college campuses by the end of this month,” Henry Harris-Burland, the vice president of marketing at Starship, said.

These robots travel at a pace of up to 4 miles per hour, and play music when students unload the cargo bays. With a 360-degree view of their immediate surroundings, 12 cameras and a collection of radar and ultrasonic sensors, they can cross roads and maneuver around people, animals and objects.

“I really appreciate having the bot delivery available because it provides another option for accessibility,” said Alexander Cheetham, a junior and co-president of the Disabled Students’ Network at Brandeis, adding that some students with disabilities may avoid dining halls when wheelchair or mobility lifts malfunction.

For now, what’s available for delivery depends on the campus and food providers’ participation. A.I. technology enables each robot to adapt to its particular environment and make changes when encountering unknown objects. They’re a little like new college students themselves — constantly learning and taking some time to get used to the campus.

JULIANA GIACONE

This story about post-pandemic education changes was produced by The Hechinger Report, a national nonprofit newsroom that reports on one topic: education. Sign up for our weekly newsletters to get stories like this delivered directly to your inbox. 

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Cuando Andrea Soto tenía 10 años, su familia emigró a Texas desde México. Su abuela, que vivía en Houston, tenía la enfermedad de Alzheimer y sus padres querían estar más cerca para ayudar con sus cuidados.

Al crecer, Soto a menudo sirvió como intérprete entre los miembros de su familia y sus médicos.

“Hice lo mejor que pude”, dijo, “pero hubo momentos que fueron complicados, y se me pasó por alto, e hicimos lo mejor que pudimos como familia”.

Hoy, Soto es estudiante de medicina de tercer año en la Facultad de Medicina de la Universidad de Texas Valle del Río Grande. Ella eligió estudiar allí — al sur de Texas, a lo largo de la frontera con México— debido a la oportunidad de trabajar con una población inmigrante de habla hispana.

“Quiero ser ese doctor moreno que una niña morena que está interpretando para sus padres hubiera debido tener”, dijo.

Su objetivo es establecer una práctica que sirva a familias inmigrantes como la suya, con una especialidad en medicina familiar u obstetricia y ginecología. Pero mientras Soto se prepara para solicitar su residencia después de la escuela de medicina, le está dando prioridad a los programas fuera de su estado natal.

Eso se debe a que, a pesar de su deseo de quedarse cerca de casa, le preocupa no tener acceso a la capacitación médica que necesita si se queda en Texas.

“Si me quedo, no obtendré la capacitación en atención del aborto que necesito, y no estoy dispuesta a sacrificar eso”, dijo Soto.

En los estados donde el aborto ahora es ilegal, los estudiantes de medicina como Soto están reconsiderando sus opciones, abandonando sus planes originales a favor de seguir una formación en los estados donde el aborto es legal.

45 por ciento de todos los programas de residencia de obstetricia y ginecología se encontraban en estados “seguros o probables de prohibir el aborto” con la revocación de Roe

Así es para Jessica Flores, una estudiante de medicina de segundo año en la Universidad de Texas Valle del Río Grande.

“Es una posición difícil”, dijo Flores, quien proviene de la pequeña ciudad de Portland en el sur de Texas y ha soñado durante mucho tiempo con servir a su comunidad como médica. Ahora que Texas ha convertido el aborto en un delito punible con cadena perpetua, ella está reconsiderando sus planes.

“¿Sigo mi educación en un estado en el que quiero estar idealmente, pero que potencialmente me perjudicará y no me preparará como un médico para mis pacientes? ¿O me voy?” dijo Flores.

En un mundo posterior a Roe, miles de futuros médicos ahora enfrentan obstáculos para acceder a capacitación clínica en atención del aborto. Los expertos dicen que estas nuevas barreras podrían, en última instancia, limitar el acceso no solo al aborto, sino a toda la atención obstétrica y ginecológica.

Durante años, los investigadores han advertido sobre una creciente escasez de obstetricia y ginecología, especialmente en las comunidades rurales de todo el país. Tras la decisión Dobbs de la Corte Suprema, aumenta la preocupación de que las prohibiciones del aborto intensifiquen esa escasez al hacer que el camino para convertirse en un obstetra y ginecólogo sea más difícil y menos atractivo.

Para convertirse en médico, los estudiantes asisten a cuatro años de la escuela de medicina y luego completan una residencia en la especialidad elegida. Los programas de residencia en obstetricia y ginecología deben ofrecer acceso a la capacitación en aborto inducido, aunque los estudiantes con objeciones morales o religiosas pueden optar por no participar.

El Consejo de Acreditación para la Educación Médica de Graduados ha hecho cumplir este requisito desde 1996, y los programas que no pueden cumplir con este estándar ponen en peligro su estado de acreditación.

Pero después de la decisión de Dobbs, a medida que los legisladores estatales de todo el país se movilizan para promulgar leyes que prohíban o restrinjan severamente el aborto, el acceso directo a la capacitación en aborto clínico ha desaparecido, o es probable que desaparezca, en las instituciones de origen de miles de médicos residentes.

Casi la mitad de los futuros proveedores de atención médica para mujeres del país podrían verse afectados. Un informe de abril de 2022 en la revista Obstetrics & Gynecology dijo que el 45 por ciento de todos los programas de residencia de obstetricia y ginecología se encontraban en estados “seguros o probables de prohibir el aborto” con la revocación de Roe. Esos programas dieron cuenta de 2.638 residentes de un total de 6.007.

En este nuevo panorama legal, los programas de residencia deben equilibrar la obediencia a las leyes estatales con el cumplimiento de los estándares de acreditación de su campo. En respuesta a la decisión de Dobbs, el ACGME redactó revisiones a sus lineamientos que proporcionarían una solución alternativa que permitiría a los programas en estados donde el aborto está restringido enviar a sus residentes fuera del estado para recibir capacitación o, si eso no es factible, brindar capacitación sobre el aborto a través de instrucción y simulación.

Mientras tanto, los directores de programas en los estados donde se restringe el aborto ahora confían en sus redes personales, comunicándose con colegas en estados que permiten el aborto para encontrar oportunidades de capacitación para sus residentes, pero la logística ha demostrado ser un desafío.

“No existe un sistema centralizado para ayudar a que esto suceda”, dijo la Dra. Kate Dielentheis, obstetra y ginecóloga y directora asociada del programa de residencia en obstetricia y ginecología en el Colegio Médico de Wisconsin. “Depende de institución por institución tratar de improvisar experiencias para sus residentes”.

Esta capacitación ad hoc está agregando presión a un sistema ya tenso.

Kristin Simonson es directora de programas y operaciones en el Programa de Capacitación de Residencia Ryan, con sede en la Universidad de California, San Francisco, que trabaja con programas de residencia de obstetricia y ginecología en todo el país para ayudar a desarrollar su capacitación en aborto y planificación familiar. Ella dijo que la organización está trabajando con programas en estados donde el aborto es legal para aumentar la capacidad de entrenamiento, pero esos médicos ya enfrentan una afluencia de nuevos pacientes.

“En este momento, están sucediendo dos cosas en los estados donde el aborto está protegido”, dijo. “Están tratando de administrar el aumento de los servicios para los pacientes, y están tratando de administrar la entrada de nuevos estudiantes”.

A medida que se prueba la capacidad de los proveedores de servicios de aborto, a muchos expertos les preocupa que los residentes actuales de obstetricia y ginecología que necesitan capacitación en aborto se pierdan.

“La residencia es finita”, dijo Dielentheis. “La residencia de obstetricia y ginecología es de cuatro años, y la idea de ‘Oh, vamos a necesitar seis meses o un año para resolver esto’ es mucho tiempo para un residente”.

Más allá de los desafíos de capacidad, a los educadores médicos les preocupa que las nuevas barreras a la capacitación en aborto desalienten a los futuros médicos de estudiar en estados que restringen el aborto.

“¿Sigo mi educación en un estado en el que quiero estar idealmente, pero que potencialmente me perjudicará y no me preparará como un médico para mis pacientes? ¿O me voy?”

Jessica Flores, una estudiante en la Universidad de Texas Valle del Río Grande

En la Facultad de Medicina y Salud Pública de la Universidad de Wisconsin en Madison, la Dra. Laura Jacques, profesora asistente, asesora a los estudiantes de medicina que planean solicitar una residencia en obstetricia y ginecología.

“Puedo decirles que el 100% de ellos están considerando la disponibilidad de capacitación sobre aborto cuando están creando la [lista de] programas a los que quieren postularse”, dijo.

La investigación apoya esa opinión. Una encuesta reciente, aún por publicar, de residentes de obstetricia y ginecología en Wisconsin y Minnesota encontró que el 95 por ciento de ellos deseaba obtener más información sobre la necesidad de una atención del aborto integral y segura, y el 84 por ciento planeaba brindar atención del aborto en su futuras carreras.

Según Jacques, la prohibición del aborto restablecida recientemente en Wisconsin, que hace que proporcionar un aborto sea un delito grave, tendrá un efecto negativo en la capacidad del programa para atraer candidatos.

“No hay duda de que los residentes no van a venir a estados que no les brinden la capacitación que valoran y creen que necesitan”, dijo Jacques.

Dielentheis está de acuerdo. “Mucha gente quiere vivir en San Francisco, San Diego o la ciudad de Nueva York”, dijo, “pero puede ser difícil atraer a un médico a un estado como Wisconsin”.

A largo plazo, Simonson del programa Ryan predice cambios en la coincidencia de residencia nacional.

“Estamos interesados ​​en ver cómo esto podría cambiar donde los residentes solicitan y tratan de igualar”, dijo. “Suponemos que los programas en los estados donde el acceso al aborto es seguro serán más competitivos”.

Los educadores médicos dicen que los residentes que no pueden capacitarse en la atención del aborto están perdiendo la oportunidad de desarrollar una amplia gama de habilidades obstétricas y ginecológicas.

“La capacitación en aborto es más que solo realizar un aborto”, dijo la Dra. Eve Espey, presidenta del Departamento de OB-GYN de la Universidad de Nuevo México y presidenta del Consejo de Cátedras Universitarias de OB-GYN.

La técnica quirúrgica de dilatación y evacuación, por ejemplo, se utiliza como método de aborto en el segundo trimestre, pero también para tratar abortos espontáneos incompletos mediante la eliminación del tejido restante del embarazo. Perder la capacitación en aborto, dijo Espey, significa perder oportunidades de preparar a los médicos para responder a los abortos espontáneos y otras complicaciones del embarazo.

“Hay consecuencias no deseadas de gran alcance”, dijo.

El escrutinio legal adicional en torno a la atención del aborto espontáneo también dificulta el aprendizaje, dice el Dr. Tony Ogburn, presidente del departamento de obstetricia y ginecología de la Universidad de Texas Valle del Río Grande.

“Me preocupa que sea un desafío tanto desde el punto de vista de la educación como del punto de vista de la práctica”, dijo Ogburn. “Ya no está pensando en cuál es el estándar de atención y qué es lo mejor para mi paciente. En el fondo está: ‘No puedo hacer esto’ o ‘¿Esto es algo que podría hacer, pero podría ser ilegal?’. Eso es lamentable, porque en última instancia, quienes sufren son los pacientes”.

Incluso antes de la decisión de Dobbs, los obstetras y ginecólogos estaban distribuidos de manera desigual en los Estados Unidos, ubicados de manera desproporcionada en y cerca de áreas urbanas. Según el Colegio Estadounidense de Obstetras y Ginecólogos, la mitad de todos los condados de EE.UU. carecen de un solo obstetra y ginecólogo, y se espera que esa escasez aumente.

La nueva legislación que limita el aborto podría sesgar aún más la distribución.

“Los proveedores realmente lo van a pensar dos veces”, dijo Espey. “Van a tener verdaderas dudas sobre mudarse a estados que anteponen la política a la relación paciente-proveedor”.

Los defensores de la salud de la mujer han advertido que la cantidad de obstetras y ginecólogos capacitados no ha logrado mantener el ritmo de una creciente población de mujeres adultas. El año pasado, 2161 estudiantes de medicina solicitaron 1503 plazas de residencia en obstetricia y ginecología en todo el país, según datos del National Resident Matching Program.

Según la Asociación de Colegios Médicos Estadounidenses, la mayoría de los médicos optan por permanecer en el estado donde completaron su formación. Pero los estados que restringen el aborto después de Dobbs podrían tener más dificultades para retener a sus médicos, advierten los defensores de la salud de la mujer.

“Es una gran pregunta que está por verse”, dijo Simonson.

Y no son solo los residentes cuyo entrenamiento se ve afectado. Los que aún están en la escuela de medicina también sufrirán la decisión de Dobbs, dicen los educadores médicos.

A diferencia de los programas de residencia en obstetricia y ginecología, que deben brindar acceso a capacitación sobre el aborto para mantener su acreditación, las facultades de medicina no están obligadas a incluir instrucción sobre la atención del aborto. Como resultado, la exposición de los estudiantes de medicina al aborto varía según el diseño del plan de estudios de su programa.

Una encuesta de 2021 de estudiantes de medicina en el Medio Oeste encontró que, si bien el 55 por ciento de los encuestados se había encontrado con el aborto en el “contenido ético”, solo el 41 por ciento había recibido instrucción sobre la atención del aborto. Se espera que las prohibiciones estatales sobre el aborto hagan que la instrucción sea aún más rara.

“No importa en qué te metas, estarás atendiendo a pacientes que han tenido o tendrán o buscarán un aborto, y si no obtienes ese nivel básico de capacitación en la escuela de medicina, eso solo va a aumentar aún más estas disparidades y problemas de acceso”, dijo Jacques.

Para muchos estudiantes de medicina que alguna vez se interesaron en obstetricia y ginecología, estos obstáculos de capacitación, junto con el riesgo de enjuiciamiento, son abrumadores.

“Ninguno de nosotros planea volver a ser OB-GYN, cero. Me rompe el corazón”.

Alexandra Chetty, estudiante, Escuela de Medicina de LSU Health New Orleans

Alexandra Chetty, estudiante de medicina de segundo año en la Escuela de Medicina de LSU Health New Orleans, ha estado fascinada por la obstetricia y la ginecología desde su primer semestre en la escuela de medicina. Pero este verano, cuando entró en vigor la ley desencadenante de Luisiana que prohíbe casi todos los abortos, Chetty dijo que decidió no seguir esa especialidad.

“Es un campo frustrante para entrar si no estás en el estado correcto, lo cual es realmente agotador”, dijo Chetty. “Número uno, no quieres lidiar con estas demandas locas o simplemente el temor de que algo suceda. Y luego, número dos, no puedes cuidar a tus pacientes”.

Chetty, quien es presidenta del grupo de interés en obstetricia y ginecología de su escuela y del capítulo del campus de Medical Students for Choice, dijo que los líderes estudiantiles en estos grupos han cambiado sus planes de manera similar.

“Ninguno de nosotros planea volver a ser OB-GYN, cero. Me rompe el corazón”, dijo Chetty. “No queremos ponernos un objetivo a nosotros mismos”.

De vuelta en el Valle del Río Grande, Andrea Soto está considerando programas de residencia en Nuevo México y Colorado. Le preocupa que el nuevo panorama legal en Texas aleje a los futuros médicos del estado.

“Muchos estudiantes se irán de Texas. ¿Volverán?” dijo Soto. “Probablemente no.”

Este artículo acerca de la capacitación en obstetricia y ginecología fue producido por The Hechinger Report, una organización de noticias independiente sin fines de lucro enfocada en la desigualdad y la innovación en la educación. Lea sus otros artículos en español.

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When Andrea Soto was 10 years old, her family immigrated to Texas from Mexico. Her grandmother, who lived in Houston, had Alzheimer’s disease, and her parents wanted to be closer to help with her care.  

Growing up, Soto often served as an interpreter between her family members and their doctors.

“I did the best I could,” she said, “but there were moments that were complicated, and it went over my head, and we just tried the best we could as a family.”  

Today, Soto is a third-year medical student at the University of Texas Rio Grande Valley School of Medicine. She chose to study at UTRGV — located in South Texas, along the border with Mexico — because of the opportunity to work with a Spanish-speaking immigrant population. 

“I want to be that brown doctor that a brown little girl who is interpreting for their parents should have had,” she said.

Her goal is to establish a practice that will serve immigrant families like her own, with a specialty in either family medicine or obstetrics and gynecology.  But as Soto prepares to apply for her residency after medical school, she’s giving priority to programs outside her home state. 

That’s because, despite her desire to stay close to home, she’s concerned she won’t have access to the medical training she needs if she stays in Texas.

“I won’t get the abortion care training I need if I stay, and I’m not willing to sacrifice that,” said Soto.

In states where abortion is now illegal, medical students like Soto are reconsidering their choices, abandoning their original plans in favor of pursuing training in states where abortion is legal.  

“It’s a difficult position to be put in,” said Jessica Flores, a second-year medical student at UTRGV, who comes from the small city of Portland in South Texas and has long dreamed of serving her community as a physician. Now that Texas has made abortion a felony punishable by up to life in prison, she is rethinking her plans.

“Do I pursue my education in a state where I want to be ideally, but it’s going to potentially undercut me and not make me as prepared as a physician for my patients? Or do I leave?” said Flores.

In a post-Roe world, thousands of future doctors now face roadblocks to accessing clinical training in abortion care.  Experts say these new barriers could ultimately limit access not just to abortion, but to all obstetric and gynecological care.   

For years, researchers have warned of a growing OB-GYN shortage, especially in rural communities across the country. Following the Supreme Court’s Dobbs decision, concern is rising that abortion bans will intensify those shortages by making the path to becoming an OB-GYN more difficult and less appealing. 

Related: If more students become pregnant post-Roe, are we prepared to support them?

To become a doctor, students attend four years of medical school, then complete a residency in their chosen specialty. OB-GYN residency programs are required to offer access to training in induced abortion, although students with moral or religious objections are permitted to opt out.

This requirement has been enforced by the Accreditation Council for Graduate Medical Education since 1996, and programs unable to meet this standard jeopardize their accreditation status.

But in the aftermath of the Dobbs decision, as state legislators across the country move to enact laws banning or severely restricting abortion, direct access to clinical abortion training has disappeared — or is likely to do so — at the home institutions of thousands of medical residents. 

Nearly half the country’s future women’s health care providers could be affected. An April 2022 report in the journal Obstetrics & Gynecology said 45 percent of all OB-GYN residency programs were in states “certain or likely to ban abortion” with the overturn of Roe. Those programs accounted for 2,638 residents out of 6,007 total.

In this new legal landscape, residency programs must balance obeying state laws with staying in compliance with their field’s accreditation standards. In response to the Dobbs decision, the ACGME has drafted revisions to its guidelines that would provide a workaround allowing programs in abortion-restricted states to send their residents out of state for training or, if that is not feasible, provide abortion training through instruction and simulation.

Meanwhile, program directors in abortion-restricted states are now relying on their personal networks — reaching out to colleagues in states that allow abortion to find training opportunities for their residents — but the logistics have proven challenging. 

“There’s no centralized system to help make this happen,” said Dr. Kate Dielentheis, an OB-GYN and the associate director of the OB-GYN residency program at the Medical College of Wisconsin. “It’s left up to institution by institution to try to cobble together experiences for their residents.”  

This ad hoc training is adding pressure to an already strained system.

Kristin Simonson is the director of programs and operations at the Ryan Residency Training Program, based at the University of California, San Francisco, which works with OB-GYN residency programs nationwide to help build out their training in abortion and family planning. She said the organization is working with programs in states where abortion is legal to bulk up training capacity, but those doctors are already facing an influx of new patients.  

“At this moment, there are two things happening in states where abortion is protected,” she said. “They’re trying to manage increasing patient services, and they’re trying to manage new learners coming in.” 

As the capacity of abortion providers is tested, many experts worry that current OB-GYN residents in need of abortion training will miss out.  

“Residency is finite,” Dielentheis said. “OB-GYN residency is four years, and the idea that ‘Oh, we’re going to need six months or a year to figure this out,’ that’s a long time for a resident.”

Related: How are college campuses preparing for a post-Roe world?

Beyond the capacity challenges, medical educators worry that new barriers to abortion training will discourage future doctors from studying in states that restrict abortion.

At the University of Wisconsin School of Medicine and Public Health in Madison, Dr. Laura Jacques, an assistant professor, advises medical students who plan to apply to an OB-GYN residency.  

“I can tell you that 100% of them are considering the availability of abortion training when they’re creating the [list of] programs that they want to apply to,” she said.

Research supports that view. A recent, yet-to-be-published survey of OB-GYN residents in Wisconsin and Minnesota found that 95% of them wanted to learn more about the need for safe, comprehensive abortion care, and 84% planned to provide abortion care in their future careers.  

According to Jacques, Wisconsin’s recently reinstated abortion ban — which makes providing an abortion a felony offense — will have a chilling effect on the program’s ability to attract candidates.

“There’s no question that residents are going to not come to states that won’t give them the training that they value and think they need,” said Jacques.

Dielentheis agrees. “A lot of people want to live in San Francisco or San Diego or New York City,” she said, “but it can be difficult to attract a physician to a state like Wisconsin.” 

Long term, Simonson of the Ryan program predicts shifts in national residency matching.

“We’re interested to see how this might change where residents are applying and trying to match,” she said. “Our guess is that programs in states where abortion access is safe will become more competitive.”

Medical educators say residents unable to train in abortion care are losing out on the opportunity to build a broad range of obstetric and gynecological skills. 

“There’s more to abortion training than just performing an abortion,” said Dr. Eve Espey, chair of the Department of OB-GYN at the University of New Mexico and president of the Council of University Chairs of OB-GYN.

The surgical technique of dilation and evacuation, for example, is used as a method of abortion in the second trimester but also to treat incomplete miscarriages by removing remaining pregnancy tissue. Missing out on abortion training, Espey said, means missing out on opportunities to prepare doctors to respond to miscarriages and other pregnancy complications.  

“There are far-reaching, unintended consequences,” she said.

The added legal scrutiny around miscarriage care also hampers learning, says Dr. Tony Ogburn, chair of the OB-GYN department at UTRGV.

“I have concerns that it’s going to be challenging both from an education standpoint and a practice standpoint,” said Ogburn. “You now are no longer thinking about what the standard of care is and what’s best for my patient. In the background is: ‘I can’t do this,’ or ‘Is this something I could do, but it might be illegal?’ That is unfortunate, because ultimately who suffers are the patients.” 

Even before the Dobbs decision, OB-GYNs were distributed unevenly in the United States, disproportionately located in and near urban areas. According to the American College of Obstetricians and Gynecologists, half of all counties in the US are without a single OB-GYN, and that shortage is expected to grow.

New abortion-limiting legislation could further skew the distribution.

“Providers are really going to think twice,” said Espey. “They are going to have real second thoughts about moving into states that put politics over the patient-provider relationship.”

Women’s health advocates have warned that the number of trained OB-GYNs has failed to keep pace with a growing adult female population.  Last year, 2,161 medical students applied for 1,503 OB-GYN residency spots nationwide, according to data from the National Resident Matching Program.

According to the Association of American Medical Colleges, most doctors choose to remain in the state where they completed their training. But post-Dobbs, abortion-restricted states might have a harder time retaining their doctors, women’s health advocates warn.

“It’s a big to-be-seen question,” said Simonson.

And it’s not just residents whose training is affected. Those still in medical school will also suffer from the Dobbs decision, medical educators say.  

Unlike OB-GYN residency programs, which must provide access to abortion training to maintain their accreditation, medical schools are not required to include instruction on abortion care. As a result, medical students’ exposure to abortion varies based on the curriculum design of their program.

A 2021 survey of medical students in the Midwest found that while 55 percent of those surveyed had encountered abortion in “ethics content,” only 41 percent had received instruction on abortion care. State abortion bans are expected to make instruction rarer. 

“No matter what you go into, you’re going to be taking care of patients who have had or will be having or will be seeking an abortion, and if you don’t get that base level of training in medical school, it’s only going to further increase these disparities and access issues,” said Jacques. 

Related: Post-Roe landscape could further stress America’s crumbling child care system

For many medical students once interested in obstetrics and gynecology, these training obstacles, along with the risk of prosecution, are daunting. 

Alexandra Chetty, a second-year medical student at LSU Health New Orleans School of Medicine, has been fascinated by obstetrics and gynecology since her first semester of medical school. But this summer, as Louisiana’s trigger law banning nearly all abortions took effect, Chetty said she decided not to pursue that specialty. 

“It’s a frustrating field to enter into if you’re not in the right state, which is really draining,” said Chetty. “Number one, you don’t want deal with these insane lawsuits or just the dread of something happening. And then number two, you can’t take care of your patients.”

Chetty, who is the president of her school’s OB-GYN interest group and of the campus chapter of Medical Students for Choice, said student leaders in these groups have similarly changed their plans. 

“None of us are planning to go into OB-GYN anymore — like zero. It breaks my heart,” said Chetty. “We don’t want to put a target on ourselves.”

Back in the Rio Grande Valley, Andrea Soto is considering residency programs in New Mexico and Colorado. She worries the new legal landscape in Texas will push future doctors away from the state.

“A lot of students will leave Texas. Will they come back?” said Soto. “Probably not.”

This story about OB-GYN training was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for our higher education newsletter.

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Last week, the Supreme Court’s 6-3 decision in Carson v. Makin left advocates on both sides of the school choice debate navigating a new legal landscape.

The Court ruled that Maine’s exclusion of religious schools from a state tuition program was “discrimination against religion.” The program uses taxpayer dollars to help rural families who live far from a public school attend a private school instead.

Writing for the majority, Chief Justice John Roberts noted that while a state is not required to fund a private, religious school, if public funding is extended to secular, private schools it must also be extended to religious schools.

Up for debate now is what the broader effects of the ruling might be, as well as its impact on public school funding.

Jessica Levin, director of the advocacy campaign Public Funds Public Schools, said that the ruling currently applies only to Maine and neighboring Vermont and New Hampshire, where similar tuition programs already exist. It would not apply to any state operating a school voucher program.  

“In light of the Carson decision, a state cannot single out and exclude religious options from a program in which other programs are allowed to participate. In doing so, it is going to pave the way for many, many more school choice programs.”

Michael Bindas, lawyer for the Institute for Justice, which represented the lead plaintiffs

“The tuitioning programs are not vouchers. Vouchers are a separate statutory scheme to provide funding for an additional private school option on top of the public schools that are available for all and that is not the situation for these historic and geographic reasons in these three states,” said Levin.

Related: I got to choose private schools, but will vouchers really help other kids make it?

Michael Bindas, a lawyer with the Institute for Justice, who represented the lead plaintiffs, said that while it’s true the case will have the most immediate impact on the administration of programs in those three states, he sees the judgment having wider consequences.

“In light of the Carson decision, a state cannot single out and exclude religious options from a program in which other programs are allowed to participate,” said Bindas. “In doing so, it is going to pave the way for many, many more school choice programs.”

According to Bindas, the ruling nullifies no-aid amendments found in 37 state constitutions. Sometimes referred to as Blaine amendments, these provisions forbid public funds from going to private, religious institutions.

Bindas said the Carson decision removes the hurdle of no-aid amendments for states wishing to establish school choice programs.

“The legal cloud has been lifted and we are going to see many more state legislatures adopt these programs,” said Bindas.

But not everyone agrees with that interpretation.

“There are a lot of attacks on no-aid clauses that have not been successful,” said Levin.

Last year, the South Carolina Supreme Court rejected an attempt by a coalition of private colleges to strike down the state’s no-aid amendment, finding that the amendment did not spring from animosity toward religion and declined to strike it down.

“People recognize that we are always struggling to get enough money for our public schools and so people have enshrined in their state constitutions firewalls to keep that public money in public schools,” said Levin.

After Carson, Levin said public school advocates must prioritize educating state legislatures on the implications of school choice programs on the allocation of public dollars.

“If they are going to create a system where parents receive public school funds [for their kids] to attend private school, they are opening up a Pandora’s box for funding religion, for funding discrimination,” said Levin.

Public school advocates in Maine, Vermont and New Hampshire say they are also considering a new campaign to repeal or reform tuition programs to ensure that only public schools receive public dollars.

“We’re talking about a Supreme Court decision that forces taxpayers to send their tax dollars to a religious institution. It’s one more opportunity to siphon public dollars from public schools,” said Don Tinney, president of the Vermont chapter of the National Education Association, a national teachers’ union.

Tinney said he will encourage union members to press districts to remove any private school option — religious or secular — from their tuition programs.

“It’s important that our members be engaged on this issue,” said Tinney, “because the entire system is at risk.”

Also up in the air following the Carson decision is how future judges may interpret the tension between an individual’s religious rights under the First Amendment’s free exercise clause and a state’s anti-discrimination policy.

Related: Vouchers may be ticket out of public schools for kids with disabilities — but is that a good thing?

After the Supreme Court announced its decision, Maine Attorney General Aaron Frey issued a statement saying that any private, religious school receiving public dollars would be required to adhere to the anti-discrimination provisions found within the state’s Human Rights Act. Last year Maine legislators amended that law to explicitly forbid any publicly funded educational institution, including private schools receiving funds through the tuition program, from discriminating based upon gender identity or sexual orientation.

Two of the religious, private schools at the center of the Carson case — Bangor Christian School and Temple Academy — have explicit policies barring the admission of LGBTQ students or hiring LGBTQ teachers, according to court documents.

In his statement, Frey said schools participating in the state’s tuition program “must comply with anti-discrimination provisions of the Maine Human Rights Act and this would require some religious schools to eliminate their current discriminatory practices.”

That means despite the Supreme Court’s decision barring Maine from excluding religious schools from the state’s tuition program, schools that refuse to comply with the state’s anti-discrimination policy — such as Bangor Christian School and Temple Academy — would remain ineligible for public funding.

Dmitry Bam, who teaches constitutional law at the University of Maine School of Law, says that because Maine’s Human Rights Act is a generally applicable legal principle, religious institutions are ineligible for an exemption, but he says this principle could be tested.

“I think the area of law is in flux. I think the AG is right that currently under the law, a generally applicable legal principle applies to everyone, so there’s no religious exemptions that are required,” said Bam. “But the court seems to be skeptical of that line of reasoning and at least in recent cases have found ways to require states to provide those exemptions, so I expect it is an evolving area of the law.”

Lawyers on both sides agree that this tension could be taken up by the courts in the future. In last year’s decision Fulton v. Philadelphia, the court unanimously found that a religious foster care agency that declined to make referrals to LGBTQ couples was entitled to an exemption from a rule forbidding such discrimination because the city provided exceptions in its anti-discrimination policy.

In Carson v. Makin, the Court did not address the question of whether a religious institution can cite sincerely held religious beliefs to violate laws against discrimination.

“The law that we challenged turned solely on religion,” said Bindas.

“Are other cases going to come up down the road, where the interaction between school choice and anti-discrimination statutes is at issue? I suspect they will,” said Bindas. “How those cases will come out — I don’t know.”

In his dissent in Carson, Justice Stephen Breyer wrote that the ruling disregarded the long-respected “wall of separation” between church and state by requiring that Maine use taxpayer dollars to fund a religious intuition.

Following Carson, Bam said it’s conceivable that a religious private school, currently excluded from the tuition program under Maine’s anti-discrimination policy, could go to the courts to challenge the state’s policy by asserting their religious beliefs entitle them to an exemption.

“When you say that you are going to publicly fund schools that engage in discrimination, that’s not a victory for choice for families, that’s a choice for schools — that’s giving them the choice to discriminate, the choice to exclude students.”

Jessica Levin, director of the advocacy campaign Public Funds Public Schools

Such an argument would challenge the precedent established in Employment Division v. Smith, a 1990 case in which the Court found that generally applicable laws don’t require a religious exemption, even if the laws burden a religious practice. But Bam said the current court may be more sympathetic to a religious freedom argument.

“There are a lot of conservative justices who think that’s the wrong approach and that the states should be required to show some higher standard of proof before they take away an exemption,” said Bam. Justice Samuel Alito, a leader of the court’s new conservative majority, argued in concurrence in Fulton that Smith should be overruled.

For public school advocates like Levin, this possibility is further cause for alarm.

“When you say that you are going to publicly fund schools that engage in discrimination, that’s not a victory for choice for families, that’s a choice for schools — that’s giving them the choice to discriminate, the choice to exclude students,” said Levin.

This story about Carson v. Makin was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for Hechinger’s newsletter.

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