Medication Abortion and Family Physicians’ Scope of Practice

Who Determines the Scope of Family Medicine?

The American Academy of Family Physicians (AAFP) “maintains responsibility for determining the philosophy, content, and scope of family practice.”9 Family physicians’ practices vary widely, influenced not only by an individual physician’s training and preferences but also by local demographics, hospital privileges, insurance reimbursement, and relationships with other specialists. Although multiple factors determine the range of services that individual physicians provide, the AAFP has resolved that, through the organization’s advocacy efforts, its members should retain control over the content of the specialty—that is, its scope.9 Because family physicians provide the only medical care in many rural areas of the United States, restricting the scope of family medicine would decrease the care available to many Americans. Without family physicians, 43% of US counties would meet the criteria for Health Professional Shortage Areas, which means that these areas would have fewer than one primary care physician per 3500 residents.10 However, even in some regions with adequate primary care medical staffing, abortion remains unavailable. In many rural areas, women must travel more than 100 miles to end an unintended pregnancy.11 The abortion provider shortage has multiple causes. Only a small minority of obstetrics-gynecology and family medicine residency programs offer abortion training, some trained physicians fear antiabortion violence, and other physicians personally oppose abortion.12–14

Medication Abortion in Family Medicine: Recent History

Insurance restrictions have not prevented all family physicians from offering medication abortion. Over the past decade, numerous family physicians have successfully integrated medication abortion into their practice. Before the release of mifepristone, some family physicians provided medication abortion with methotrexate,15 and several participated in the US mifepristone trials. Most of these family physicians have liability coverage through their institutional employer rather than individual policies. The National Abortion Federation, the organization representing abortion providers, reports that 18% of its members are family physicians and 50% are gynecologists.16 Numerous articles published in family medicine journals (Table 1) and presentations at family medicine scientific and academic meetings (Table 2) demonstrate that family physicians can safely provide medication abortion and that they consider it within their scope of practice.

During mifepristone’s approval process, the FDA considered restricting the medication’s use to gynecologists. However, the final approval allows mifepristone to be sold to “physicians who can accurately determine the duration of a patient’s pregnancy and detect an ectopic (or tubal) pregnancy.” All family physicians receive training in the determination of gestational age and in detection of ectopic pregnancy. Physicians who prescribe mifepristone “must also be able to provide surgical intervention in cases of incomplete abortion or severe bleeding—or they must make plans in advance to provide such care through others.”17 This language conforms to the way family medicine is practiced: family physicians treat to the extent that they can, and refer to specialists when indicated. Studies have demonstrated that surgical intervention (ie, a uterine aspiration procedure) is needed in only 0.8% to 5% of mifepristone abortions.18–20

Conclusion

Medication abortion is not a surgical procedure but rather a treatment process that requires a significant amount of counseling. Assessing the patient’s support system, emotional state, and understanding of the process fits squarely within family medicine. Family physicians’ extensive training in counseling prepares them well for this service. Perhaps even more important, the skills required for medication abortion are easier to apply in the context of an ongoing relationship between a patient and her family physician.

Medication abortion clearly falls within family physicians’ scope of practice. The incidence of complications with mifepristone abortion is extraordinarily low.18,21 Providing medication abortion entails less risk than managing a continuing pregnancy.22–24 In fact, mifepristone may be less risky to prescribe than the recently released medications for erectile dysfunction.26–29 Professional liability carriers seem to have based their decisions regarding insuring family physicians for providing medication abortion on factors far removed from actuarial risk. Perhaps the politically charged nature of abortion plays a role here? In any case, insurance companies’ refusal to cover family physicians for medication abortion amounts to an inappropriate restriction of our scope of practice—effectively impeding American women’s access to a much needed service. The AAFP should work with insurance companies and their regulators to resolve this problem.