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Doctors needed who focus on teens

December 12, 2008|By LEE BOWMAN / Scripps Howard News Service

In some families, it's as straightforward as a 13-year-old declaring him or herself too old to continue seeing a "baby doctor."

For others, the reality of a sexually transmitted disease or a substance abuse problem makes it apparent that a teen suddenly requires services that are, at best, awkward to obtain from a practice with coloring books and toy boxes in the waiting room.

But even if parents and teen patients agree that a new doctor is needed, finding a provider who can serve as a medical bridge to adulthood can be daunting.

A new report out this week from a committee formed by the National Research Council and the Institute of Medicine notes that the nation's office-based system of primary care doctors is ill-equipped to deal with many health needs of adolescents, particularly issues related to behavioral and developmental issues.

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The 42 million Americans aged 10-19 are basically healthy most of the time. But they're also most likely to die from vehicle accidents, homicide or suicide -- risks all tied to risky or unhealthful behaviors like drinking or drug use. An estimated 10-to-20 percent of teens experience mental health problems at some point, but a third of them don't get treatment.

The 15-minute office visit offers little chance for probing teen concerns about their bodies and what they're doing with them. And several recent studies have shown that primary care docs often don't know what to do about substance abuse problems in patients of any age, even if they identify them.

The very logistics of getting a teen to a doctor's appointment can be difficult. Parents still provide the rides, the insurance cards or the money to pay for services. Even though parents may be willing to "stay outside" during the visit, teens worry their revelations may not stay between them and the doctor or nurse.

"Even when services are accessible, many adolescents may not find them acceptable because of concerns that confidentiality is not fully ensured," said the committee report.

State laws on the age of medical consent and minor's expectations of privacy vary, sometimes widely. Most ethical guidelines for primary care physicians call for them to give adolescents the opportunity for exams and counseling without a parent or adult present, but also stress that they need to encourage kids and parents to talk.

Almost all doctors agree that confidentiality has to be breached if they think a patient is at dire risk, and state laws mandate them reporting physical or sexual abuse and certain communicable diseases. Still, that leaves a lot of shades of gray when it comes to giving parents a "heads up" about sexual behavior, substance abuse or mental health issues -- or maintaining the confidences of the patient.

This, the report notes, leads many teens to seek care from "safety net" providers like school clinics, public health clinics or hospital emergency rooms, in a quest to keep parents out of the loop.

The clinics may be more "accessible" to teens, particularly those who are uninsured, but they too are a patchwork of care that is dependent on tax dollars or charitable grants, the committee noted. And while accidents and sports injuries send plenty of teens to emergency departments legitimately, many more go for non-emergencies because they lack a steady relationship with a doctor.

Another option is adolescent medicine specialists, a subspecialty of internal and family medicine that has emerged in recent years. These doctors are often affiliated with children's hospitals or teaching hospitals, and tend to handle patients with chronic illnesses or complex behavior problems that are beyond the expertise or time available from most primary care docs.

The adolescent health services committee said there is not enough evidence to say what models of care for teens work best, but stressed that any reorganizing of health services by Congress and the Obama administration needs to take into account the unique health service needs of teens.

Robert Lawrence, the head of the committee and a professor at the Johns Hopkins School of Public Health, said not only do risky behaviors in teens deserve special attention, but. "because adolescence is a critical period for developing habits that build a strong foundation for health throughout one's entire life, services need to focus on promoting healthy behaviors, preventing diseases and managing health conditions."

On the Net: National-Academies.org

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