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Perspective Post-Roe Emergency Medicine Education Considerations
By Giovanni Rodriguez, MD; Margaret Samuels-Kalow, MD; and Amy Zeidan, MD on behalf of the SAEM Academy for Women in Academic Emergency Medicine
On June 24, 2022, the United States Supreme Court overturned Roe v. Wade, resulting in new restriction laws on abortion across the country. This change had significant implications for pregnant patients and the role of clinicians across the country, including emergency clinicians. The Guttermacher Institute estimates 26 states will ultimately have bans on abortion; 11 states currently have made abortions illegal at conception. It is estimated that one in three women ages 15 to 44 live in states where abortion is banned or mostly banned, according to United States (U.S.) census data. The emergency department (ED) has a crucial role in reproductive care — providing postexposure prophylaxis, emergency contraception, and care for new pregnancy or risk of pregnancy loss. Our newly released article on Academic Emergency Medicine titled Post-Roe emergency medicine: Policy, clinical, training, and individual implications for emergency clinicians details the multifactorial implications of this new era in the ED. In this abbreviated summary, we highlight new educational considerations that emergency medicine (EM) residency programs can incorporate to ensure trainees are prepared for their new role in providing reproductive care. The emergency department serves as a critical access point for reproductive care, especially for patients that may have barriers to accessing routine care. We see 900,000 ED visits each year for early pregnancy loss, excluding ectopic pregnancy or other pregnancy complications. Prior to 1973, pregnant people in the United States had complications such as hemorrhage, sepsis, pelvic injury, and death from unsafe abortions. We now need to expand our core obstetric EM content to include complications of self-managed or unsafe abortions, high risk pregnancies, and pregnancy related complications previously managed with abortions and delayed prenatal care. We must define what new medical knowledge, procedural expertise and communication skills will be needed to care for these patients. As demonstrated in our paper, these new laws affect multiple Accreditation Council for Graduate Medical Education (ACGME) core competencies: patient care, medical knowledge, interpersonal communication, professionalism, practice-based learning and
improvement and systems-based practice. Additionally, we may need to consider expanding our procedural competencies depending on the practice setting, geographic location, and local needs of the patient population to include management of uterine hemorrhage (e.g. from self-managed abortion), IUD insertion for emergency contraception, medication abortion, and medications for management of miscarriage. It may be important to update department policies to offer surgical options in the ED with our obstetrics and gynecology colleagues.
As we prepare to increasingly manage complications of abortions, we also need to be knowledgeable of current reproductive care guidelines to provide appropriate care and education to patients. It may be beneficial to understand our patients’ unmet needs related to reproductive health and provide education and resources accordingly. A study by Liles et al. demonstrated that while many ED providers referred patients for contraception, there was no universal standard for contraceptive counseling and management. In this study, ED providers had incorrect understanding of the efficacy, risks, and eligibility associated with contraceptive methods. Another study by Alexander et al. demonstrated that approximately 55% of women wanted to receive contraception and information about contraception in the ED. As the ED may now serve as a timely and critical point of access for contraception counseling and management, it may be important to incorporate this topic into existing resident education as well as develop institutionally specific protocols for implementation. Similarly, it may be important to consider basic prenatal screening (e.g. sexually transmitted disease, basic labs, and type and screen) in the ED for new diagnosis of pregnancy and ensure referral to obstetric care, especially if there are significant barriers to accessing routine care.
Despite uncertainty and constantly evolving policies impacting access to reproductive care, the ED will continue to serve as a place for patients to seek care. We can prepare for these changes by recognizing ways that we can advance our medical knowledge and procedural competency to best serve our patients. Table 1 reprinted with permission from the December 2022 issue of Academic Emergency Medicine Journal.
ABOUT THE AUTHORS
Dr. Rodriguez is a current emergency medicine resident at Harvard’s Affiliated Emergency Medicine Residency program at Massachusetts General Hospital (MGH) and Brigham and Women’s (BWH). She is also on the board of SAEM AWAEM, as the resident member. Dr. Samuels-Kalow is an associate professor at Harvard Medical School and an attending physician in adult and pediatric emergency medicine at Massachusetts General Hospital (MGH). Her work focuses on developing interventions to reduce disparities in emergency care and designing strategies to use the emergency department visit to address adverse social determinants of health. Dr. Zeidan is an assistant professor at Emory University School of Medicine and adjunct professor in the Rollins School of Public Health. She is codirector of the Georgia Human Rights Clinic and cofounder of the Society of Asylum Medicine.
About AWAEM
The Academy for Women in Academic Emergency Medicine works to promote the recruitment, retention, advancement and leadership of women in academic emergency medicine. Joining AWAEM is free! Just log in to your member profile. Click “My Account” in the upper right navigation bar. Click the “Update (+/-) Academies and Interest Groups” button on the left side. Select the box next to the academy you wish to join. Click “save.”
