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 What are the barriers, e.g. insurance limitations or outdated restrictions?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.