For those who intend to go beyond your initial training, there are many options to consider in becoming a reproductive health provider. Consider opportunities to develop and maintain your skills, knowledge, and leadership, both during and after training. Contacts can be identified through the help of your mentors or existing national networks.
BUILDING A STRONG KNOWLEDGE BASE
To develop expertise and keep up with current evidence, consider:
- Signing up with a national listserv (such as STFM Access Listserv) to participate in ongoing discussions — membership requires referral by a current participant for security reasons.
- Completing supplementary readings suggested in each Workbook Chapter
- Staying abreast of medical journals such as Contraception, Green Journal, Journal Watch Women’s Health or International Journal of Gynecology and Obstetrics.
- Attending one of these annual reproductive health conferences:
GAINING AND MAINTAINING CLINICAL COMPETENCY
Studies show that both training availability and procedural volume are correlated with future abortion provision, regardless of previous intention to provide (Turk 2014, Goodman 2013, Steinauer 2008).
The easiest time to gain procedural experience and advanced training is during professional pre-service training (i.e. residency or nursing program), when both credentialing and malpractice can be covered under interagency agreements between your training program and a high-volume clinical site. The procedure number to achieve confidence will vary between individuals, by comfort level, and exposure to more complex cases. Each skill can be delineated into clear steps with observable competencies for learners and for trainers-in-training (Cappiello 2016). Your reproductive health faculty can help you estimate what it will take to achieve competency in the services you hope to provide.
It is also of importance to consider where you will have a receptive environment before investing heavily in training, as the skill is lost if not immediately applied in an ongoing way.
Important aspects of clinical competence include patient comfort and rapport, procedural completeness, speed, and timely ability to identify problems (Levi 2012). Advanced skills include complication management, diagnostic and intra-operative ultrasound, and procedures with advancing gestational age.
Due to the limited training opportunities, skill maintenance and re-training have been significant challenges in most regions of the country. The competition may be greater in urban coastal areas where there are more providers. Clinics in provider shortage areas may be more willing to help with credentialing and malpractice, but back-up and security issues may be more challenging. In either case, persistence is usually essential. For more information on training outside of your program’s standard curriculum or after graduation, see Organizational Resources: Training and Employment Section below.
MENTORING AND BECOMING A MENTOR
Tap every opportunity for receiving mentorship and serving as a mentor during and after your training. As you near completion of your professional training, connect with the larger community of reproductive health providers.
- Ask faculty to put you in contact with providers where you are going, and to serve as a reference.
- Use the chapter questions to stimulate ideas for practice opportunities and interview strategies.
- Mentor a student or trainee by helping fill in gaps in training at their school or program, or develop a project related to reproductive health.
LEADERSHIP, ADVOCACY, AND POLICY
Using opportunities for early leadership and advocacy during training can allow you to develop these skills with guidance from faculty mentors. Educational and advocacy organizations have created advanced curricula and structured electives to help programs integrate these opportunities into training (see TEACH Advanced Training Curriculum and Organizational Resources Table).
Consider collaborating with faculty or reproductive health organizations to tap into other teaching, research, or advocacy projects during training. For example:
- Work with faculty to help lead didactic, experiential or hands-on sessions for incoming trainees, such as values clarification or papaya workshops.
- Speak at a meeting of Medical or Nursing Students for Choice.
- Work with faculty to expand reproductive health services in your clinics. Successful projects have included protocols for EC access, management of EPL in outpatient settings, and clinic integration of medication abortion.
- Help document successes and obstacles encountered integrating these services.
- Collaborate on a research project, conference presentation, or article publication via the network of educators in reproductive health.
- Consider completing Physicians for Reproductive Health’s Leadership Training Academy.
ADVOCACY AND POLICY
Access to evidence-based reproductive health care has been under increasing threat due to state and federal legislative restrictions, and religious mergers. Laws that increase disparities in abortion access have included public and private insurance prohibitions, required waiting periods, mandated counseling, and targeted regulation of abortion provider (TRAP) laws, to name a few. At the time of this writing, only five states allow advanced practice clinicians to perform aspiration abortions (Vermont, New Hampshire, Montana, Oregon, and most recently California); one state (Mississippi) restricts abortion provision to obstetricians and gynecologists (Guttmacher, 2016 ). These regulations are not applied to provision of comparable medical services, such as uterine aspiration for miscarriage management.
As a clinician, your opinions and expertise are highly respected by both the public and legislators. You have the potential to influence policy and legislation on a local and national level. Clinicians innately have the skills for being effective and powerful advocates, including a wealth of patient stories, technical and scientific knowledge, access to and understanding of research, and experience advocating on behalf of patients (Earnest 2010). An easy introduction to legislative advocacy can be undertaking by joining a lobby day coordinated by a reproductive rights organization, since the scheduling and talking points are usually provided by the organization. To make an impact on institutional policies, consider joining a clinic or hospital committee on practice, training or quality.
Working within your state or national chapter of your professional organization, such as the American Academy of Family Physicians and American Academy of Nursing, is another way to improve education and influence policy and legislation. For example, you can join the curriculum advisory for your specialty or the ACGME Residency Review Committee to ensure adequate inclusion of sexual and reproductive health in the curricula. Or you can advocate within your organization to develop the scope of practice for clinicians to include abortion provision (Weitz 2009) or for transparency in medical education in faith-based restrictions that may interfere with training (AMA and adopted AMA Policy 2014). Many organizations have chapters for trainees or early career clinicians, encourage involvement by younger clinicians, and provide funding for meeting attendance.
For organizations that provide materials, support, and training for clinician advocates, see Organizational Resources Table: Advocacy Section. A concise overview of advocacy opportunities can be found through Physicians for Reproductive Health, which offers:
- Advocacy Elective: One-on-one training opportunity for residents and students
- Advocacy Module: an advocacy Powerpoint toolkit for practical knowledge and next steps.
FINDING PRACTICE OPPORTUNITIES
In what setting do you visualize your future participation in reproductive health services? There are many job opportunities available to you that can include reproductive health care provision.
You may join a setting where reproductive health services are already integrated or are the main focus of the practice. If services are not yet integrated, you can have the excitement and challenge of pioneering them at a site. It may be possible to offer some services initially, and expand with time. Below are a few ways to begin thinking about the integration of reproductive health into your future work.
When considering post-graduate employment opportunities, these questions may help you interview and evaluate whether reproductive health service provision will be possible in different practice settings.
- What is the scope of practice specifically regarding reproductive health care? For example, does the site already provide prenatal and obstetric services? What are the patient demographics? What is the mix of reproductive-aged patients?
- What is the range of contraceptive services accessible to patients, and are there patient challenges gaining access to long-acting reversible contraceptives? What are the barriers, e.g. insurance limitations or outdated restrictions?
- What is the political climate in the area? Consider talking to other regional reproductive health providers before approaching a new job site directly.
- How are prenatal care, early pregnancy loss, and /or genetically indicated abortion referrals managed? These questions can help better understand their feelings about reproductive health and their referral systems. Ask how they respond to patients who ask for abortion services.
- If appropriate, consider letting them know that you have special training in abortion care, advocacy, and administrative set-up; and that you would be willing to spearhead the effort to bring a broader array of these services to the practice or training program. If they seem interested, follow up with these questions:
- Do they encourage staff training? Or training for nurses or clinicians?
- What arrangements do they have for hospital or OB / GYN back up?
- Do they already provide 24-hour call?
- Is there a way you can build in abortion provision from the start? Ideally this can be figured out before you go to your home institution so that the new skill can be applied without a gap, as gaps often mean a retraining will be needed.
- Talk about the importance of continuity of care to your patients, or the importance of including these topics for trainees. Share a success story from your training—a patient who was able to be seen by her own continuity provider and how comfortable felt receiving her reproductive health services in a familiar setting.
- We know that the decision to provide reproductive health services may be one of many issues you discuss in the interview. You can use these strategies to identify how the practice responds to patients’ reproductive health needs generally and to undesired pregnancies specifically.
ADDRESSING BARRIERS TO PRACTICE INTEGRATION
Following training, graduates in a variety of fields have experienced barriers to practice. While trained family medicine graduates considered comprehensive reproductive services as important to include in their ideal practice, many faced barriers such as lack of authority or time to implement services, practice restrictions, malpractice coverage, staff resistance, and strength of competing practice interests (Goodman 2013). Post-training practice restrictions, both formally and informally imposed by employers, were associated with decreased odds of provision among obstetrician-gynecologists (Freedman 2010). Advanced practice clinicians have the potential to expand abortion access but have also faced barriers in obtaining training and legal barriers in providing services (Samora 2007).
Consider gradually building on the types of reproductive health care you offer in your setting. For example, begin expanding contraceptive services and abortion referrals, followed by integrating miscarriage management. Cultivate relationships with key stakeholders, involve staff early in the process, and find support from mentors and reproductive health organizations. Be patient and persistent, as the process will take some time. Keep returning to your core beliefs about the importance of expanding care for your patients.
JOINING EXISTING CLINICAL SERVICES
Consider becoming a contract clinician for a high volume abortion provider. This can be done as your primary work or to supplement another position. It is a great way to maintain your skills, add variety to your job responsibilities, and become more involved in the reproductive health community. Perhaps you can work as a contract clinician in your own community or fly into other parts of the country that lack providers. Speak with your mentors and contacts about the regional needs where you are going, and level of experience suggested to apply. National programs, including Creating a Clinician Corps (C3), can match trained clinicians with clinics currently in need of abortion providers. You willingness to travel to areas of need may assist to get your foot in the door. Your mentors may be willing to provide you phone backup to allow you to feel more comfortable as a new provider.
One way to build on your skills is to work at a professional training program that needs or already offers reproductive health services. Working alongside more experienced clinicians is a great way for early learners to solidify their experience and confidence. Gaining insight into the steps that your training program took to integrate reproductive health care services can help you be prepared to consider replicating the model in a different setting in the future. Reproductive Health Education in Family Medicine (RHEDI) can connect you with many family medicine residencies around the country. Interested advanced practice clinicians should contact the Primary Care Initiative at UCSF’s ANSIRH Program.
BECOMING A TRAINER
Consider becoming a trainer in your own training program or at another site. This is a great way to advance your own skills while becoming a resource person to others. It will also ensure that you are keeping abreast of the latest research and advances. More detailed information on becoming a trainer is available in Chapter 11.
EXPANDING CONTRACEPTIVE METHODS IN YOUR PRACTICE
Consider whether your practice environment ensures that patients have easy access to the full range of contraceptive options, including the most effective ones (IUDs and implants). Insertions and removals are core skills to acquire during training. For privileges to insert and remove the contraceptive implant, it is necessary to take a training class offered directly by the pharmaceutical company. Integrating long acting methods into your practice can usually be done with minimal effort, equipment, and a bit of research on product ordering and reimbursement. Working to minimize barriers to access, by improving logistics or implementing same-day services, are other areas for productive improvement. For more tools, see http://beyondthepill.ucsf.edu and http://larcprogram.ucsf.edu
IMPROVING REFERRALS IN YOUR PRACTICE SETTING
Taking an active role in improving referrals at your practice may be an excellent first step in expanding access to abortion care (Zurek 2015), and especially important as targeted legislation restricting abortion access has resulted in facility closures and greater complexity in obtaining services. Competent referrals (see Chapter 2 ) can help counter misperceptions or deliberate misinformation about legality and safety of abortion, and can assist with complex social or medical circumstances faced when accessing care. Improving care coordination is especially important in settings with limited access where patients face greater stigma.
INTEGRATING MANAGEMENT OF EARLY PREGNANCY LOSS (EPL)
Expanded options for managing EPL – including expectant, medication, and aspiration management – can be integrated into one’s outpatient clinic setting or into Emergency Department services. The counseling, consent, and follow-up for different management options are addressed in Chapter 8. Misoprostol can be pre-ordered and available on-site for patients who desire medication management. Manual vacuum aspiration requires further training of clinic staff in order to ensure a safe environment (see Getting Started Section of Office Practice Chapter for planning steps).
Because EPL does not involve a viable pregnancy, its management is not considered an abortion for funding or malpractice purposes, and can be treated like any other minor surgical procedure that you routinely provide. Integrating EPL management might be a stepping-stone towards integrating abortion care in your practice, as the skills and equipment are similar, but the path may be more readily approachable.
As you develop your skills and begin your job search, reflect on how public you want to be as an abortion provider. This decision will be influenced by your local environment and family situation. Your stance may evolve as your career, personal relationships, and political environment change. Regardless of how public you decide to be, it is important to consider personal security precautions. It may be safer to begin with tighter security and become more lax in the future, than the reverse. Taking some basic precautions may also help reduce the stress of living and working in an environment where you could be targeted.
You can start by considering your online security, with privacy settings on social media, avoidance of personal photographs connected to your name, and avoidance of your name on public records (such as home purchases). To avoid having your private information accessible, opt-out information is usually hidden within the “privacy statement” or in website FAQs. Most sites require that you send in a written letter with some proof of your identity and statement that your safety is at risk. There is no cost for doing this. More information and a sample letter are available for you here.
Talk to providers in your area about their own personal security precautions. It is helpful to get mentorship from a provider with security knowledge and personal experience before you get started rather than to remedy problems after they occur. National Abortion Federation members can be provided with personal security assessments, in addition to clinic security support. Physicians for Reproductive Health has launched the Partnership for Physician Safety which aims to supply abortion providers with the information and resources needed to be more secure at home, at work, and in their communities. See the supplementary tool Personal Security Tips for more specific advice on personal security. And see Chapter 11 Office Practice Integration for detailed information on clinic security.
There is a proud, egalitarian, and cooperative history of women’s health care that informs the training process around abortion. This movement and the integration of comprehensive reproductive health training into the core curriculum of many professional training programs have vastly changed the delivery of reproductive health care in this country. As we proceed with efforts to improve training and access to abortion services, there are many inspiring examples of collaboration within and across disciplines, not only between specialties, but also between clinicians, staff, scientists and activists. Extensive clinical research and expanding evidence has enhanced effective training and practice in reproductive health. We hope this workbook has given you the knowledge and enthusiasm to join with us as providers and to further expand access to these essential healthcare services.