Part One: Residency programs and medical practices drew them to Tennessee. Then came Dobbs.

(This is the first in a two-part series on how Tennessee’s abortion ban has affected the training, recruitment and retention of OB-GYN doctors in Tennessee. It was originally published on April 25.)

When Dr. Grace Meade matched with a Tennessee medical program for her OB-GYN residency in 2021, Roe v. Wade was still intact. She and her husband moved from New Orleans to Nashville, where they had friends and family and where she would have access to quality training. That Tennessee’s lawmakers would swiftly ban abortions and alter the training she sought, just one year later, was not a concern. 

Had she determined her residency choices after the Dobbs v. Jackson Women’s Health Organization decision, “my rank list probably would have looked very different,” Meade said.

Meade has only praise for every other aspect of her medical training in Nashville, including her faculty and co-residents, but she said the abortion ban prompted her to seek an out-of-state rotation and has given her pause on where she will practice after residency. Definite plans to stay in Nashville now feel less certain if she cannot care for patients as she would like to. 

“I always assumed that we were going to stay in Nashville. We bought a house here,” she said of her practice decision. Abortion care “is something I’m passionate about and something I always wanted to include in my future practice. Knowing that I can’t do that here definitely plays into it.”

Beyond its direct impact on pregnant women, Tennessee’s abortion ban is shaping how and where OB-GYN residents train and ultimately practice. As medical leaders navigate these restrictions, they are also contemplating what the long-term effects could be on patient care in a state already short on health care providers.

“It is a consideration for many folks in admission to residency. And, for faculty recruitment, it makes it harder,” Dr. Scott Strome, University of Tennessee’s Health Science Center executive dean and vice chancellor for clinical affairs in Memphis, said. “The offenses here are criminal offenses. As physicians, that is a scary word. We are kind of a rule-following group, so when you attach the word ‘criminal,’ it’s going to scare some folks away.”

Tennessee medical leaders say it is still too soon to gauge the law’s full impact on training programs. At Tennessee’s eight OB-GYN residency programs, 97% of positions were filled during the match in March, according to the National Resident Matching Program. Nationally, however, OB-GYN residency applications fell by 10.5%  in states with abortion bans this year, nearly double the drop seen in states where abortion is legal, according to the Association of American Medical Colleges.

“Everyone is worried about it,” Tennessee Medical Association CEO Russ Miller said. “It’s definitely something all of us are keeping an eye on.” 

‘It’s wanting to be able to help people and not being able to’

Meade’s training hospital is part of a Catholic system and, as a result, abortion restrictions were in place prior to Dobbs. Her residency program had been able to meet abortion training requirements through an independent clinic in Memphis, she said. After Tennessee’s trigger abortion ban went into effect in August, that option no longer exists. Meade is able to learn miscarriage management skills, but the volume of those cases is lower than if she had a dedicated rotation on abortion care, she said. When medical students ask her how her program is navigating the abortion law, Meade said she answers them honestly.

“It’s definitely something that all medical students who are applying to residency are thinking about when they are choosing where they want to train,” Meade said. While there are no guarantees on abortion training, “our program leadership is very receptive and very helpful and is trying to help us get these opportunities.”

Not being able to provide the care that will most help her patients weighs on Meade. She has had to tell patients about care they can access in Illinois. She’s had to tell a patient, who had tried for years to get pregnant, that even though she would ultimately miscarry she would have to continue to carry the fetus despite her objections to delaying the inevitable loss and delaying efforts to become pregnant again. The patient miscarried four weeks later.

“It kind of wears you down after a while, having to constantly see patients not be able to access care they desire and care that they need,” Meade said. “Constantly having to tell patients, ‘I understand, and I can’t help you,’ and ‘here are places out of state that you can go,’ gets kind of just exhausting.” She added, “It’s wanting to be able to help people and not being able to.”

Tennessee lawmakers approved changes to the state’s abortion ban in April. Beyond adding exceptions for ectopic and molar pregnancies, they removed an “affirmative defense” clause, which required a doctor to prove, after they were charged with a felony, that an abortion was necessary to prevent death or substantial harm to a major bodily function. 

Under the new version of the law, awaiting Gov. Bill Lee’s signature, an abortion is not a criminal offense if a physician uses “reasonable medical judgement” to determine an abortion was necessary to prevent death of a pregnant woman or to prevent “serious risk of substantial and irreversible impairments” to her bodily function. Those found to be violating that law still face a felony charge and if convicted, up to 15 years in prison, and a $10,000 fine. 

State Rep. Bryan Terry, a Murfreesboro Republican and a doctor specializing in anesthesiology, said “there should not be any major impact” to Tennessee residency programs with the recent changes to the abortion law. A first trimester abortion is similar to addressing a miscarriage and those who want to include abortion care in their practice can study that in family planning fellowships outside of Tennessee after their residency, he said.

 “Residents can learn the procedure and learn how to prescribe, medically, without actually participating in an abortion,” Terry said in a statement. 

State Sen. Richard Briggs, a Knoxville Republican who is a cardiac surgeon and who sponsored the recent changes to the abortion law, said he would have liked to have included more exceptions to the state’s ban. He pointed to the example of a pregnant woman having a premature rupture of membranes who seeks an abortion to prevent infections and preserve her fertility while a heartbeat still exists as potentially still in the “gray area” under the amended law. While he does not foresee a prosecutor pursuing charges against a doctor in those situations, he acknowledged that they could choose to.

“Most of the time on these absolutely gray areas, the prosecutor is not going to prosecute it unless he thought something else was going on,” Briggs said. But, a doctor must still rely “on the presumed goodwill of the prosecutor.”

For Meade, the changes to the law bring some relief but provide little assurances for responding to many other pregnancy complications beyond the two exceptions. 

“No one was sitting on an ectopic pregnancy in our program already,” Meade said. “A lot of us wish it was going farther and doing more.”

Part Two: A looming shortage of OB-GYN physicians comes as Tennessee faces maternal health challenges.