SUBJ: Doctors Tailoring Services To Meet Adolescents' Unique Needs
By Ellen Flax
As any member of the American Academy of Pediatrics' section on adolescents can relate, treating an adolescent for a health problem differs significantly from providing medical care to a young child or to an adult.
"The advice you give to an adolescent about smoking is very dif- ferent than what you would tell a 50-year-old with emphysema," Marc Manley of the National Cancer Institute told a packed section meeting on teenage-health issues at the A.A.P. 'S convention in New Orleans this fall.
"My kids are not going to be highly motivated by cancers that are 30, 40 years down the road," said Dr. Manley, the program director of the cancer institute's health-professional education program. "/ emphasize cosmetic things, like 'No one will want to kiss you.'"
Like Dr. Manley, a growing number of physicians are realizing they have to tailor their messages as well as their services if they want to meet the needs of adolescents, a group that historically has been overlooked by the medical profession.
Not only do doctors feel uncomfortable with teenagers, but adolescents feel disenfranchised by the medical system, health experts' and child advocates agree. Many adolescents are reluctant to go to a physician about sensitive health matters because they fear their parents will hear of their problems. Others simply cannot go because they lack health insurance or because the office's location or hours are inconvenient, observers note.
"There's more recognition on the part of everybody that people need to address teenagers' problems and that teenagers are not just big pediatric patients," said Jeanie Tolmas, a clinical assistant professor of pediatrics at Tulane University.
The impetus for this new attention to the needs of teenagers, many health observers say, is the plethora of statistics showing that the greatest threat to an adolescent's physical well-being is his own behavior.
Although teenagers are probably the healthiest segment of the population in the sense that comparatively few of them die each year, many suffer from emotional and physical problems--such as mild depression, drug abuse, and family and school problems--that are not easily treated.
Because their problems often center on morally questionable behavior, such as sexual activity, and their personalities frequently are trying, adolescents have often fallen through the cracks of the various medical specialties. Perceived by many as being too old to be treated by a pediatrician and yet too young to go to an internist, adolescents have long been slighted in receiving treatment for their health problems, observers say.
"To some degree, there is a mismatch between the needs of adolescents and what the traditional health-care system is set up to address," said Arthur Elster, the director of the department of adolescent health for the American Medical Association.
But in recent years, physicians have begun to direct more of their efforts to the often intractable, behavior-based problems that afflict teenagers. By attempting to alter or eliminate certain risky behaviors in youths, such as smoking or drug use, physicians say they hope to create a healthier adult population in future years.
Teenagers are unlikely to suffer from heart disease or cancer-- the two leading causes of deaths among adults. For adolescents, federal health statistics show, the leading cause of death is motor-vehicle accidents, many of which are alcohol-related. These accidents, combined with the homicide, suicide, and other accident rates for teenagers, account for about three-quarters of the adolescent deaths recorded in the United States each year.
Likewise, early sexual activity has led to about 1 million teenage pregnancies a year and high levels of sexually transmitted diseases, including the virus that causes AIDS, among adolescents.
Adolescents 'Talk Back'
Doctors who treat teenagers must be aware of these problems and be sensitive to the psychosocial needs of adolescents, many health experts say. But establishing a large cadre of "adolescent friendly" doctors to prevent these problems will be difficult, medical observers note.
To begin with, most doctors who serve adolescents have received little if any specialized training in the health needs of this population. As a result, many feel uncomfortable dealing with teenagers and their problems, experts say.
"It's not that [doctors] don't want to treat adolescents," Jennifer Johnson, an assistant professor at the University of Oklahoma's medical college, said. "It's just they don't feel comfortable talking about the issues you have to talk about with adolescents."
"Pediatricians are used to having patients who don't talk back," she said, "and adolescents talk back."
"Taking care of adolescents is a very tricky business, since it involves a lot of social and behavioral issues that are not part of most mainstream training programs," added Paul Jellinek, vice president of the Robert Wood Johnson Foundation, which has been a leader in adolescent-health issues.
Treating teenagers, above all else, is a matter of good communication skills, Richard MacKenzie, an associate professor of pediatrics and medicine at the University of Southern California's school of medicine, said. But many doctors, he said at the American Academy of Pediatrics convention in October, lack those listening and communication skills.
"Probably one of the most important things to be able to do with an adolescent, like the ability of a surgeon to hold a scalpel, is to be able to interview an adolescent," Dr. MacKenzie said. "We can't project onto the adolescent who and what we think they are."
Lower Reimbursement Rates
Moreover, since adolescent medicine is one of the lowest-paid medical specialties, many doctors feel they cannot afford to make adolescents the primary focus of their private practice, physicians at the pediatrics convention said. The average total medical-school debt for new doctors is close to $50,000, a burden that persuades many of them to eschew the lower-paying specialties, such as pediatrics, internal medicine, and family practice, for higher paying areas of practice. (See Education Week, Nov. 6, 1991.)
At the heart of adolescent medicine, many say, is providing young people with "anticipatory guidance" and counseling services. But health insurance companies, they note, provide higher payments for medical services, such as an ear examination, than for cognitive services.
To really talk to a teenager, and build up enough trust so that he can be honest about his risk-taking behaviors, takes far longer than the average 16.5-minute office appointment, physicians say. But insurance plans, they contend, do not adequately reimburse them for their time.
"I think there are a number of young physicians who would happily deal with adolescents if they could be assured of a comfortable income ," said William Long, a pediatrician in Jackson, Miss., whose patients are almost exclusively adolescents.
Dr. Long, who said he sees about four patients an hour, instead of the normal six or eight seen by most pediatricians, bills patients according to the time he spends with them.
"We get precious few complaints," from parents, he said. But he acknowledged that insurance plans "pay part of the fee, but they don't pay well for cognitive functions."
Teenagers are also reluctant to seek out medical care, experts say. For about one out of seven, the reason may be primarily financial--a lack of any form of health insurance.
But even adolescents who have health coverage are often reluctant to go to a doctor for reproductive health care or other sensitive matters because they fear the confidential doctor-patient relationship will not be respected, a report on adolescent medicine released this summer by the Congressional Office of Technology Assessment concluded.
An earlier volume of the three part report concluded that school-linked or community-based health centers may be the best way to provide health services to medically needy adolescents. (See Education Week, May 1, 1991.)
Doctors who regularly treat adolescents acknowledge that maintaining a young patient's confidentiality can often be a sticky issue. Although some states provide adolescents with a greater privacy shield than others do, such protection can be destroyed the minute a doctor mails a bill home to the patient's parents.
Cathryn Louise Samples, the director of the adolescent program at a neighborhood health center in Boston, which is funded largely with public money, said her clients are given the choice of whether or not their parents should receive a bill. About half of the clinic's patients are on Medicaid, she said.
"If the kid says it's confidential, we won't bill the family and we basically have to eat the loss," she said.
Action by Medical Groups
Despite these barriers, many experts on adolescents believe that the medical profession is in the process of becoming much more aware of and sensitive to the unique medical needs of adolescents. They point to the following developments:
- Starting in 1993, the medical field will formally recognize adolescent medicine as a medical subspecialty. Pediatricians who want to extend their training by one-, two-, or three-year segments and then pass a special series of tests will be recognized as adolescent specialists. Internists, too, will be eligible for this additional training.
- The A.M.A., which represents some 280,000 physicians from all specialty backgrounds, has established an office to promote adolescent medicine. In cooperation with the U.S. Centers for Disease Control, this department will develop national guidelines for preventive services for teenagers.
- Over the past two years, medical associations representing internists and obstetricians and gynecologists have issued papers outlining the proper medical care for adolescents.
- An association that represents medical-school faculty members who specialize in family medicine held an all-day session about adolescents at its annual meeting this summer. Family physicians are the primary medical care-givers for about 35 percent of all adolescents, a greater percentage than for any other medical specialty, the second Office of Technology Assessment report said. . The Robert Wood Johnson Foundation has spent more than $30 million over the past decade on programs that consolidate health services for high-risk young persons and on efforts to promote school-based health services.
"I think one can be somewhat encouraged by these developments," said Julia Lear, the coordinator of the school-based adolescent health-care program funded by Robert Wood Johnson at Children's Hospital National Medical Center in Washington. "I feel there are a lot of signs of a growing awareness that these [teenagers] are neither overgrown children nor small adults."
Giraffes on the Walls
Despite this new awareness, the number of physicians who specialize in adolescent medicine remains small--about 1,000 nationwide, according to the Society for Adolescent Medicine. And only about 60 young doctors are enrolled in adolescent medicine training programs in any given year, according to the second volume of the o.T.A. report.
Robert Blum, the president of the adolescent-medicine society, said most specialists in the field are affiliated with medical schools and do not provide primary care to teenagers; rather, patients with difficult problems are referred to them. Only about a dozen doctors nationwide have private practices that work with teenagers almost exclusively, he said.
"The message is clearly being translated to kids that there is not the capacity to deal with the complex concerns and issues they have," Dr. Blum said.
Teenagers usually go to a doctor if they have a physical complaint, such as aches and pains, he said, "but it's the things they don't come in for that we don't do well."
Physicians who regularly work with adolescents say they take many steps to ensure that teenagers feel comfortable. Many times, they note, it is the little things that make teenagers feel at home.
Dr. MacKenzie, for example, said he always tries to let an adolescent know that he is the focus of the doctor's professional attention. He does this, he said, by always coming out of his office to greet a new adolescent patient in the waiting room. With his back turned away from the parent, he said, he shakes the adolescent's hand. The teenager, in turn, is then asked to introduce his parents.
John Edlin, a physician who works almost exclusively with patients between the ages of 12 and 21 in his Dallas practice, said his waiting room contains magazines that cater to a teenage audience and yearbooks from local high schools.
"So many of them come from an office where they are not the focus, ... where giraffes are painted on the walls and toys are on the floor and someone saying, 'And how are you today?'" he said.
More difficult than rearranging a waiting room, Dr. Edlin said, is maintaining the confidentiality of his dealings with patients. While the visits are confidential, he said, he strongly urges the patients to talk about sensitive matters with their parents. And if a patient's life is in danger, or if there is a serious health problem, he said, he will definitely call a parent.
"They say, 'My parents will kill me,'" Dr. Edlin said, "but we haven't had a homicide yet."