Presenting STAT’s First Opinion: How Two Abortion Providers Grapple with Their Post-Roe Reality

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode! 

Dan Gorenstein: Hey, it’s Dan. This week’s episode comes from our friends over at STAT, the health news outlet.

Their First Opinion podcast is hosted by editor Torie Bosch who sits down with patients, doctors, nurses, anyone in and around health care with a thought provoking perspective to share.

In this episode, Torie talks with doctor Ali Block and Nikki Zite, an OB-GYN from Tennessee. They dig in to how patients and providers are navigating a post-Roe world. We hope you enjoy this timely conversation.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.

Ali Block: Every day in the Kansas clinic where I perform abortions I take care of pregnant people who have driven 10 hours or more across state lines for their procedures. They’re exhausted after moving mountains to get there, taking time off work, arranging child care, gathering funds. They’re excessively grateful and their gratitude makes me sad. These are the lucky ones, I think. These are the few that have managed to get here.

Torie Bosch: That was Ali Block, a family medicine doctor, abortion provider, writer and co-creator and host of the podcast The Nocturnists: Post-Roe America. She was reading from her recent First Opinion essay on the unintended consequences of the end of Roe. After a quick break, I’ll bring you my conversation with Ali and Nikki Zite, an OB-GYN in Tennessee, about the ways new abortion restrictions are affecting patients and providers alike.

Welcome to the new season of the First Opinion Podcast. I’m Torie Bosch, editor of First Opinion. First Opinion is STAT’s platform for interesting, illuminating and provocative articles about the life sciences writ large, written by biotech insiders, health care workers, researchers and others.

Welcome, Ali and Nikki. Thank you so much for being here.

Block: Thank you so much for having us. We’re happy to be here.

Bosch: So you both are or have been abortion providers, a field that, of course comes with a great deal of baggage in many ways. So what made you decide to go into this form of patient care?

Block: That’s a good question. Nikki, you want to take it first?

Zite: Sure. It’s actually a relatively long origin story, but I’ll condense it to say that I went to OB-GYN residency thinking I wanted to do high risk obstetrics, and within a few months of being at my institution where they were doing amazing work with high-risk patients who wanted to stay pregnant, I realized that a lot of the women didn’t want to be pregnant, and it would be safer for them to not be pregnant in a lot of the cases. So I started exploring family planning, and at that time there was a fellowship, but it was really young and new, and I looked into it and I was lucky enough to find a fellowship spot back home in Chicago. And the rest is history.

Block: And for me, I was always interested in reproductive health and reproductive rights just from the way I grew up. I grew up in a very liberal family in New York City, and supporting those causes was always kind of part of the water in my family that we were all drinking. And then when I went to medical school and decided to go into family medicine for my specialty, I knew that I wanted to stay really broad and continue with  comprehensive reproductive health care as part of my practice. So I matched into a residency program in Santa Rosa in Sonoma County in California that has a wonderful abortion training program and got trained up there. And then when I graduated from residency, took a faculty job and another residency program in Northern California, where I continued the work both providing abortion care to patients and also teaching the next generation of abortion providers.

Bosch: And what year did you both start providing abortions, if I can ask?

Zite: I finished my residency in Memphis in 2002 and did my fellowship from 2002 to 2004, and then moved to Knoxville, which has its own interesting stories about whether or not I was providing at different times after 2004.

Block: For me, I finished medical school in 2011. So again, abortion was really baked into my residency program. So I started providing then, but then as an attending when I graduated in 2014. So it’s been almost 10 years.

Bosch: So, Nikki, I’ll start with you on this. How has the politicization of abortion changed since you started this work? Did you have any idea when you started just how intense it was going to end up being in 2023? 

Zite: I think people on the family planning community kind of always knew it was there. Certainly when I moved to Knoxville, I was actually shocked that there weren’t a lot of laws dictating how abortion care was provided.

That changed in 2014, when we had our state referendum on whether or not abortion was a state constitutional protection. Abortion lost with very small numbers at the ballots and very little attention to the issue. Then we started having the same restrictions that you saw across the country with parental requirements, ultrasound requirements, delays for consent, and then worse and worse until it became obvious that there was going to be a lot of legislation in 2019.

Our trigger law passed not with, in my opinion, a lot of attention, and that was actually highlighted after it went into effect. No one actually knew what it said. It was only two pages long. And the response I got when I talked to people about needing to make sure it did not pass was that it didn’t matter because Roe was there and nobody actually thought our trigger would ever go into effect because Roe prevented it from being in effect.

And then in 2020, in the middle of the night, attached to a COVID budget, we had another abortion ban that was called a cascading ban. So it basically meant whatever was legal to ban throughout the country would be where our ban would be. So there was a six-week ban, a 10-week ban, a 12-week ban, and they were just going to say whatever was the most restrictive that was going to be allowed. Tennessee would follow that. And that, like I said, passed in the middle of the night. Again, nobody fought it. So I was aware these things were going to interfere with our ability to take care of patients. But it really didn’t get any attention until the Dobbs decision.

Block: Yeah, I really like the way that Nikki talks about it in our Post-Roe America series of the Nocturnists. She talks about how she sort of felt like Chicken Little running around for years and years, and I think that I to some extent felt that way, too. I mean, I was in a much more protected bubble, obviously living in California all that time, but I would go to these same conferences probably that Nikki was going to where everybody, I mean, especially after the Trump election where everybody thought the writing’s on the wall, Roe is, you know, coming down. And then especially with all the Supreme Court appointments that Trump got, it seemed very clear.

And everybody not in the family planning community thought that we were kind of hysterical. I think, I mean, really thought like, that’s nuts. You know, you guys are obsessed with abortion and this is all you think about and talk about it. So of course you think that this is the case. Again, what Nikki was saying, you know, running around feeling like Chicken Little. And then of course, the sky fell.

Bosch: Did the politicization ever make you second guess going into abortion care, or was it something that motivated you to really be determined to do it?

Block: I think for me, again, I was so naive and so protected in this California bubble. So I think that for providers like me, who mostly work in coastal blue states, we sort of get the credit for being abortion providers, but really are not doing anywhere near the amount of sort of emotional labor that goes into being an abortion provider in a red state. I mean, basically, whenever I introduce myself to new people, the entire time that I lived in the San Francisco Bay area, if I mentioned that I was an abortion provider, that was suddenly like the most amazing, interesting new thing about me.

And I have a feeling that that is not Nikki’s experience when she meets new people in Tennessee. 

Zite:  Yeah, I would say that I probably contributed to some of the stigmatization or marginalization because I didn’t talk about it that much. I just went about doing my business, and most of mine was kind of siloed and protected within a hospital setting. So it’s a lot of the, quote, good abortion, right? The stuff that people don’t necessarily label or talk about as abortion when you’re ending a pregnancy because the woman is actually close to death or the pregnancy is not survivable, people don’t tend to, you know, we’ve seen it play out. They’re trying to say it’s not abortion. Obviously it is.

And obviously teaching our trainees how to take care of those patients but also get the experience in induced abortion is important because we don’t have the volume of those emergency cases to get people good at this kind of care. And in those emergency cases, I’m not letting an intern or a lower level resident get that experience. And so we need easier cases that can be done with some kind of repetitive volume to get our future generation OB-GYNs who will provide abortion care trained to be safe. And we’re not getting anywhere close to that anymore in Tennessee, and certainly I would think in most red states.

Bosch: And I want to get into those sort of unintended consequences of ROE in a minute. But first, I want to ask you both where you were when you found out from the Supreme Court leak that Roe v. Wade was almost certainly going to be overturned. What were your immediate responses?

Block: I was in my house in San Francisco going from one child’s bedtime routine to the next child’s bedtime routine, walking up the stairs, looking at my phone in that, you know, 30 seconds that I had between that, as I tend to do, and I saw it come in on my phone as a ping. And I just remember sort of like grabbing the banister and hyperventilating and, you know, weeping and then also, you know, putting it away and putting my phone in my pocket because ultimately I still had to put my one year old to bed.

And then there were a lot of text messages and a lot of emails that happened over the next few hours. I think what struck me the most and again, what came through in those sort of text chains throughout the rest of the evening was I was quite surprised at how devastated I was because of what we’ve said already. I thought I was preparing myself for years. I was telling anybody who would listen: Roe is getting overturned, Roe is getting overturned. And so I think I sort of created this illusion for myself that I was actually preparing for it.

But, you know, just because you say that, you know, that a hard thing is coming doesn’t mean that you’re actually emotionally prepared for that hard thing. So I was not surprised, but I was still really, really sad is was kind of what I would say.

Zite: Yeah, all the same, except for that my kids are grown so their bedtime routine is ignoring me. I keep relating it to other situations of grief or loss. You know, like, you know, someone is terminally ill, but you’re still really sad when they pass.

And up until the end, you might still be going through the bargaining and the anger and all the cycling through the different phases. And I think the phases that we had before the leak just amplified after we started doing the same discussions. Well, maybe this was leaked so that they won’t actually do this. Maybe it was leaked because it’s not where the final decision is going to be. And then other people are like, nope, this is what it’s going to be. Let’s start working on it.

Bosch: So do you think that the fact that it was leaked a couple of months ahead of time changed that response? Do you made that sort of bargaining a little bit easier within the field?

Zite: I think for me it helped at least make people outside of the field aware that it was real. And I didn’t have to wait until the day of the decision to get the key stakeholders at my institution to pay attention.

Bosch: And that’s huge. So, you know, you had a little bit of time to prepare because of the leak. But what’s something that has surprised you both about the aftermath of Dobbs?

Zite: I think I’m still surprised — and some of it I was reminded about in the podcast — but the lack of awareness even among physicians that are not OB-GYNs and somewhat even among OB-GYNs that typically avoid this care. The other physicians that would normally refer patients to me with a terminal anomaly, you know, called after the decision with like, you know, the baby has no brain and we normally could offer a termination for that patient at our institution. And I had to say, sorry, now I’m partnering with people in — it was North Carolina or Georgia for a few minutes and then it can’t even be those because of different laws. So we had to keep up to date. I became like a navigator instead of a physician.

But it was shocking that when people would say, “But that pregnancy can’t survive, what do you mean you can’t do that?” [I was like], “I told you, our law is only two pages long and it says all abortion is a felony.” So even people who were potentially going to be in the situation where they were taking care of patients with an ectopic pregnancy or a miscarriage and technically committing a felony didn’t know what the law said.

Block: I’ve been really surprised to hear from, I mean, Nikki’s talking about the provider side people that didn’t know. Also tons of patients, you know, people, things that I’ve been reading or friends or colleagues or family who say, I didn’t really know that I had an abortion. Like I didn’t think of myself as getting an abortion because, you know, Nikki’s describing these specific cases where we sort of, again, because of the stigma, don’t even use the word. And we don’t want to make people feel bad that they’re getting an abortion when it’s for a “good reason.” And so I think I have been surprised at how many people were surprised.

That’s one place to start. And then I’ve been pleasantly surprised at how much it’s really galvanized the left and the movement and the the pro-choice sentiment among, you know, people everywhere. So, for example, Kansas had a ballot measure last summer that I was following closely because of the clinic where I work in Kansas, and everybody sort of thought it was going to be a nail biter. And it wasn’t. It was a landslide in favor of abortion care.

And so I think, you know, to some extent, maybe that’s a failure of the pro-choice movement that it took people losing their rights to understand what their rights were in the first place. But now they lost them and now they understand, and now they’re mobilizing. So I would say that that is a pleasant surprise.

Bosch: So, Ali, you correct me if I’m wrong, but you live in California and are practicing in Kansas, right?

Block: Sorry, that was confusing. I have been talking about California a lot. I lived in California for many years. I moved to the East Coast about a year ago, so now I live and work on the East Coast, where I also provide abortion care, and I travel to Kansas to do abortion care there as well. And I’m also a full scope family doctor at a residency program here. So reproductive health is a small but very important piece of what I do.

Bosch: So what is it like kind of going between the East Coast and Kansas, where, as you say, there was this sort of surprising — at least for me — support for abortion recently but it’s also, you know, a state that’s more conservative? Is there a sort of like, interesting psychological thing that happens to go back and forth between the two places?

Block: I think that the experience with Kansas is sort of what I would expect. And truthfully, when I’m there in the building, it doesn’t feel that different than when I’m here on the East Coast. I mean, every abortion clinic where I’ve ever worked has protesters outside and they kind of have the same flavor. I think what’s really different is actually the conversations and the work that we’re doing inside the building. So I talk about this and actually in the third episode of the Post-Roe series we’re going to go into the Kansas clinic where I work. So I brought two of my producers with me on one of my trips to Kansas, and we go inside the clinic and everybody will get to see and meet and hear the amazing staff that works there and kind of what it’s like to be doing that care there right now.

But what really surprised me and what feels so different is the stakes in terms of the patient care. So first of all, I think the main thing is just that there are no alternatives. So anywhere else that I’ve practiced before, if you have a patient who is high risk in some way or not even that high risk, just a tiny bit high risk, or has some sort of social complication where maybe they can’t do it today or we can’t do it today, you know, if anything is off in the littlest bit, it’s just kind of not a big deal. You refer them to the academic medical center [or] you refer them to the local hospital. 

And so that happens all the time, right? Your patients come in at the beginning of the day. You’re doing ultrasounds, you’re doing your medical screening, things come up. And I would say in my California practice or here [for] a couple patients every day we say we’re not going to do this procedure today. We’ll set you up at this other institution. And so when I got to Kansas, I would see a patient and they would be a little high risk and I was so naive, you know, and I would sort of say, “So what do we do with this patient? Where are we going to send them?”

And the staff would sort of laugh at me and be like, this is where we treat them. There is nowhere else for them to go. So if we don’t do it here, if we don’t do it today, they’re not getting their procedure. And that just creates a lot of psychological stress and pressure on the staff, because you really feel for that patient. You really want to get it done.

At the same time, of course, you never want to do anything unsafe that’s going to jeopardize the health of that patient or frankly, jeopardize the viability of the clinic as a whole. So there’s just always that sort of meta narrative happening in the back of your head at the clinics in the red states. But of course, you know, Nikki can probably talk to it better than I can.

Zite: No, I think that’s great. I mean, sometimes we talk about killing people with kindness, right? Like where, you know, it’s not the best decision, but the patient really pulls on your heartstrings and you consider it. Then you have to take yourself back and say it’s not the best for the institution, and you’re not actually going to help them.

Bosch: And Nikki, you know, having to make these calculations, which I imagine must come up every day — or at least every week — does it ever make you think about moving to a state where you’re better able to provide the care that you want to, or are you sort of committed to Tennessee?

Zite: Just like all those other things, I fluctuate. The roller coaster is very wild. I have an Illinois license. I’ve kept it since fellowship as my security blanket. But this is the best place for my family. My husband has a career also. My kids are teenagers in school. Like uprooting them is not an option.

I could travel like Ali, but I also live in a city that has a horrible airport. No offense. I mean, I love it, but I love that I can get there three minutes before my flight. But I don’t love that I can’t fly anywhere direct, and it’s exceedingly expensive. So there’s, you know, pros and cons.

I think that part of me feels like now that I’m here and I’m doing this, this is why I’ve been here. I had an amazing colleague when I first got here that walked me through my imposter syndrome and my guilt about not providing care at outpatient abortion clinics after doing this fellowship. And she said, “I can do that. I’ve got grown kids and I am situated well for that. You stay where you are. You teach the next generation. You take care of any complications or people that I have to refer to you. You take care of the more complicated patients and try to normalize this work.”

And so she really helped me to feel okay about what I was doing. And then now that this is happening, I feel like that MPH that I got in policy and advocacy is finally coming into work as well. And so I’m able to, you know, if not me, then who quite a bit? And then every once in a while I look at my Illinois license, I’m like, oh, maybe.

Gorenstein: After the break, Torie and her guests dig into more of the Dobbs decision’s unintended impacts.

MIDROLL

Gorenstein: Welcome back. We’ve turned over the feed this week to our friends at STAT News, featuring an episode from their podcast “First Opinion.” Here again is host Torie Bosch talking with abortion providers Ali Block and Nikki Zite about the future of reproductive care in America. 

Bosch: I want to shift gears back to talking about these unintended consequences of the end of Roe. So, Nikki, you talked a little bit about the lack of training, about how this is making it harder to train new doctors on important reproductive health care procedures.

Have you heard from any trainees about how this is kind of impeding their ability to develop necessary skills? 

Zite: Yeah, I do think that my residents are fearful that they will be that one that goes out into an area where there is not someone else, and they’ll be on call in an E.R. by themselves and some poor patient will come in as a victim of a motor vehicle accident in early pregnancy and be bleeding from an abruption, and the fastest way to treat them would be a D&E and they don’t feel comfortable at the gestational age that she’s at.

I mean, we have that happen here enough that they’ve heard about it. And so they want to be trained well enough to take care of it. And they also don’t want to have patients that they diagnose with some awful anomaly and have to tell them that they have to go somewhere else. I think that’s pretty morally distressing to feel like you should have a skill that you could take care of your patient, and then you’re adding to that patient’s stress by making them figure out where it’s legal to go, how much it’s going to cost, how much time off they’re going to need, even though it’s legal, how many days in advance do they have to be there for either consent or cervical prep, like things that we should be able to take care of our patients when they’re going through these traumas.

Bosch: You know, Ali, one thing you wrote about that’s somewhat related in your column was the fact that this is leading to a dearth of care in rural areas. Can you tell us a little bit about what you’re seeing?

Block: Well, I think it’s it’s twofold. So you have providers that are leaving that already have the skills that are attending providers that have been living and working in their communities that feel like they really can’t stomach the moral harm that Nikki is talking about — that they can’t practice what they feel is appropriate, standard care, that the politicization is too much. And so they’re leaving.

I talk in the article about these two counties in northern Idaho that now have no obstetric providers. So certainly you’re going to see big impacts on communities there. And then what we’re going to see unfold is more what Nikki is talking about, about the trainees and the decisions that they’re making.

So, you know, the residents who had already matched into programs when Dobbs came down, they are where they are. But we have now a whole generation of medical students that are having to make the choice between going and training in areas where maybe their families are or maybe they grew up, maybe their whole vision in life was to go back and serve those communities. So they have to choose between that and getting the training that they want.

What we know is that a lot of people stay where they do residency training. So if you have medical students who say, you know what, I’d really love to be, let’s say, in Tennessee, but I want to learn abortion care, whether they’re family medicine or OB-GYN residents. So I’m going to go to Chicago or I’m going to go to New York, or I’m going to go to one of these states that isn’t restricted to learn. A lot of those folks are not coming back.

And so that is sort of an incalculable loss that those communities will suffer of not having the providers that really want to live and work there at all. 

Zite: I think there’s two other issues with trainees. One: They are reproductive age people typically, so they don’t necessarily want to put themselves at risk of being in a situation where they don’t have the freedom to make a medical decision for themselves without leaving their state. And then also the fear of being criminalized, like we as physicians always were worried about malpractice, right? We always want to do the right thing so that we don’t do harm and don’t get sued for malpractice. But this whole fear of committing a felony is a whole different issue that never was, you know, taught in med school or residency and never something that we thought we would have to deal with.

Block: And again, these folks that are really early in their careers that have 50 years potentially of practice and livelihood ahead of them aren’t about to take that kind of risk. We’ve talked to one provider, Linda Prine, who’s a family medicine mentor of mine in New York City who has spoke openly in the press. She’s like, listen, I’m sort of approaching retirement age. My kids are grown. If anybody should be taking these risks, it’s me. If I lose my medical license, it’s kind of fine. I was going to retire anyway. That’s not true for a 26 year old.

So yeah, I mean, I think those calculations are really tough. And then the folks who do go and choose to train in these places are not getting the training that they need to really care for these communities safely.

Bosch: And, Nikki, what are you hearing from the trainees who decide to go to Tennessee? You know, what made them decide to to go for it despite everything that’s happening there?

Zite: So I think there’s a mix. Thankfully, at my institution, I haven’t seen it be, “I didn’t want that training anyways. This is a relief.” It’s more my family’s all in the southeast. I wanted to stay in the southeast. It’s what makes sense. And, we’re making some not promises, but we are telling people that we are going to do our best to figure out ways to train them. I mean, 26 states have bans of some kind. That’s over half the residency programs. So somebody has to train in these places and so they can look for places that at least are, you know, hoping to partner with programs outside of the state, doing as much as they can with simulation and online courses, and just really trying to push the advocacy side of the education, the contraception side of the education, do as many procedures as we can possibly do legally so that they get competent.

Bosch: I know you said that not so much in your program but do you have a sense of whether there’s a portion of people in OB-GYN who are anti-abortion, who are excited about these sorts of changes?

Zite: I mean, there clearly are those people. There is a professional organization dedicated to people who don’t believe in choice. I personally believe that they contribute to the issues with the language because they’re out there saying there’s never a reason to end a pregnancy, to save someone’s life, when clearly there is. And they’re the ones not calling it abortion or talking about fetal pain at ridiculously early gestational ages to try and pull on heartstrings and help legislators to make the decisions that they’re making against reproductive freedom and choice. But I feel like the younger generation, I haven’t seen as many, you know, based on the most recent match, which was last year.

There was an overall 5% decrease in applicants to OB-GYN and 10% decrease in applicants to ban state programs. So I think maybe rather than going into the field, if you don’t want to provide that care, you’re just not going into the field. Or people who would have gone into the field in the past are afraid of all the stuff that Ali mentioned and are choosing other fields.

The only field that is struggling more right now with a downward trend is emergency medicine, after all of the COVID issues. So you can see that moral distress does impact the next generation of what people go into in medicine.

Bosch: And just to start to wrap up, what advice do you to have for anyone thinking about going into reproductive health care in a post Dobbs world?

Block: I assume you can edit out the long pause.

Bosch: Take your time if you need a second.

Zite: It’s really hard. I mean, you know, I have two kids and my husband and I are both physicians. And people always ask, you know, are you telling your kids, you know, not to go into medicine? And I think they’ve watched us struggle. So I think they know that it would be a challenge. And we definitely are not pushing them towards medicine. But if one of them ended up going into medicine, we would assume it was because they have the same passion and desire that we did when we were younger and we wouldn’t dissuade them…

But if you’re actually going to provide that care, you’ve got to be ready for all of the battles that you will encounter being able to do that. And I hope that the next generation has people that are maybe smarter than I was about using the language and talking about it more openly so that we can get ourselves out of this corner and more into mainstream medicine.

Block: And I think I would also be sure to mention that it’s incredibly rewarding, gratifying work. I mean, family planning care, abortion care, you are providing a service that people really need, really want, and you can do it with your skills, with your own hands, in a relatively short amount of time and drastically alter the course of somebody’s life in a way that they want. And that’s really empowering for us and for the patient.

So I think if you have sort of the gumption and the stick-to-it-iveness and the long-game vision of what this fight is going to be, there’s no field that I would rather work in. But I think that part of it is there’s a lot of, you know, certainly when I was younger, I had a lot of impatience around the advocacy. And I think telling, you know, younger people and trainees going in: It’s going to be a long haul and a long slog, and you’ve got to pace yourself. You’ve got to find ways to make the work — both the advocacy work and the clinical work — sustainable for you because this fight will take a very long time.

I mean, it took the right 50 years to dismantle and overturn Roe v. Wade, and it will take us a long time to bring back those rights. But I think it can be done. I think there’s a lot of people doing incredible work, and I think that the popular opinion is generally on our side, but it’ll be a lot of work.

Bosch: Ali Block and Nikki Zite, thank you so much for joining the First Opinion podcast today.

Zite: Thank you so much for having us.

Block: Thank you for having us. 

Bosch: Thank you for listening to the First Opinion podcast. If you enjoyed this conversation as much as I did, please keep an eye on the podcast feed. We’ll be sharing the first episode of the Nocturnists’ Post-Roe America, which is hosted by Ali and features Nikki talking about her experience. And it’s just really, really compelling listening. I highly recommend subscribing.

The First Opinion podcast is produced by Teresa Gaffney. Alissa Ambrose is the senior producer and Rick Burke is the executive producer. I would really like to hear what First Opinion contributors you would like to hear on the show and what topics the column should tackle.

Email me at First Opinion@statnews.com, and if you have a minute, yes, I’m asking you again: Please leave a review or rating on whatever platform you use to get your podcasts. And while you’re at it, sign up for the First Opinion newsletter, which comes out every Sunday. Until next time, I’m Torie Bosch, and please don’t keep your opinions to yourself.