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Ruchika Talwar: Hi everyone, and welcome to UroToday's Center of Excellence in Health Policy. My name's Ruchika Talwar, and I'm really excited to be joined today by Dr. Chloe Peters, who's a resident at the University of Washington.

We'll be having a discussion today on her research surrounding attitudes as they relate to the Dobbs decision. This is a really important topic in healthcare in general, and it has a lot of implications in urology that I think are not as openly discussed. So I hope you find our discussion today enlightening. Thanks, Dr. Peters, for joining us.

Chloe Peters: Thank you so much. It's great to be here.

Ruchika Talwar: So let's start with framing the background of your research study. Tell me about what your question was, and what brought you to going down this path.

Chloe Peters: I think it's really important to just briefly review the Dobbs versus Jackson ruling. So this is a Supreme Court decision in June of 2022, that said that there's no constitutional right to abortion. And that allowed states to regulate any aspect of abortion care that's not covered by federal law. And since then, there have been a lot of states that have out outlawed abortion, or had placed really significant restrictions on the procedure.

And when I was thinking about this, so this started, this happened right at the beginning of my research year, and I realized that if this had happened when I was applying to residency, it would have really significantly changed my rank list. And so, I realized that, if people consider state abortion laws, when they're deciding where to live and where to work, there are really significant implications for our workforce that we have to be aware of.

And so, we decided that we wanted to look into how abortion laws are going to impact where urologists choose to work. And we did a couple of different studies there. So we first did a survey of members of the Society of Women in Urology. So we asked them about their views on the ruling, and how it might impact clinical their clinical practice, and then personal decision making. We also did an analysis of the distribution of urologists in the country and mapped that against abortion laws. And then we did a survey of applicants to urology as well for this past year, to get a sense of how these laws might have impacted their decisions about where to apply.

So the findings, just kind of a brief summary. Our smooth survey showed that significant numbers of 42% of residents and fellows said that this would've changed their rank list. 41% of practicing urologists said that, if the Dobbs ruling had happened when they were looking for their current position, they would've picked a different job. And 60% said that, when they're looking for their next job, there are states that they will avoid because of the Dobbs ruling.

And then, our NPI analysis showed that, states that have more restrictive abortion laws have fewer urologists per person. So already, before these laws went into place, they already had shortages of urologists, and they also have fewer female urologists. And so, these are places that are most at risk for workforce shortages going forward.

And then our survey of applicants to urology, showed that one out of five took programs off their list, because they're located in states where abortion is illegal. So that's a really, really big number. And almost 60% said, that if they matched in a state that has strict abortion laws, they would worry about their health and safety, or that of their partner.

Ruchika Talwar: These are really, really stark findings. Thank you for such a comprehensive overview. I love how you looked at this issue at different levels of urology training and career paths. So first, I'll start with the trainee implications. I think that 60%, that is a huge number, of people who would not rank a place lower, but physically remove an institution from their rank list.

Chloe Peters: Right. So sorry. I'm just sorry to interrupt you.

Ruchika Talwar: Yeah.

Chloe Peters: It's 20% for the trainees.

Ruchika Talwar: Okay. So 20% of trainees would actually remove a program from their rank list. That is really an alarming number. I think it becomes difficult, because often, the states that have the heaviest restrictions on abortion care, are also the states that tend to not have things like Medicaid expansion. And they're already disadvantaged, and have vulnerable populations that have really significant disparities. So you're removing a population of female urologists, who we know are already, I'll say, underrepresented in the field of urology, in places that you need them the most. So that is really interesting.

And the fact that, I think, I got my numbers mixed up when I spoke initially, 60% of people would change their next job, based on the ruling, is also a really interesting statistic. Because I think it speaks to the fact that once again, the most vulnerable areas are going to be impacted. These are areas that already have barriers to access, since they're not expansion states. And often have a shortage of urologists, such as what we know is happening in rural America. And also, have an aging population of existing urologists. So young people are more likely to go to urban metropolitan areas. So it really is going to impact our field, I think, more than people realize.

Now, tell me a little more about what your thoughts are on the findings of the existing SWIU members. So female urologists who are already out there practicing. Just let's delve into that a bit more. People who may be established. How do you think this impacts their practice?

Chloe Peters: I think that there are a couple of different levels. On one extreme, there are people who are looking for new jobs, and we saw that in a lot of comments. There are people who even if they are past childbearing years, they want to be in a state where their adult daughters can visit them if they were pregnant and feel safe. So there are going to be people who are going to leave jobs and look for new work.

There are also clinical implications. So we don't provide abortions as urologists, but we do infertility care, vasectomies, vasectomy reversals. We do pediatric care. So prenatal counseling might be different. Or you might see higher rates of babies born with severe GU abnormalities. And we deal with the sequela of pregnancy, prolapse incontinence. So there are true clinical implications for our field. There's good data that we've seen significant increases in vasectomy rates after the ruling.

And then, just from a personal aspect, there are people who are going to feel unsafe. So one thing that's really important to remember is that, as politicized as the term has become, abortion is a medical procedure. And it's also the standard of care for a lot of miscarriages. And we also know, that female surgeons have twice the rate of miscarriage compared with the general population. We have a 42% miscarriage rate. That is so high. And so, for no other reason, there are a lot of women in urology, and people who can get pregnant, who are going to need abortion care at some point, so this affects us. And if you are going to have to travel out of state to get abortion care that you need, or have significant health complications, that is going to impact our whole field.

And you mentioned so many things that are really important to highlight. I mean, 30% of urology trainees are women. So this is, even though the number of attending urologists who are women who identify as women is pretty small, that's changing. And if more than half of them now avoid states with restrictive abortion laws, that's a really substantial proportion of the urology workforce. And especially in areas like pediatrics or female urology, that might be overrepresented with women in urology. So that that's going to change the demographics of who's practicing here.

Ruchika Talwar: Yeah, absolutely. I mean, I couldn't agree with you more. I think obviously, it has effects on urologists personally, whether or not they are going to embark on pregnancy. It affects their family members, it affects their children, it affects their partners. So I think there's a lot to unpack here.

We've had discussions previously on the effects that the Dobbs ruling has had on vasectomy rates. And as you alluded to, we have seen a significant increase. But I think your points are really well taken, as it relates to post-pregnancy, pelvic healthcare, and pediatric urology care in the setting of congenital abnormalities. So I think, although this data will really be forthcoming in the next decade or so, I'd say, because you have to look at trends there, it's all stuff that we need to keep in mind. And it's not that easy for us to just say, we are not abortion providers, so this issue does not impact us.

Chloe Peters: I was just going to say, and as you mentioned, we know that we have a shortage of providers, especially in rural areas. And we also know that having a shortage of providers leads to worse outcomes all across urology. So who's going to treat your bladder cancer or your stones if there's no urologist in your area? So that piece of it as well, it's an indirect effect, but we are certainly not immune to the outcomes from this ruling.

Ruchika Talwar: Yeah. Again, I couldn't have said it better myself. So thank you so much, Dr. Peters, for taking the time to chat with us today. And a sincere appreciation from all of us for embarking on this important work. I think this data will help inform us on the effects of health policy related issues that people may think are not directly related to urology. But I think that your data sheds important insights on how this affects not only our workforce, but our patient population as well.

Chloe Peters: Thank you so much. I really appreciate you having this conversation and raising awareness about this topic.

Ruchika Talwar: And thanks to our UroToday audience. We'll hope to see you next time.