When longtime Oklahoma resident Christen Jarshaw joined the OU College of Medicine’s class of 2023, she knew the limitations she would encounter as a studying provider with interests in OB-GYN.
She stayed in state because she wanted to improve Oklahoma’s 1,630-to-1 patient-to-provider ratio and increase access to reproductive health care in a state burdened by uncomprehensive sex education and the fourth highest maternal mortality rate in the U.S., as of 2018.
Jarshaw, who is in her first year of clinical training, is among OU medical and pre-med students who are considering leaving Oklahoma to expand their education on reproductive health care. But the reasons behind their applications to out-of-state medical schools and residencies are more complicated than the overturning of Roe v. Wade.
Laws like House Bill 4327 and Senate Bill 1503 — which allow anyone to sue someone who provides abortions or “aids and abets” someone in accessing abortion — limit OU medical students’ opportunities to counsel patients. But their ability to learn how to provide abortions has already been restricted by state funding to cases of rape, incest and threats to maternal life for many years.
The hands of faculty from the OU College of Medicine have long been tied by legislative framework inhibiting what they can teach about abortions. For many soon-to-be physicians in Oklahoma, the Dobbs v. Jackson decision was the final straw.
past and present
The OU College of Medicine’s curriculum is split into preclinical for the first two years of medical school and clinical training for the remaining two. Jarshaw said medical students take their first course about reproduction in the second semester of their second year of preclinical curriculum.
The course is designed to “teach undergraduate medical students about the normal and abnormal structure, function and development of male and female reproductive systems” with an emphasis on “treatment options for conditions and functions that are specific to women,” according to the college of medicine’s curriculum.
Alexandra Regens, an OB-GYN resident physician at the OU Health Sciences Center who helps organize curriculum on reproductive topics, said she doesn’t expect the overturning of Roe v. Wade to impact what she can include in the course’s curriculum. She said it’s impossible to talk about reproductive health care without including conversations on abortion and abortion access.
But beyond this course, Jarshaw said state legislation already prevented medical students interested in abortion care from effectively furthering their education at OU, causing many to either lobby for an expansion of curriculum or look outside the traditional medical system.
For Jarshaw, this was not an issue. She joined OUHSC Medical Students for Choice during her first year and serves as the group’s co-president. There, she participates in educational events and lobbies alongside her peers for more comprehensive education.
She also volunteered in less restrictive medical facilities outside OU to further her skills in obstetrics and gynecology. But the overturning of Roe v. Wade limits Jarshaw’s access to opportunities outside of medical school, meaning she has to rely on clinical training in a space whose services were already limited by state funding.
Regens, who is also the associate clerkship director for third-year medical students, said students entering clinical training will experience the greatest impacts on their learning, as the university’s clinic can only provide abortions in cases threatening maternal life.
Before the overturning of Roe v. Wade, providers in the college could also counsel patients and connect them to external resources. Now, because Oklahoma prohibits anyone from “aiding or abetting” someone in accessing abortion, they are limited in how they can guide patients.
The need for abortion care exists, Jarshaw said, as patients carrying unwanted pregnancies have made it to the doors of OU's clinic. If the political landscape looked different, Jarshaw could implement the counseling skills she learned from OU or outside involvements.
The frustration shared between patients and providers is apparent in moments of silence, Jarshaw said, as she and her patients take deep, deliberate breaths. She said it feels like a disservice to know clinical guidelines but be prohibited from following them in ways that would align with everyone’s experience and morals.
“I think everyone across the board is incredibly dissatisfied and upset with the concept that the government is determining what we can and can’t say to our patients,” Jarshaw said. “The patient-and-provider relationship is no longer private and sacred.”
Now, Jarshaw is considering whether her studies will continue at OU as she applies for residencies. A close adviser encouraged her to try studying out of state, but she doesn’t know where she could go.
It’s a reality many current and future medical students face at OU.
OU Health Communications Director April Sandefer wrote in an email to the Daily that, as an academic health system, OU Health provides comprehensive care for women and children of all ages and at all stages of life. She wrote that their health care complies with state and federal laws along with health care regulations and compliance, and they will continue to monitor state and federal legislation and legal changes and ensure full alignment as new laws are enacted.
Some OU pre-med and medical students don’t want to wait for legislation to change and are considering other options while they are earlier in their education.
Danielle Digoy, a second-year preclinical medical student, became passionate about reproductive care because of her grandma, who died from cervical cancer when she was in middle school.
Although she is not set on a specialty, Digoy enjoys shadowing OB-GYNs and participates in OUHSC Medical Students for Choice to further her education on reproductive health. She even volunteered at Oklahoma City’s Trust Women Clinic for a few weeks before it shut down.
Oklahoma is where Digoy’s family lives and where she has planned to stay in the long term, but she fears she will have to travel out of state to continue learning how to provide comprehensive care in abortion provision and counseling.
The state already faces a shortage of OB-GYNs, and Digoy fears the patient-to-provider ratio will continue to shrink if medical students feel they can’t access comprehensive education.
“We need people who feel this obligation, provide high-quality patient care and provide for their patients and advocate for them,” Digoy said. “We don't want them all to leave.”
Megan Talbot, a biology pre-med senior, is a peer health educator at the OU Goddard Health Center and participates in OU Women’s Health Advocacy, a group focused on “increasing campus awareness of women’s health, tackling stigma and easing access,” according to its Instagram page. Both involvements have expanded her interest in OB-GYN by providing spaces for students to discuss and learn about reproductive health care.
Talbot also faces the reality that if she applies to medical school in Oklahoma, she will experience limitations in what she can study. She said she is applying to medical schools in California to receive a comprehensive education.
Physician shortages and patient needs are both things Talbot said she is keeping in mind, but she wonders how the state can expect her to stay when they are limiting how she could care for Oklahomans.
“Luckily, I have more time, but even when I'm looking at medical schools … it's very limited because, also as a person of color, I don't want to stay here,” Talbot said. “I want to go somewhere where I can learn the full scope of medicine and not be limited in my education as a provider because should there come a day where abortion is totally fine, I want to be able to provide that medical care, if necessary.”
Regens said she doesn’t blame medical students for wanting to leave Oklahoma when there are legal, financial and criminal repercussions for physicians, but that the state’s continued shortage of providers has the potential to be very dangerous.
“Our best shot is the people who are from here, people who have trained here and people who have ties to the state. … It’s not a time that I would think a lot of physicians from our state are wanting to come here,” Regens said.
Medical training in
less restrictive states
Outside of Oklahoma, there are 21 states where there is expanded or protected access to abortion, according to the Center for Reproductive Rights. The closest options for students in Oklahoma seeking more comprehensive abortion education are in Kansas and Colorado.
At the University of Colorado Anschutz Medical Campus, providers operate under statutory protections, meaning abortions at any stage of pregnancy are protected as a fundamental right. Michael Belmonte, the college’s senior fellow in complex family planning, chose to work and educate residents in Colorado for this reason.
Belmonte came to Colorado after he completed a residency at Indiana University, where he could only perform abortions in cases threatening maternal life. Now, he can effectively perform abortions up to 24 weeks and, in certain cases, beyond that.
The university’s educational programs usually include upper-level medical students and residents in the operating room. Starting as early as their first year in residency, students build up basic surgical skills and enter their second year feeling comfortable providing first-trimester abortions.
Belmonte had to wait until the end of his residency in Indiana to provide first-term abortions. He said Colorado students’ ability to learn how to perform these procedures and counsel patients early helps decrease the stigma felt by the provider and patient.
“It really normalizes abortion and makes it a health care decision that you come to with your medical provider and, because of the lack of barriers here, that can start the same day that you decide that this is what you want to do. … Being able to support our patients in any choice that they make and doing my best to make that as comfortable and seamless as possible is a really nice change,” Belmonte said.
In light of restrictions placed in other states, Belmonte said the university’s clinic has seen more demand. It began with the passage of Texas’ near-total abortion ban and has only increased with the overturning of Roe v. Wade.
Belmonte said he was surprised to hear just how far people need to travel, as it’s difficult to track down clinics with available appointments, even if a patient lives near a state with fewer restrictions.
Belmonte said he can’t fully quantify how many people they see each day, as that number fluctuates depending on circumstances, but there have been moments where their “phones were ringing off the hook.” A high patient load means students receive a lot of training opportunities, but he said it’s unfortunately at the expense of their patient’s difficult circumstances.
Looking ahead, Belmonte said there have been conversations at the University of Colorado about how to open opportunities to medical students, residents and fellows studying in programs restricted by state laws.
It would be logistically challenging, Belmonte said, as there would have to be contracts written between universities, and students would need malpractice insurance. Partnering universities would also have to decide who would pay for expenses like lodging and traveling.
As a former medical resident in Indiana, Belmonte recognizes the considerations and restrictions medical students in states like Oklahoma are experiencing. He said he’s felt intimated by anti-abortion advocates, who have sent him anonymous letters and followed him home.
He said he knows he’s privileged to practice in an accepting and supportive environment and feels nothing but empathy for students who are being forced to decide if they will stay close to their in-state support system or seek education out of state.
“It's just a matter of what you prioritize, and it's OK to prioritize being in your home state or city with your family with the intention of building those skills in other ways,” Belmonte said. “I hope those opportunities will continue to grow as we settle from all the changes that have been happening very rapidly.”
Policy moving forward
In the aftermath of Roe v. Wade being overturned, the intersection of policy and medicine is becoming increasingly clear to the general public. Abortion has become a top issue in the upcoming midterm elections and is pushing more people to vote in November.
But for medical students and providers in Oklahoma, the overturning of Roe v. Wade was more so a continuation of medicine clashing with policy.
Regens, who is also a member of the American College of Obstetricians and Gynecologists, said she tries to use her experience in advocacy work to equip medical students and residents. She organizes an advocacy curriculum for OB-GYN residents and provides sessions in the college’s reproductive course reflecting on Oklahoma’s status in women’s health.
She also invites students in OU’s OB-GYN interest group to advocacy days at the Oklahoma state Capitol, where they have advocated against several bills restricting abortion that have come through the state over the years.
The main issue these students face is that many legislators have made up their minds on abortion, Regens said. ACOG is against any bill that limits access to abortion care, but Oklahoma providers must also move the needle on issues like maternal mortality and access to contraception.
Regens said they have to pick and choose their battles.
It’s frustrating to medical students like Jarshaw. She has always seen the gaps in Oklahoma’s reproductive health care system and is dedicating her 20s to clinical training so she can help fill them.
When Roe v. Wade was overturned, Jarshaw woke up to five texts from friends confirming what she already knew was coming. Her education would continue to be dictated by government officials who hadn’t completed the years of medical training she had.
All she could do was put her phone down, get up and clean something in her apartment. She took care of what was around because she knew — as many medical students did that day — she couldn’t fix what was happening outside her closed doors.