Abstract
Introduction: Most family physicians do not provide abortion care, despite an apparent alignment between the defined values of family medicine and provision of abortion in primary care. This study seeks to understand how family physicians themselves perceive the relationship between their specialty’s values and abortion provision.
Methods: We conducted in-depth interviews in 2019 with 56 family physicians who do not oppose abortion in the United States. We employed a deductive-inductive content analysis approach with memos to identify key themes. This analysis focuses on participants’ beliefs in the core values of family medicine and how those values relate to abortion in family medicine.
Results: Participants identified and described six values of the specialty they prioritized, which included relationships, care across the lifespan, whole-person care, nonjudgmental care, meeting community needs, and social justice. Family physicians in the study overwhelmingly believed that abortion aligned with family medicine values, regardless of whether they themselves provided abortion care.
Conclusions: Providing abortion care in primary care settings gives family physicians an opportunity to provide comprehensive care while improving access to meet community needs. As abortion care becomes increasingly restricted in the United States, family physicians can manifest the values of family medicine through integrating abortion care into their practices in states where abortion remains legal.
Introduction
Family medicine has from its inception been defined by the core values of caring for the whole person and adapting to the evolving needs of patients and communities,1 in contrast to other medical specialties that are defined by a focus on certain organ systems or specified realms of expertise. Since family medicine’s founding, these core values have been described in multiple formats over time,1⇓⇓–4 with the 2004 Task Force for the Future of Family Medicine, defining them as providing, “continuing, comprehensive, compassionate, and personal care for their patients” and “access to what is needed for people of any and all backgrounds and life circumstances” as well as being “knowledgeable and willing to accept any type of problem and take responsibility either to provide the care or assure that care is provided by an appropriate source.”2
Abortion provision in the primary care setting seems to align with the values of the specialty in providing whole-person, continuous care to improving access to meet community needs. This is particularly salient in areas where communities experience limited access to abortion, including in rural areas, where family physicians can be the only source of care.5,6 Medication abortion, in particular, requires less training and equipment than aspiration abortion, and is a promising method to increase abortion access in primary care settings.7
Although many family physicians in the US have indicated they believe abortion is within the scope of family medicine, the majority do not provide abortion care despite managing early pregnancy loss.8 An analysis using data from the Family Medicine National Graduate Survey in 2016 to 2018 found just 3% of family physicians were providing abortion care three years after residency.9 There seems to be a disconnect between the defined values of family medicine and physician practice patterns related to abortion care. Given this, we conducted a qualitative study to understand how US family physicians who are not opposed to abortion view the values of the specialty and their relationship to abortion provision.
Methods
This analysis draws on a larger project that explored how communication strategies can be leveraged to support integration of medication abortion into family medicine. To focus on physicians without ethical or moral barriers to this work, we excluded individuals who self-identified as opposing abortion. We interviewed early career family physicians who graduated residency within the last ten years and family medicine thought leaders. We describe the sample as well as recruitment, data collection, and analysis in-detail in previous articles focused on barriers to providing abortion care.10,11
Data Collection
The interview guide was designed to explore participants’ conceptualization of the values of the specialty and how those values relate to abortion in family medicine. The guide included the following interview questions: “What personal values influenced your decision to become a family physician?”, “What do you think are the core values of family medicine?” and, “Thinking of the values you mentioned, how do you think these relate to your beliefs about abortion in family medicine?”
Research staff obtained oral informed consent and participants completed surveys with questions about demographics, training, and clinical experience before the interviews. Recruitment ended when the research team established that the themes related to the relationship of the specialty’s values and abortion provision reached saturation. This study was approved by the University of California, San Francisco Institutional Review Board (#18-26392).
Analysis
A HIPAA-compliant professional transcription service transcribed verbatim and deidentified all transcripts. Research team members read transcripts, discussed impressions with the study team, and developed a preliminary codebook. We used a deductive-inductive content analysis approach,12 with memos to identify broad themes. Deductive coding was informed by preexisting knowledge of the defined core values of family medicine, including continuity of care and relationship-centered care. The team regularly met to discuss memos and themes derived from the transcripts to develop an understanding of participants’ views on the core values of family medicine and how those values relate to abortion provision in family medicine.
Results
Between January and October 2019, we conducted in-depth interviews with 56 family physicians, including 49 early career family physicians and seven family medicine thought leaders (Table 1). Participants were from four regions of the US and the majority of the participants (77%) identified as female. Most of the participants (70%) did not provide abortion care, despite the majority (70%) having received abortion training (either aspiration, medication, or both) during residency.
Participants’ Characteristics and Abortion Experience in 2019*
Family Medicine Values
Participants in the study identified the values of the specialty that they prioritized, which included relationships, care across the lifespan, whole-person care, nonjudgmental care, meeting community needs, and social justice.
Family physicians described themselves as “experts in relationships” (P51) and believed having trusting relationships with patients strengthened their ability to provide quality care. Participants shared stories of their patients telling them, “You are the only person I trust to do this” (P9) and, “I’ve never told anybody…three-fourths of the stuff that I just told you” (P60). Participants also reported valuing the opportunity to provide care across the lifespan and felt continuity of care distinguished family medicine from other specialties. Participants explained, “Family medicine is the only one [specialty] that you will have that continuous care from the day they were born to the day they die” (P43).
Participants viewed whole-person care as caring for the entire person in the context of their families and lives and contrasted it to treating a disease or caring for an organ system. They valued being able to meet their patients’ needs by providing full-spectrum care without referring to specialists and felt their broad scope enabled them to provide whole-person care. “There is not anything that is not our problem” (P10), one participant explained.
Providing compassionate, nonjudgmental care was also considered central to family medicine; participants discussed the importance of being aware of personal bias and not allowing biases to be reflected in the care they provide. As one participant explained, “Our job is not to judge…our job is to provide care, and it is that person's decision” (P43).
Participants viewed the role of family physicians as being both part of the community and adapting their scope of practice based on community needs. They discussed family physicians’ broad skillset as one that should be “tailored to the needs of community” (P48) and evolve over time. Although participants mentioned social justice as a core value that personally drew them to family medicine, some felt that including social justice as a core value of family medicine was overly optimistic given that the specialty is large and includes physicians with diverse views on social justice and its role in the specialty. Despite this concern, many participants shared that their reasons for being drawn to family medicine are based in equity and justice. As one participant explained, “Family medicine was probably the biggest place where I saw people interested in enacting change and caring about the patients and – and giving them full access to care” (P61).
Family Medicine Values and Abortion Provision
Participants overwhelmingly expressed the belief that abortion provision aligned with the core values of family medicine, regardless of whether they themselves provided abortion. Below we discuss themes that demonstrate how participants described the alignment between abortion and what they considered to be core values of family medicine. We indicate for each quote whether the participant had abortion training during residency (T) or not (NT) and whether they are an abortion provider (P) or not (NP). Additional quotes related to themes are included in Table 2.
Additional Quotes on Family Medicine Values and Abortion Provision
Relationships
Participants felt that family physicians should be able to provide abortion care because of their relationships with patients. As one participant shared, “I think that is – again, foundational to what we do as family doctors is, by knowing patients and…the context of their life, we're able to counsel them and help them through those difficult decisions” (P41, NT, NP). Participants also discussed the importance of having trusting relationships with patients and described how trust enabled them to be able to support patients seeking abortion care (Table 2).
Care Across the Lifespan
Participants also expressed the importance of providing care across the lifespan and described reproductive health care as “just another piece of what we do” (P48, T, NP). As one participant explained, “We're the ones that see the patients the most, and so we should be the ones to be able to help them at all stages of their health care”(P4, T, P). Participants also discussed how common it is for family physicians to care for patients that are or will become pregnant (Table 2).
Whole-Person Care
Whole-person care was another value participants brought up when discussing abortion provision in family medicine. As one participant explained, “I think they go hand in hand. I mean, if you are going to care for the whole person…providing that service is just part of that. Because abortion care is part of, you know – health care” (P26, T, NP).
Non-Judgmental Care
Participants felt that including abortion care in family medicine was part of providing compassionate, nonjudgmental care. Participants talked about how physicians cannot let their own biases impact the care they provide, and how patients should be able to come to them to “seek appropriate medical care without worrying about being judged or ostracized” (P61, NT, NP).
Meeting Community Needs
Meeting community needs was a value reiterated by participants when discussing abortion provision. As one participant stated, “As I said, the reason family docs go into practice is to take care of communities. If the community needs abortion services, that is what they need” (P37, NT, NP). Another participant explained it was important for family physicians to provide abortion care given that “family doctors are geographically everywhere” (P10, T, P).
Social Justice
Although many participants discussed family physicians’ ability to improve abortion access through abortion provision, only a few participants directly connected providing abortion to social justice. As one participant described:
If you have enough money, you're always gonna be able to travel to a place where you can get an abortion and get your procedure. That was true even before Roe v. Wade. But if you don't have those resources, then your options are much more limited, and essentially…you don't have the access to the full range of options for your life. And I think that - that abortion care really fits into the social justice piece of family medicine (P3, T, P).
Conflicting and Evolving Values
A few participants expressed conflicting views between their deeply held beliefs about family medicine values and difficulty supporting their patients who choose abortion. As one participant explained, “I think that the role should be to support whatever the patients want or to help them work through that decision for themselves.” Despite this, she followed by saying, “So, I am not opposed to abortion depending on, you know, what the situation is (P84, T, NP).”
Some participants’ views on if they would want to provide abortion care evolved throughout the interview, reporting that participating in the interview made them want to take action to make abortion more accessible. As one participant explained:
I really appreciate having this opportunity to talk… Sometimes you kind of know what to do, but if you talk out loud to somebody else…it gives you some clarity (P24, T, NP).
Reconciling Values and Abortion Provision
Many participants were frustrated that they were not able to provide abortion care, care they felt strongly aligned with the values of family medicine. Those who were trained to provide abortion care but could not provide this care in their work settings expressed feeling it was awkward, upsetting, and disruptive to their relationships with patients (Table 2). Participants who did provide abortion care in family medicine settings shared how providing this care helped them live up to their family medicine values (Table 2).
Others felt that by not including abortion care in the services family physicians provide, patients who need abortion care would feel stigmatized or abandoned. One participant explained:
Because that’s still creating another barrier for someone and they can be shamed, they can feel guilty. There’s so many different levels – of emotion that can come from that. And we’re not doing our job if we’re kind of feeding into that (P22, NT, NP).
Participants agreed that at a minimum, family physicians should be able to counsel patients on abortion care. As one participant shared, “At least I would hope that our patients would feel comfortable talking with us about these issues, and I think that if they are not comfortable, then we have failed in our role” (P87, T, NP).
Discussion
Our study explored how family physicians situate abortion into the core values of family medicine. This study suggests family physicians relate to a core set of values that are consistent with the values described in the literature and by family medicine professional organizations including care across the lifespan, whole-person care, nonjudgmental care, meeting community needs, and social justice.1⇓⇓–4 Findings also suggest family physicians who are not opposed to abortion believe abortion care does align with family medicine values, even among those who did not provide abortion care. Both participants who provide abortion care and those who do not discussed how not providing abortion care was a barrier to being able to live up to the values that drew them to the specialty in the first place.
These findings should be contextualized with previous studies that have found that many people prefer to go to their primary care provider for an abortion.13,14 This preference is grounded in a desire to receive care from providers and clinics with whom there is an established, trusting relationship and continuity of care. In addition, geographically family physicians often provide care in places with limited access to specialty services,5,15 including abortion care. Together, these contextual factors indicate that family physicians providing abortions does reflect the core values of the specialty, including relationships, care across the life course, and meeting community needs.
The discomfort many participants felt about not providing abortion care given their values raises the question of what stands in the way of providing this care for those interested in doing so. Studies have documented a range of barriers, including lack of training, legal restrictions, administrative and practice-level resistance, and logistic barriers.16⇓–18 Increasing efforts are being undertaken to provide support to navigate these obstacles for motivated family physicians through learning collaboratives and online resources.19,20 The recent revision of the Food and Drug Administration (FDA) requirements for mifepristone prescribing – which eliminates the need for in-person provision – will potentially decrease the administrative and clinical burden of providing medication abortion specifically. In addition to these external barriers, we also noted in our study that some participants became increasingly motivated to provide this care through the course of the interview. This suggests that inertia around expanding scope of practice could in part be addressed by increasing conversations and engagement with family physicians about their decision making around scope of practice and abortion care specifically, including the relevance of their values.
The disconnect between the perceived alignment of abortion care with family medicine values and the fact that most participants did not provide these services relates to an ongoing conversation within family medicine about scope of practice. The comprehensiveness of care provided by family physicians, both in the hospital and the ambulatory setting, has been documented to be declining, and family physicians’ actual scope of practice is generally more limited than what many describe as their desired scope of practice at the time of graduation from residency.21,22 This indicates that although there are the unique contextual factors impacting abortion provision, the failure to meet patient and community needs for abortion services is also connected to a broader set of questions about the nature of the specialty and the extent to which it will continue to manifest full-spectrum care across the life course.
This question is of particular relevance in the context of health care services in which there are access challenges. In these situations – which includes low/no access to abortion as well as other stigmatized care such as treatment for opiate use disorder and gender affirming care, full-spectrum practice is consistent with another identified value of the specialty, that of social justice. Social justice has been a core component of family medicine since its inception. Dr. G. Gayle Stephens, a founder of family medicine, described social justice as essential to the specialty23 and family physicians continue to reiterate the need for family medicine to maintain its social justice roots.24,25
The relationship of abortion provision to social justice has become even more pronounced given the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade and has led to state abortion bans and increased barriers to abortion access.26 Providers who integrate abortion into their scope of practice in states where abortion remains legal can help reduce strain on abortion clinics and improve access for their patients. Because the most marginalized and under-resourced patients are those most impacted, actions taken by family physicians can have a direct impact on health equity.
A limitation of this study is that we did not include participants who self-identified as personally opposed to abortion. By excluding these participants, we did not get the full range of views on the role of abortion in family medicine among family physicians. However, as available literature suggests, family physicians are generally supportive of legal abortion,27,28 our findings have relevance for the majority of the population of interest. In addition, compared with the general population of family physicians, our sample was younger and more likely to have received abortion training and had a higher proportion of women, which may have also impacted the results. Further research, such as interviews with a more representative sample of family physicians or surveying themes in a quantitative manner would be warranted to assess the prevalence of these values and relationship to abortion care.
Overall, our study provides insight into how family physicians who are not opposed to abortion view the values of the specialty, and how they perceive abortion care as aligning with these values. Especially in the context of increasing abortion restrictions, ongoing work to expand abortion care in family medicine is an opportunity for the specialty to manifest its core values.
Acknowledgments
Authors thank Edith Fox for her contributions as well as the many physicians who shared their values, experiences, and stories with them.
Notes
This article was externally peer reviewed.
This is the Ahead of Print version of the article.
Funding: The research reported in this publication was funded through the Society of Family 386 Planning Research Fund (grant award number SFPRF12-MA9).
Conflict of interest: None.
To see this article online, please go to: http://jabfm.org/content/00/00/000.full.
- Received for publication September 1, 2022.
- Revision received December 22, 2022.
- Revision received March 7, 2023.
- Accepted for publication March 20, 2023.
