Where Will Doctors Train? Residency Applications, Abortion Restrictions, and the Coming Workforce Crisis

The Supreme Court’s 2022 Dobbs decision returned abortion policy to individual states, creating a patchwork of restrictions with far-reaching implications for the physician workforce. In this SoundPractice episode, host Mike Sacopulos interviews Drs. Anisha Ganguly and Anna Morenz, co-authors of a study in JAMA Network Open examining post-Dobbs residency application trends. Analyzing nearly 24.2 million applications across all specialties, their research demonstrates significant declines in applications to abortion-restricted states among both male and female applicants, with the sharpest drops in primary care, OB-GYN, and emergency medicine. The authors discuss workforce implications, lag times, and their next research directions.

This transcript of the discussion has been edited for clarity and length.

Mike Sacopulos: Tell us a little about your background.

Anisha Ganguly, MD, MPH: I am an assistant professor of medicine at UNC Chapel Hill. Dr. Morenz and I trained together in residency at the University of Washington — that’s how we became friends and future research collaborators. We are both primary care physicians, trained in internal medicine, and we’re both clinician investigators as well. Our primary research careers are focused on health services research, policy-informed research, and addressing social needs. Both of us have an interest in cancer screening, and we came to this topic almost as a side project based on observations we were seeing among our peers in the healthcare workforce. I completed a postdoctoral fellowship at UT Southwestern and at their county health system, Parkland Health, where I got dedicated time to develop my health services research skills.

Anna Morenz, MD, MPH: I’m Dr. Anna Morenz, and like Dr. Ganguly, I’m a primary care physician and researcher at the University of Arizona. A lot of my research has focused on evaluating the health impacts of various policies across the U.S. — including Medicaid expansion policies and their impact on patients’ receipt of organ transplant, and the impacts of paid sick leave policies on colorectal cancer screening. This was an exciting expansion of that work to look at the impacts of state-level abortion restrictions on our healthcare workforce in the form of residency applications. I completed my master’s in public health at the University of Washington after residency and took a class on causal inference methods — the key methodology used for policy evaluation — under Dr. Anirban Basu, who is a coauthor on this article and provided a great deal of methodologic rigor and expertise.

Sacopulos: In June 2022, the Supreme Court released its opinion in Dobbs v. Jackson Women’s Health Organization. Can you talk about that decision and its significance to healthcare?

Morenz: The June 2022 Supreme Court decision overturned the former decision from the 1970s — Roe v. Wade — and essentially returned abortion policy decisions to individual states, instead of allowing a nationwide protection for abortion rights for women. As a result, you saw a patchwork emerge of abortion policies across the U.S. Many states had been anticipating this decision and had so-called trigger laws — restrictions on abortion at a certain gestational age, whether six weeks, ten weeks, et cetera — that were ready to take effect if Roe was overturned. That’s a good summary of where we were in the summer of 2022.

Sacopulos: Your study analyzed nearly 24 million residency applications across more than 4,300 programs. What prompted you to look beyond OB-GYN at the entire residency pipeline?

Ganguly: There have been important studies previously published showing the impact of state abortion restrictions on the OB-GYN workforce and training pipeline, and that makes a lot of sense because OB-GYNs deliver the vast majority of abortion care in the United States. I was interested in how this may be affecting our healthcare workforce more broadly — particularly through my lens as a primary care physician — because PCPs do deliver a lot of family planning services. We counsel patients preconception and around preparing for pregnancy. We diagnose pregnancy. And we do deliver some abortion care in the United States, increasingly so because medication abortion is the primary abortion modality in the U.S., particularly post-Dobbs.

It’s also important to remember that resident physicians are individuals who are planning their own families during their young training years. They may have personal reasons for choosing the state where they want to train based on these policies. It felt like a good time to widen that lens. When we think about abortion care, our first instinct is OB-GYN, but it may be a bigger problem than that. We wanted to expand to all specialties.

Sacopulos: The headline finding is that applications dropped in abortion-restricted states among both women and men. Many would assume this was primarily a women’s issue. What does the decline among male applicants tell us?

Morenz: We wanted to stratify our analysis by self-identified gender because we were curious about that very question. We viewed there as being both professional and personal reasons why applicants may prefer not to complete their residency in a state with abortion restrictions. Many would surmise that the personal reasons could be more magnified for women applicants, particularly as residency is a time that often happens during prime childbearing years.

But our finding that applications decreased significantly among men as well reflects that these residency program decisions are often being made with a family in mind — a partner or spouse coming along, children to be mindful of — as well as the professional ramifications of practicing in a state with restrictions where they may feel they’re not able to provide the quality of care they would like to. I also think some of these states that have enacted abortion restrictions may be more likely to enact other restrictions, for example on diversity, equity and inclusion curriculum. We weren’t able to tease out those nuances in this study, but that’s a future area of research we’ve been discussing.

Sacopulos: The steepest declines were clearly in OB-GYN and family medicine. What happens to patients in restricted states if residency slots go unfilled?

Ganguly: So far, there hasn’t been a meaningful increase in unfilled residency slots. Our study looked at volume of applications submitted to residency programs — it does not tell us about match rates in those states. But a decreased volume of applications is an indicator of lower interest in going to those states. We’re planning future work to continue following this trend to see how it may affect the training pipeline long term.

The reason the training pipeline matters is that more than 50% of residents go on to practice in the state of their residency. Wherever residents want to train matters, because more than one in two will stay there to be doctors in those states one day. Many abortion-restricted states already have existing workforce shortages, particularly in primary care. Policymakers considering the ramifications of these abortion policies are thinking about turning off abortion care delivery in those states — but they don’t think about the impact on primary care provision. We also found that emergency medicine was particularly affected. These policies could affect the individual who’s going to save you from your heart attack — healthcare workforce supplies in ERs and in clinics, not just in family planning clinics.

Morenz: I’ll add one thing: Even though match rates are extremely high by virtue of how the residency match works, in the most recent match cycle this past March, there were two OB-GYN residencies that did not fill all of their slots. Both of those programs were in Texas. This is an area that needs further monitoring, and that’s concerning.

Sacopulos: Some of the most competitive specialties — dermatology, neurosurgery, orthopedics — were largely insulated from this trend. What does that tell us about the limits of physician choice?

Morenz: This was an expected finding for us. These are the most competitive specialties — applicants are usually encouraged to apply very broadly to a high number of programs, and generally feel in some cases lucky to match at all. Wherever they match, that’s where they go. There’s less agency in being choosy about where you apply if you’re in one of these most competitive specialties. There’s been a lot written over the decades about the residency match system, even court cases, about how it interferes with an individual’s agency in choosing. You rank programs, they rank you, and then a computer algorithm matches you together. In terms of the impact of abortion policies, it was expected that these individuals in the most competitive specialties would still need to apply wherever programs might be, and be willing to potentially go places they may not want to live long term to complete their training.

Sacopulos: Can we talk about lag times? It seems like if there’s a problem, it may not manifest itself for some years.

Ganguly: This is a very early signal of a potential problem, and it doesn’t even reflect a decreased supply of residents yet — it reflects a decreased level of interest from residents in abortion-restricted states. But there are many steps that may go on to confer bad patient outcomes in the future. Decreased interest may lead to decreased numbers of residents, meaning unmatched slots for programs in these states. Long term, that leads to a thinner workforce in those states. And when there are not enough doctors, that leads to bad patient outcomes. It is something we need to be monitoring very closely.

Our study also looked at only one year immediately post-Dobbs. What really hasn’t been shown yet is how durable these decreases are. One potential thing we may see in future research is some evening out between restricted and non-restricted states. We don’t know that yet until we evaluate the data, and that’s something Dr. Morenz and I are pursuing.

Sacopulos: The data shows a gap in applications from women to abortion-restricted states even before Dobbs. What does that tell us about how the reproductive health climate was quietly shaping physician careers for years?

Morenz: I think this reflects the fact that there have been a lot of attacks on abortion access that preceded the overturn of Roe v. Wade. Listeners may be familiar with TRAP laws — Targeted Regulation of Abortion Providers — which really started gaining momentum in the 2010s. These were things like requiring physicians who performed abortions to have hospital admitting privileges, even though the risk of a complication requiring hospital admission is exceedingly low after what is a common outpatient procedure. That’s just an example of the sorts of things that were leading clinics to close or providers to no longer offer these services. That was likely something women applicants were more attuned to, both for professional and personal reasons. It may have taken the Dobbs decision really escalating these issues to a very visible national scale for men applicants to feel a heightened sense of alarm about potentially practicing in states with restrictions.

Ganguly: The pre-existing differences we see among women prior to Dobbs absolutely reflect unfriendly reproductive climates that existed in these states. Dr. Morenz and I have been using the term “reproductive climate” to reflect the broader landscape — not just provision of abortion services, but red tape around contraception access, other parameters of family planning and female reproductive autonomy that women would be more aware of. And then the Dobbs decision resulted in all these policy changes happening very quickly, kind of unmasking a problem that suddenly the public consciousness, including men, became more aware of all at once.

Sacopulos: Were you at all surprised by the results?

Ganguly: We had originally hypothesized that the drop-off in applications would be primarily among women. We had written into our analytic plans that we expected to see primarily an effect among women applicants, not men. The decreases we saw among men opened my eyes to understanding that this is a wider problem — we’re not just going to lose women doctors in these states, we may lose men doctors too. This is an “all of us” problem. I want audiences to appreciate that. I want physicians to know that. I want policymakers to know that. I want patients to know that it’s not just a certain type of resident trainee who’s going to be affected by this. It may be much bigger than we anticipate.

Sacopulos: Have you seen any research on physicians exiting practice early or taking early retirement in restricted states?

Morenz: That is the next step in our own research portfolio. The Centers for Medicare and Medicaid Services maintains a database of where physicians are currently practicing, linked to a physician’s National Provider Identifier, or NPI, which is given when they graduate from medical school. It’s a lifelong identifier that reflects your practice address, which changes if you move. We are using that database — through a collaboration Dr. Basu has at the University of Washington’s Center for Rural Workforce, which has maintained NPI files going back to around 2009 with quarterly or yearly updates — to look at exactly that question: Are physicians in states with restrictions more likely to be moving their practices or potentially exiting the workforce entirely?

Ganguly: There are some initial reports that the average age of retirement for OB-GYNs is getting younger in response to these policies that make it so difficult for OB-GYNs to retain their autonomy in their practice. It is definitely something we need to be looking at. Our first study showed the signal among people starting their career. But an important question to answer is: who’s ending their career too early because of this?

Sacopulos: What other projects are you and Dr. Morenz working on?

Ganguly: Another unanswered question about these policies is how they affect patient outcomes. Cancer screening is one of the most important things we deliver for patients in primary care. Dr. Morenz has proposed an interesting analysis to understand the impacts of abortion restrictions on the provision of preventive care. Senator Elizabeth Warren posted recently reminding constituents that the questions around Planned Parenthood funding matter because closure of Planned Parenthood clinics doesn’t just remove abortion services — it’s also a critical access point for preventive care, including contraception, STI testing, and breast and cervical cancer screening, some of the most life-saving aspects of preventive care that women need. We are interested in quantifying that, and in understanding how these policies may be affecting cancer screening for women.

Morenz: I think Dr. Ganguly summarized it well. We’re looking to get funding for the robust data sources we’d need to really address this question. And echoing back to your question about lag time — cancer screening is often every three to ten years depending on the type, and cancers themselves can take a very long time to develop. We may need more lag time and the correct data to really get a sense for the impacts on these outcomes.

Listen to this episode of SoundPractice .