Since the June 2022 Dobbs versus Jackson Women’s Organization US Supreme Court decision that removed the constitutional right to abortion, patients and physicians have been left with confusion and uncertainty, as state-based abortion restrictions exist across the country in a patchwork fashion, leaving certain communities, notably the southeastern US and rural communities nationwide, especially vulnerable to deficits in care. While often considered an issue primarily for obstetrician-gynecologists (Ob-Gyns), I wish to highlight the importance of training in medication abortion for all capable and interested physicians—including internal medicine doctors.

As physicians we know that abortion care can mean many things—any pregnancy that does not end with a child is said to have undergone an abortion. This can include “elective abortions,” which are most commonly spoken of in not only abortion-related debates, but also abortions performed for fetal abnormalities or to protect the health of the mother.

Women, at 167.5 million individuals, make up 51.1% of the population in the USA. It is well studied that many women do not enter the healthcare system until after having a baby. For those that do have primary care, data from the Kaiser Family Foundation show that about 75% of women with private insurance and 75% of low-income women report having a family medicine or internal medicine physician as their primary doctor.1

Additionally, while data show that 93% of women have seen in a doctor over the course of the preceding 2 years—for well-woman care including cervical cancer screening and contraception—the majority of patients saw a family or internal medicine physician if they had a relationship with one.1 While it may be thought that internal medicine physicians are not qualified to perform basic gynecological care, internal medicine physicians are in fact trained in residency in many facets of women’s health including management of sexually transmitted infections, cervical cancer screening, contraception, and menopause. These areas encompass most of the general non-pregnancy women’s healthcare needs.

Even prior to the discussion of Dobbs, the landscape of women’s healthcare provided by Ob-Gyns has been declining. According to a 2021 projected work force analysis conducted by the U.S. Department of Health and Human Services, the number of Ob-Gyn physicians was expected to decrease by 7% over 10 years, while demand for Ob/Gyns was projected to increase by 4% over that same time.2 Since the Dobbs ruling, these numbers have changed precipitously in areas with near-total abortion bans, with a 10.5% decrease in applicants to Ob-Gyn residency programs in those states this year.3 Many of these same states, unfortunately, already have some of the highest maternal complications and mortality in the country.4 In areas considered women’s health deserts, where do patients turn? Some travel long distances to find obstetric care, though this takes financial resources that many may not have. Others may turn to their primary care physicians as a place to access women’s healthcare. This places internal medicine physicians in a position of being a critical bridge to care, and potentially asked to handle questions and requests traditionally outside of an internist’s scope, including those related to pregnancy termination.

Currently, there is a gap in medical education for internal medicine physicians related to medical abortion. While this may fall outside of the graduate medical education scope for internal medicine trainees, it should be available following training as continuing medical education (CME) for those interested in filling these critical needs, understanding that not all internists will desire to pursue this. Barriers to providing this care include the multitude of changing laws regarding abortion care, insurance challenges related to the Hyde Amendment restricting use of federal funds to pay for pregnancy terminations except in specific, life-threatening cases, and personal religious and/or philosophical objections.5 Additionally, physicians in group practices will need to be cognizant of cross-cover and on-call needs as it relates to training and comfort of all members of the physician and nurse team as well as training for all members of the support staff that may interact with patients at this vulnerable time.

Professional organizations such as the American College of Physicians can bridge this gap by working with the American College of Obstetrics and Gynecology, the American Academy of Family Physicians, and other organizations to provide educational resources on this important topic, including when to refer. Medical abortion care is an evidenced-based intervention that internal medicine physicians are well-qualified to provide with appropriate education. One large study with over 20,000 women who underwent this treatment showed a complication rate of 0.04%, far less than what is seen in many routine medications prescribed in internal medicine.6 By availing themselves of additional education, internal medicine physicians can better serve their patients and provide safe, effective medical abortion care when needed, in addition to knowing how to offer supportive care for complications which may arise from telehealth-prescribed treatment in more restrictive states.

As such, a resolution was proposed and adopted by the American College of Physicians to support this type of education. And while we know opinions and comfort levels with women’s healthcare vary by person to person, these educational options should be available for those who wish to provide patient-centered, high-quality, and non-judgmental abortion care to their patients.

Training should be available soon at local and national meetings, as well as online. In the meantime, I provide an “internist-friendly” guide to medication abortion and early pregnancy loss here (Fig. 1). For those physicians who are not yet ready to use their “pen” to provide medication abortion in their own practices, or see the obstacles listed above as too much of a barrier, you can still follow the call and use your voice to advocate for full-scope reproductive care for all of our patients nationwide.

Medication abortion for internists.6, 7