Education Columns

Grace Shih, MD, MAS, Ying Zhang, MD, MPH, University of Washington; Sarah McNeil, MD, Contra Costa Family Medicine Residency, Martinez, CA

Introduction
At least 36 family medicine residencies include abortion training fully integrated into their reproductive curriculum or through available local electives.¹ While clinical training during residency is important to increasing access to abortion care, studies have documented that graduates face many barriers when integrating abortion care into their postresidency practice.^2,3

Among graduates from programs that included abortion training, the greatest barriers to providing abortion care postresidency include lack of authority and institutional barriers from clinic/hospital (eg, abortion not allowed by hospital, inadequate facilities, staff resistance).² The Continuing Reproductive Education for Advanced Training Efficacy (CREATE) was designed to address this gap, emphasizing advocacy and leadership skills as necessary complements to clinical skills, to successfully provide abortion care postresidency.

Methods
The CREATE program’s first cohort was a group of residents from four family medicine residencies in 2013 in the Bay Area. It has since expanded to programs in Seattle and New York City. Currently, four Bay Area residencies and four Seattle residencies have participating residents.

While the exact requirements of each CREATE program vary depending on training site, there are similar components. Residents who participate in the program must:

Participate in evening workshops. CREATE faculty lead three to four evening workshops. Each workshop is approximately 3 hours each, which includes dinner/networking (30 minutes) and didactics (~2.5 hours). Exact didactic topics are selected based on the training site needs, but cover the following major areas:

• Advocacy training—storytelling, resolution writing, letters to the editor, state and national level lobbying
• Preparation for postresidency abortion practice—discussing abortion care in job interviews, reading job contracts, interpreting ethical and religious directives from Catholic Health Care services
• Careers in abortion care postresidency—panel discussion on opportunities in abortion care
• Clinical topics—abortion complication management, clinical simulations, evidence-based updates in family planning

Complete a scholarly project. Each CREATE participant completes a scholarly project mentored by CREATE faculty. This project may overlap with the scholarly requirements of the participant’s residency program. The aim of this project is to provide mentored leadership around skills necessary to affect change including: negotiation, effective communication, relationship building, and goal setting. Quality improvement projects at the primary care clinics are encouraged since practice change may be integral to the continued provision of abortion care. Past CREATE projects have included:

• Needs assessment of intrauterine device interest and attitudes among juvenile detainees
• Integration of IUD services at residents’ continuity sites
• Providing care packages to women who present to the emergency room for miscarriage
• Assessing contraceptive needs for homeless patients in downtown Oakland
• Qualitative interviews with providers regarding integration of abortion care in a primary care setting
• Writing a resolution and testifying at a local and national Academy of Family Physicians meeting

Complete advanced clinical training sessions in abortion care. Residents are expected to spend elective time to improve their clinical skills in the following areas: ultrasound, medication abortion provision, uterine aspiration, IUD placement, and implant placement.

Details including supporting documents on how to run the evening workshops can be found at: https://www.teachtraining.org/leadership/create/.

Results
In total from all the sites, there have been 89 CREATE graduates. In experiences across the CREATE sites, participants report high satisfaction (average 4.6 on a 5-point scale, 5=highly satisfied) with the formal didactic components of the evening sessions. CREATE participants most highly rated opportunities for networking/mentorship and additional procedural training. Comments in evaluations reflect this value:

“I learned about finding allies, collaborating with key stakeholders, and working as part of a team.”

“The CREATE program helped me learn the skills I needed to be able to help women reach their life goals. The program has also provided me with connections into this rich community of providers and advocates that support each other in this emotionally and politically tough work.”

Pre- and postevaluations from the Seattle CREATE site showed increases in self-assessed knowledge on a 5-point scale: ways to keep skills and knowledge active (2.3-point increase), networking (2.2-point increase), and job strategies (2.2-point increase).

The Bay Area group recently published follow-up data in Family Medicine, reporting that approximately 80% of their CREATE graduates were providing IUD or contraceptive implant services postresidency, and approximately 30% reported providing uterine aspiration (abortion or miscarriage management) postresidency.⁴ Many Bay Area graduates reported that market saturation of abortion providers was their main barrier to practicing abortion care postresidency.

Discussion
Given that advocacy and leadership skills may be as important as clinical training to increase family physician provision of abortion care, the CREATE curriculum provides a unique multiresidency structure to address these skills specifically as they apply to abortion practice. Furthermore, the success of CREATE to expand to other sites suggests that our curriculum can be replicated. In our experience, gathering a cohort of two to three motivated residents and two to three supportive faculty members is sufficient. Currently, our sites are located in areas with high abortion access, however the greatest need for programs like CREATE exists in areas with few abortion providers. Given the positive feedback received regarding networking and community building, the implementation of a CREATE program may help build a structured system of support that is particularly needed in areas with few abortion providers.

Corresponding Author: Address correspondence to Dr Shih, University of Washington Department of Family Medicine, PO Box 356390; Seattle, WA 98195. ghsih@uw.edu.

References

1. RHEDI. Family Medicine Residencies with Abortion Training. http://www.rhedi.org/education/residency-training/#rhediprograms. Accessed July 3, 2018.
2. Goodman S, Shih G, Hawkins M, et al. A long-term evaluation of a required reproductive health trainingrotation with opt-out provisions for family medicine residents. Fam Med. 2013;45(3):180-186.
3. Romero D, Maldonado L, Fuentes L, Prine L. Association of reproductive health training on intention to provide services after residency: the family physicianresident survey. Fam Med. 2015;47(1):22-30.
4. Block A, Dehlendorf C, Biggs MA, McNeil S, Goodman S. Postgraduate experiences with an advanced reproductive health and abortion training and leadership program. Fam Med. 2017;49(9):706-713.