The cartoons lampooning abortion providers arrived in Jody Steinauer's mailbox one day last year. The jokes were ominous: What would you do if you found yourself in a room with Hitler, Mussolini and an abortionist and you had a gun with only two bullets? Answer: Shoot the abortionist twice.
A week after Ms. Steinauer and 20,000 other medical students across the country received the mailing, an abortion provider was fatally shot outside a Florida clinic. The incidents angered Ms. Steinauer and inspired her.
Today, the 25-year-old medical student at the University of California, San Francisco, is spearheading a national effort among medical students to increase abortion education and training for America's future doctors.
The push comes as abortion rights supporters emphasize the declining number of physicians who perform abortions and the decrease in abortion training opportunities within the graduate medical community.
"If doctors are not being educated in the full range of women's reproductive health," explained Ms. Steinauer, who helped co-found Medical Students for Choice, "then the whole range of services won't be available. And we know what happens when abortion services are not available. Women die."
A recent study has shown that only 12 percent of training programs for medical school graduates who want to specialize in obstetrics-gynecology mandate training in abortion, compared with 26.3 percent in 1976.
Another 57 percent of those same residency programs today offer the training as an option, according to the 1991-9292 study. In 1976, that figure was 66 percent.
The dearth of abortion providers can be attributed to several factors.
Physicians retiring
Many of those physicians who turned to the work early because of the horrors they witnessed during the days when abortion was illegal are fast nearing retirement.
In the years following the Supreme Court's 1973 decision to legalize abortion, abortion services shifted from hospital wards to outpatient, free-standing clinics.
Physicians who train in hospital-based programs had fewer opportunities to learn the relatively simple procedure.
As a result, abortion services became less a part of mainstream medicine.
And the anti-abortion movement stepped up its efforts to discourage women from obtaining abortions.
A climate of fear and intimidation has prompted some physicians to stop performing abortions in their practices.
And it has made some medical students broaden their feelings about abortion, from concerns solely about a woman's right to choose to have an abortion to a physician's responsibility to patients.
The idea of Medical Students for Choice arose from this attitude change.
Ms. Steinauer and two other students, Sarah Cada of the University of Kansas and Hillary Kunins of Columbia University, formed the group last year.
Begun as a fledgling grass-roots organization, the group recently received a start-up grant from an anonymous donor and is seeking a non-profit, tax-exempt status.
Petition drive
Since its start, the organization has found supporters on at least 100 medical school campuses, including Johns Hopkins in Baltimore. Its members have collected nearly 4,000 petition signatures from students at 35 medical schools in support of mandating abortion training for obstetricians and gynecologists (with the option to be exempted for moral or ethical reasons).
Talking among themselves, the medical students realized just how little they know -- and are being taught -- about abortion.
"In our medical school, we have an elective class on ethics. That was the only place in two and a half years in medical school that abortion was talked about," said Ms. Cada of her training in Kansas.
Other students who attend large, inner-city medical schools, such as Hopkins, the University of Maryland and New York University, get a chance to observe abortion procedures during a 6-week, work-study rotation in a hospital, usually in the fourth year.
"Every physician, no matter what specialty, is going to have patients who are contemplating abortion or who have been through an abortion or find themselves in the position of an unplanned pregnancy," said C. Annette DuBard, one of several Johns Hopkins medical students trying to organize a local chapter of Medical Students for Choice at the East Baltimore campus.
"We need to be comfortable and knowledgeable about referring patients to physicians who can counsel them and inform them non-judgmentally," said Ms. DuBard. "At the very least, people need to be trained to do that -- know the procedure, know the risk of the procedure, know alternatives for women."
Legal for two decades, abortion is among the most common surgical procedures in this country. (The number of abortions in recent years has held at about 1.5 million a year.)
The teaching of abortion techniques and pregnancy termination has been confined to a doctor's post-graduate training in obstetrics and gynecology (OB/GYN) during a 4-year program known as a residency. Curriculum guidelines for OB/GYN residency programs have never specified abortion training; instead the requirements refer to "clinical skills in family planning."
A proposal to change that is under consideration by the professional body that accredits residency training programs.
"We in academe have fallen down on our responsibility to both lead, to articulate the need for the service and provide the service as part of comprehensive women's reproductive health," said Dr. David A. Grimes, a San Francisco obstetrician who has written on the subject.
Across the medical community, efforts are under way to address the shortage:
* Planned Parenthood of New York City Inc. began a program in July 1993 to train physicians in abortion techniques. So far, 33 doctors have completed the program and 12 are performing abortions at Planned Parenthood, affiliates or other clinics.
* A panel of the Accreditation Council for Graduate Medical Education has recommended that OB/GYN residency programs mandate abortion training, provided residents can be exempt for moral or ethical reasons. Catholic hospitals, for example, would be required to provide that training off-site for their residents. The council is expected to take up the matter early next year.
* The American College of Obstetricians and Gynecologists also has supported mandating abortion training in the 271 residency programs. The group, the professional organization for the specialty, also has backed a proposal to have nurse practitioners licensed to perform abortions.
* The American Medical Women's Association has drafted a model, medical school curriculum in women's reproductive health that includes abortion training. Columbia University and the University of Iowa will offer the pilot program -- a monthlong elective for fourth-year medical students -- in July and September of 1995, respectively.
Dr. John I. Fishburne, Jr., chair of the Accreditation Council's OB/GYN residency review committee, practiced in the days before abortion was legal.
"I was in a college town in my residency, and I was terribly distressed that we almost always had on our service one teen-age woman suffering complications of criminally induced abortions," said Dr. Fishburne, a resident of Oklahoma City. "And we had a number of deaths. I would hate to think the procedure, a safe medical procedure, would become unavailable and we would return to that situation."
But colleagues who oppose abortion say the move to mandate the training is an attempt to bolster the image of a procedure that commands little attention and respect within the medical community.
The problem is that "abortion has no status in the obstetrical community," said Dr. Daniel J. Martin, a Wisconsin physician and president of the American Association of Pro-Life Obstetricians and Gynecologists. "The idea that there is a lack of technical ability to do abortions is just a fabrication," said Dr. Martin. "The training in abortion is not lacking. Everybody knows how to do one."
As the medical establishment considers whether to mandate abortion training, Planned Parenthood and Medical Students For Choice go ahead with their effort to inform future doctors about abortion's place in women's health care.
Planned Parenthood has conducted seminars at NYU, Yale, Cornell, Albert Einstein Medical College in the Bronx, the University of Missouri-Columbia and other schools. "They are demanding to have a voice in their medical school education. This is an opportunity to make a different kind of doctor," said Mary Ann Castle, director of Planned Parenthood's physician training program.
Jennifer Petrillo may be one of them. When she and other women students at Albert Einstein sought to get information on abortion included in a course on reproductive health, they were advised: Raise your hands and ask questions.
The women agreed among themselves to do just that. But questions only generated more questions. So Ms. Petrillo, a second-year medical student, got her hands on the "purple book," a digest of abortion facts and figures put out by Planned Parenthood of New York City.
She copied sections of it, received permission to distribute it and personally stuffed the handouts in 200 student mailboxes.
"We wanted to get across to our classmates that this is a legal, medical procedure and one-third of women chose abortion at some point in their life," said Ms. Petrillo, of Storrs, Conn.
"It is not an issue that can be avoided, no matter how uncomfortable some may feel about it."