Myths Among the MythBusters: How OBGYN Residency Structures Limit EBM and Reproduce Reproductive Injustice

In the last two decades, evidence-based medicine (EBM) has emerged in the healthcare community as a strategy for improving and standardizing patient care. However, EBM has so far done little to move the needle of health disparities between men and women, and between white women and women of color. American women continue to face unique and stubbornly persistent healthcare challenges compared to their male counterparts. These challenges are even greater for low-income and minority women, especially in the context of reproductive medicine. Using the case of contraceptive counseling, I employ ethnographic and interview-based data to identify mechanisms that reproduce gendered, racialized, and classed inequities in clinical encounters despite the implementation of EBM. I find that while EBM is touted by nearly all healthcare providers the structure of residency programs as well as individual-level factors constrain residents’ ability to practice it. Major constraints to EBM in OBGYN residency programs include time, limited training in research methodologies and statistical analysis, limited formal didactic time, the marginalized status of family planning in the field, and professional hierarchy. Thus, while providers see themselves as “MythBusters,” they unconsciously internalize and reproduce myths themselves. That is, I find that when residents lack a nuanced understanding of the medical data, they default to positions shaped by 1) gendered beliefs around women's health,) a bias toward pharmaceutical forms of contraception, and 3) classed and racialized norms of motherhood fitness. Ultimately, this leads them to prioritize contraceptive efficacy over patient goals and exhibit dismissive attitudes towards patient concerns. Because residents nearly exclusively counsel marginalized un- and under-insured populations—who are overwhelmingly Black, Brown, and poor—in the outpatient setting, these findings have stark implications for medical inequality.