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University of California, San Francisco Department of Family and Community Medicine, United StatesCollective Energy for Nurturing Training in Reproductive and Sexual (CENTRS) Health, United States
Abortion training for clinicians is crucial to ensure patients’ future access to full-spectrum reproductive healthcare. Given the complex sociopolitical context of abortion, consent to allow a trainee’s involvement in abortion care requires careful attention to avoid harm to patients while also ensuring adequate clinician training for the future provision of care. In order to inform the development of patient-centered recommendations, we assessed patient experiences and preferences around consent for trainee participation during abortion care.
Study design
We interviewed participants who received abortion care at sites with medical trainees in the United States. We conducted interviews via zoom (video-off) between August 2021 and January 2022. We audio-recorded and transcribed the interviews. We coded transcripts using NVivo software and analyzed inductively using thematic analysis.
Results
Twenty-four (n = 24) participants reflected a diverse range of sociodemographics as well as location of abortion service. Some reported experiences of coercion related to trainee involvement, ranging from subtle to overt. Participants preferred consent for trainee involvement in abortion care be a process outside the procedure room, while clothed, without the trainer or trainee present to allow for time to consider options without pressure to say yes.
Conclusions
Patient-centered approaches to seeking consent for trainee involvement in abortion care must reduce potential for coercion. A standardized consent before the procedure room by a trained staff member without the trainer or trainee present can help prioritize patient autonomy. Understanding care team member roles and upholding confidentiality and privacy are paramount to patients feeling safe with trainees present.
Implications
Our finding that patients experience varying levels of coercion to allow trainee participation in their abortion care highlights the dire need for patient-centered systemic changes—such as ensuring that consent take place outside the procedure room in a scripted fashion at eye level, while patients are clothed, and without trainers/trainees present—to maintain patient autonomy.
Training clinicians to provide abortion care is necessary to ensure patients’ ongoing access to full-spectrum reproductive healthcare. Trainee participation involves a range of roles—from observation to hands-on participation—and a range of trainees—from medical students to fellows pursuing subspecialty training. There is wide consensus that specific consent must be sought for trainee contact in medical care [
]. Because academic institutions were founded on a history of medical experimentation and reproductive coercion on Black and Brown bodies for centuries into the present, ethical informed consent policies have been developed as a means to prevent history from repeating itself [
Optimizing trainee involvement in all forms of healthcare requires a patient-centered approach. In gynecologic care, this is particularly important as a means of protecting bodily and reproductive autonomy. The critical nature of informed consent for trainee involvement has been highlighted by the exposure of nonconsensual pelvic exams on anesthetized patients, both in the United States (US) and internationally [
]. This practice represents assault for patients and moral distress for trainees.
Compared with general pelvic exams, abortion care is further complicated by its unique politicization and stigmatization, which can affect both patients’ experiences and their care needs [
]. People who receive abortions in the United States are disproportionately People of Color who confront systemic barriers to accessing care and encounter racial discrimination during care [
]. As restrictions to abortion access grow and access to training is threatened, there is pressure on abortion care settings to continue to provide training while simultaneously adapting their workflows to new laws and patient volumes. Restrictions may increase patients’ psychosocial needs, making trainee involvement even more challenging. Given the context of reproductive oppression in the United States, it is critical to continue to build trust among reproductive healthcare providers and patients to avoid harming patients while also ensuring adequate training for the future provision of and access to abortion care.
Despite a growing body of evidence that recommends standardization, there are no current standards to aid academic training clinics in conducting this unique consenting process [
]. To our knowledge, no other research has examined patient experiences with consent for trainee participation in abortion care. We sought to fill this gap, with the goal of improving upon this process. The foundational concept influencing this work is the right to maintain personal bodily autonomy in the context of abortion care training and delivery. This study is therefore rooted in the framework of Reproductive Justice, which is defined by SisterSong as the human right to maintain personal bodily autonomy, have children, not have children, and parent children in safe and sustainable communities [
We performed a qualitative study to explore people’s experiences and preferences around consent for trainee participation in abortion care. Between August 2021 and January 2022, we conducted semistructured qualitative interviews via Zoom with participants recruited through social media throughout the United States.
2.1 Population and recruitment
We recruited participants via paid advertisements in English and Spanish on social media platforms Craigslist and Snapchat in specific cities throughout the United States. Eligibility criteria, assessed through an online screening form, included age 18 years or older and prior abortion at clinics with medical trainees within 5 years. We prioritized geographic diversity given geopolitical differences in abortion care and training throughout the United States and accordingly targeted advertisements at 12 specific cities where known abortion training programs (e.g. Ryan or RHEDI residency programs) exist, spanning all four US census regions. We prioritized racial/ethnic diversity given the salience of racism to people’s experiences of reproductive healthcare and chose cities with substantial Black and Latinx populations [
], monitoring, and considering participant characteristics when choosing whom to invite to participate as interviews progressed.
2.2 Data collection
Researchers LCO and JM conducted virtual interviews independently via HIPAA-compliant Zoom (video-off for privacy). LCO is a family physician who completed fellowship in family planning and JM is a medical student, both with previous experience working in reproductive healthcare. In preparation, LCO and JM conducted mock interviews to ensure a consistent approach and to practice techniques to attenuate the common tendencies of their positions as medical professionals, which included refraining from summarizing and validating participant responses. LCO conducted 21 interviews and JM conducted 3. Both introduced themselves to participants in their role as researchers. Interviews followed a semistructured guide and took place between August 2021 and January 2022. Participants provided oral consent and received a $60 e-gift card as compensation for their time. We collected optional sociodemographic information via oral survey after the interview was complete. The Institutional Review Board at the University of California, San Francisco, approved this study.
2.3 Instrument
We developed an interview guide (see Appendix) with input from family planning experts at the University of California, San Francisco’s Family Planning Fellowship, and the Person-Centered Reproductive Health Program’s Patient Stakeholder Group, a standing group of racially diverse community members from the Bay Area who are compensated to meet monthly to provide input into research projects. The interview guide started with sharing an online illustration of the “medical hierarchy” (specifying distinctions between medical students, residents, and fellows) and defining a trainee as someone obtaining professional healthcare training to become medical doctors in the United States [
]. Questions were open-ended and encouraged interviewees to reflect on their abortion care experience with special attention to interactions with care team members and the consent process for trainee participation. Interviewers shared two scripted scenarios based on real clinical experiences and asked follow-up questions. Participants were asked to share their preferences for the consenting process of trainee participation in abortion care.
2.4 Analysis
We employed a HIPPA-compliant professional service to transcribe audio recordings. We used NVivo 12 software for coding. Researchers LCO and SS used an inductive approach to thematic analysis wherein an initial codebook was developed based on emergent themes identified during interviews and transcript review [
]. LCO and SS then coded 2–3 transcripts independently and met with KH to resolve disagreements about the presence, range, or definition of codes until the team reached intercoder agreement. We coded the remaining transcripts after the codebook was finalized. We began coding and memoing while interviews were in progress to track emergence of new themes and determine adequate sample size. We conducted interviews until we observed no new emergent themes. We summarized findings by code and then synthesized findings across codes.
3. Results
3.1 Participant characteristics
We completed 24 interviews with participants who experienced abortion care at clinics with medical trainees. Interviews ranged 20–52 min (mean 36). The majority of participants experienced a procedural abortion (n = 22) versus a medication abortion (n = 2) or both interventions (n = 2). Participants identified with a range of self-reported sociodemographic characteristics (Table 1). The majority (75%) were 26 years or older (mean age was 30), White (46%) or Black/African American (46%), and college-educated (55%), with locations in all 4 US census regions.
Table 1Participant characteristics
Participant characteristics (n = 24)
n
Percent
Age (y)
18–25
6
25
26–35
13
54
36–45
4
17
>45
1
4
Mean age: 30
Race/ethnicity
Latinx/Hispanic
5
21
White
11
46
Black/African American
11
46
Asian
2
8
Other
1
4
Abortion care location (United States census region)
We first explored interviewees’ experiences of their abortion care by asking about their interactions with their healthcare team, including the consent process for trainee involvement. Participants shared a range of experiences with trainees either observing or hands-on participating in their abortion care.
Some participants reported remembering signing consent paperwork for the abortion procedure itself; however, when asked specifically about consent for trainee participation, few participants remembered having a choice. One participant recalled a rare positive experience with full written and oral consent for trainee participation in their abortion care:
“Oh, yeah, on the paperwork, I did have to give my consent to allow medical trainees to be present in the room with me as part of their learning. And after that, I was also reminded vocally about it…I’d say they did a good job.” (age 30, White, abortion in Southern US)
On the other end of the spectrum, a few participants shared that no consent discussion or forewarning was given before trainee(s) participated in their abortion care: “No, they didn't – they didn't ask me about [consent for trainee participation]. I feel that was wrong for them because they should have asked me if I was comfortable for the student to be there.” (age 27, Black, abortion in West US)
Most common was an experience somewhere in-between the above. Participants experienced varying levels of engagement and varying degrees of pressure related to trainee participation in care, as described in the next section.
3.3 Is there truly a choice? Experiencing pressure to allow trainee participation in care
Participants who reported an oral opt-out process rather than an opportunity to provide written consent reported experiencing subtle or overt forms of influence to encourage agreement. In one case representing direct use of pressure by a provider leveraging their position of power to induce guilt, a participant shared that when she said she did not want trainee involvement, she was coerced into agreement:
“At first, I refused because I wanted it to be, like, private… It's not something that everyone should see. So, at the beginning, I did not give consent, but the doctor again asked me and told me the importance of the intern being there with him and helping him with the procedure. So, I kind of agreed because, I mean, what was I to do? I wanted to get better and go home.” (age 21, Black, abortion location undisclosed)
Even in the absence of oral coercion from providers, patients described the influence of the power dynamic between provider and patient, particularly when gowned and already on the exam table, on their feeling that they were obligated to accept. As one patient said:
“This is like, ‘If I say, 'No,' I'm not sure how the doctor feel about me.’ So, when I am in the medical gown, again, I'm in the crossroads, kind of a situation. I don't know what to do. For safe answer, I'll say, 'Yes.' Because doctor has to do his or her own job… I don't want to kick myself. So, I would say, ‘Yes’ maybe to impress the doctor.” (age 32, Asian, abortion in Northeast US)
Another participant's description exemplifies this common experience; here, we see clear articulation that asking for consent when the patient is already on the exam table creates pressure:
“Maybe, they should have told me way before…I got into that procedure room [to] prepare mentally for that. Maybe, it would have been better. I felt like I had no option. I just had to say yes because I was already settled in there, the students were already at the door, the doctors were already by my side. So I just decided to say yes.” (age 23, Black, abortion region undisclosed)
This participant shares that the physical presence of the providers and/or trainees ready in the procedure room while seeking consent is in itself coercive.
3.4 Is there truly a choice? It is such an overwhelming time
More common than direct pressure were the ways in which the care environment induced subtle forms of influence to steer patients toward agreement. The fact that care teams consist of many individuals served to overwhelm patients and created an environment of anxiety, particularly when the names and roles of each one were not clearly delineated. One participant shared,
“The first counselor I talked to who gave me my options – now that I look back on it, I guess I don't really know who I was talking to. They were trying to do their due diligence, but it seemed like a lot of people to have to interact with…And then, when it came to the actual procedure…I don't remember anyone introducing themselves. I was just immediately laid down. There was a room of – it just seemed like a room of people, and then, they put me under.” (age 34, Latina, abortion in West US)
Many participants similarly shared an increase in anxiety and fear related to having more people in the procedure room, noting that this created an overwhelming environment that was not conducive to a true consent process.
One participant noted that when consents happen once a person is already on the exam table, it feels like an after-thought and represents a disconnect between provider–trainee teaching goals and the reality of the patient experience:
“You're already on the table, and you've already signed all the forms. And then, they just pop… ’Oh, by the way, Joe's here, and – that's okay, right?’ And then, you're just – because your mind's not on – you do not care about Joe. You know what I'm saying?. It's not that you care so much that a medical student is there. You're probably not even paying attention…But honestly, you don't think about [medical trainees] – you're thinking about what's about to happen to your body, and your relationships, and whatever brought you to that moment. That's what's on your mind. And then, they're like, ‘Yeah, it's cool, though, right?’” (age 35, White, abortion in Northeast US)
Whereas the provider is focused on the procedural training, the patient is focused on the reality of their lived experience and the anxiety and emotions related to their upcoming procedure, reflecting a perceived misalignment of priorities between the patient and their care team.
3.5 Consent preferences
When prompted for preferences around consent for trainee participation in abortion care in comparison to other areas of healthcare (primary care, nursing, dental care, etc.), participants felt strongly that regardless of situation or context, consent should be sought for trainee participation and patient autonomy should be respected. One participant highlighted the importance of noncoercive consent practices while reflecting on abortion training:
“Okay. I tend to think it's [trainees’] rights to… get at least that experience to help other patients in the future. So, their involvement is not that bad, but at least the [consent for trainees] should be asked and allowed to give what we think about it. If we say no, the answer should be taken that way and we should not be pressured to have them around.” (age undisclosed, Black, abortion in Northeast US)
Some felt strongly that: “abortion care [compared to other health care] is different. I feel like abortion care is more personal and emotional. So, it'd be more difficult to have a trainee because you might feel more uncomfortable about it” (age 30, White, abortion in Southern US).
Below, we outline areas participants highlighted as important to creating an environment conducive to informed consent for trainee involvement in abortion care (summarized in Fig. 1).
Fig. 1Guide to consent for trainee participation in abortion care. Synthesis of this guide was informed by participants and established ethical frameworks.
3.5.1 Minimize potential for coercion by optimizing structures and systems
When asked if they would prefer the consent process for trainee involvement to be oral, written, or both, participant responses varied but overall supported an explicit written consent with accompanied oral discussion conducted by a member of the care team who is neither the trainer nor trainee. This is exemplified in a participant’s reflection on their experience and preference of having both written consent with an accompanied oral discussion when they shared:
“I think it [combined written & oral consent] was quite appropriate, because it was just added on the consent form that was documented. And they were just cross-checking to make sure that I did read and understand that part vocally. So, it was I think the best way to do it, actually…they were just really making sure that I knew what I was signing.” (age 30, White, abortion in Southern US)
Participants preferred the person seeking consent to do so at eye level in a room separate from the procedure room while the patient is still in their own clothes, to avoid the vulnerability of a gown and the pressure of already being on the exam table. Finally, it is important that this discussion happens without the trainee present to avoid coercion, as one participant posed, “If they ask when the student is already there, I mean, the student is already here. Then why are you asking me?” (age 21, Black, abortion region undisclosed)
3.5.2 Advance notice and clarity
Many participants felt as though they did not have adequate physical and/or mental “space” to consider consent for trainee involvement in their care. As a solution, participants proposed multiple touchpoints to remind patients and check-in about consent. For example, one patient shared “It would have been nice to know, honestly, before I even came into the office so I had time to think about it… maybe they would have told me when they called me for a reminder or you know, or even send me, like, a email saying, like, are you okay with this?” (age 39, White, abortion in West US) Some suggested presenting information on the clinic website in addition to a formal consent discussion. Participants emphasized a need for information to be shared in simplified and understandable language. Several participants shared that the visual aid used in the interview guide (see Appendix) would be helpful to understand care team member roles, especially that of the trainee [
Many participants mentioned the importance of confidentiality and privacy when it comes to having trainee involvement in care. For example:
“To be honest… it's probably not as much of a fear of safety, but a fear of confidentiality. So, I think [confidentiality or the emotional aspect] is probably more of a focus for when somebody goes into a clinic like that, […] rather than like the fear of, are these people trained enough type of a thing.” (age 32, White, abortion in Midwest US)
Providers may be focused on patient safety, while patients are more focused on the care team’s ability to uphold their privacy and confidentiality. Participants viewed the presence of additional people in the procedure room as a potential violation of confidentiality. This perceived disconnect between providers and patients can result in patients feeling coerced and unsafe. Having many care team members in the procedure room with unclear roles exacerbated the feelings of fear and anxiety. Therefore, it is preferred that team members introduce themselves, their roles, and while doing so, ensure patient confidentiality and privacy. Another participant highlights how uniquely critical privacy is to abortion care compared with other medical care:
Abortion care is different because it's something that requires privacy…someone losing a child or someone getting rid of a child is not something to, like, show off publicly and tell everyone…so I think it should be private and it should be taken with utmost care because you have the life of the woman who …holds the life inside of her […] I may be a patient having COVID, but it’s so different from me being an abortion patient and I need that they see that and confidentiality must be there. (age 23, Black, abortion location undisclosed)
4. Discussion
4.1 Review of findings
Our study explores patients’ experiences of and preferences for being asked consent for trainee participation in abortion care. A main theme from participants across the country was a range of nonautonomous experiences ranging from being directly pressured into accepting trainees, to more subtle pressure such as being asked consent with the trainee present, and/ or while in a vulnerable position, gowned on the exam table. Other factors contributed to feelings of coercion, such as having many care team members whose roles are undefined, not having enough space and time to consider trainee participation, and the perception of conflicting agendas between trainers, trainees, and patients. Patients’ main concern with trainee involvement was privacy and confidentiality.
In reproductive healthcare training, assessments of bias or coercion are most often taught as coming from within the intimate partner dyad. This research shows that perpetrators of reproductive coercion, even in the absence of ill intent, also involve members of the care team [
]. Although this study is specific to abortion care, these findings of coercion in medical training are not specific to abortion care and have been documented in other areas of healthcare, including inpatient and outpatient obstetrics and gynecology among others [
Don’t ask, don’t tell: a change in medical student attitudes after obstetrics/gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient.
]. As evidence of both structural and interpersonal coercion was found in global family planning programs pursuing contraceptive uptake to achieve broader development goals [
], the requirements of medical training can result in instrumentalizing marginalized bodies in the pursuit of achieving training targets. Coercion, like racism and sexism, can be perpetuated individually but also through structural and systemic processes. Regardless of the route, these are equally substantial threats to personal bodily autonomy.
The shift in workflows generated by abortion restrictions across the country offers an opportunity for quality improvement in consenting for trainee participation in care. Experiencing patient-centered structures to seek consent for trainee participation is an important component of medical training itself [
]. We offer a summary of ideal elements for the consent process from the perspective of patients and informed by established ethical frameworks in Figure 1. It is important for clinical care teams to be reminded that although maintaining patient confidentiality feels routine, upholding and reminding patients of confidentiality and privacy when involving a trainee in care are paramount to participants feeling safe. This patient-centered guidance can inform efforts to ensure nondirective consent and is intended to enhance, not obstruct, training and to ensure bodily autonomy is maintained in abortion care.
These findings echo survey results indicating physicians themselves may be a source of bias regarding medical students’ involvement in general gynecologic care [
]. Our review of the literature on consent for trainee involvement in pelvic care showed a lack of patient-centered qualitative data. To our knowledge, no other studies have examined patient experiences and preferences related to trainee involvement in pelvic care. The need for abortion care settings to respect and maintain patient privacy, and provide care in more intimate settings with fewer people involved, has been highlighted in other qualitative works [
While qualitative studies can contribute in-depth insight to stigmatized topics, our study has limitations that may impact our conclusions. Our data rely on patient recollection. The recruitment process using advertisements on social media platforms limits selection to those individuals who are literate and have stable Internet access. While there was fairly equal distribution of abortion region and White- and Black-identifying participants, this study failed to adequately represent Asian and Latinx individuals and skewed on the side of educated and more financially privileged, potentially limiting the perspectives captured. Though open to gender nonconforming and transgender individuals, all participants in this study identified as cis-women. Similarly, though recruitment was conducted bilingually in both English and Spanish, all participants enrolled in the study spoke English. These limitations highlight the need for more diverse recruitment efforts for which we did not have the resources. Finally, we did not interview adolescents, who may have different experiences and preferences than adults.
4.3 Conclusion
This study sheds light on patient experiences and perspectives related to trainee participation in abortion care. Varying levels of coercion to accept trainee involvement were common, highlighting the critical need for mechanisms to reduce potential coercion. In combination with existing literature on modern medical ethics, our findings suggest that training staff members to conduct consent for trainee involvement using a script in advance of the procedure, while the patient is fully clothed at eye level, without the trainer or trainee present, are practical steps to preserve patient autonomy. Coercion in trainee involvement in healthcare is not specific to abortion and recommendations to improve consent can be translated to other areas of healthcare, especially when care involves intimate examinations.
Acknowledgments
We would like to thank the staff and patient stakeholder group at the Person-Centered Reproductive Health Program. Thank you to the program and providers at TEACH, Jessica Ma, Katie Watson, Drs. Emma Chew Murphy, Biftu Mengesha, Alissa Perrucci, and Kim Koester for their invaluable support. We would also like to acknowledge artist MJ Robinson for their contributions.
Don’t ask, don’t tell: a change in medical student attitudes after obstetrics/gynecology clerkships toward seeking consent for pelvic examinations on an anesthetized patient.
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