The years of living dangerously (AAFP annual scientific assembly)

There is increasing recognition that this age group is underserved and increasing awareness that for most teenagers, health threats come not from diseases but from their own behaviors.

By Victoria Stagg Elliott — Posted Nov. 7, 2005

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When faced with a teenage patient, physicians should take "behavioral vital signs" to track the factors most likely to put teens at risk. The more traditional physical vital signs should still be recorded but are less important in terms of young people's overall well-being. That notion was a key take-home message from several presentations at the American Academy of Family Physicians annual scientific assembly in San Francisco, Sept. 28 to Oct. 2.

"Pulse and blood pressure are not as critical to what may happen to a teen as it is to know if they're smoking, drinking, having sex and those kind of things," said Nicole Chaisson, MD, one of the leaders of a course on the adolescent office visit and a physician at Smiley's Family and Community Residency Medicine Program at the University of Minnesota in Minneapolis. "Most of the causes of adolescent morbidity and mortality are related to behaviors rather than biomedical stuff."

This advice comes along with an increasing recognition that teenagers are significantly underserved by the health care system and have very different health care needs than other age groups. To address the challenge of reaching them, AAFP focused on these patients' treatment needs, along with that of children, by making it the centerpiece of next year's annual clinical focus initiative as well as the focus of a number of the meeting's sessions. This theme was organized in cooperation with the American Academy of Pediatrics and the Society for Adolescent Medicine.

"They're a forgotten generation in terms of health care," said Mary Frank, MD, AAFP's immediate past president. "If they're not coming in for a sports exam, we don't see them."

This population can be particularly tricky for physicians. On one hand, most are physically very healthy. On the other, their behaviors are more likely to change their health status for the worse. Additionally, with patients of any age, lifestyle issues are usually more touchy than physical ones. But experts say tackling these issues with adolescents is extremely important. Not only can various behaviors affect a teen's health in the short term, but they also can set up long-term health risks.

"They don't necessarily have the best health habits," Dr. Frank said. "And they're at a stage where a little bit of preventive guidance can be very helpful. The life habits that they're going to set in their teens are what they're going to carry through into adulthood."

Building trust

Building a rapport with teens aside from that of their parents also can be a sensitive undertaking.

Because most teens are under a care of parent or guardian, physicians' first test to broaching these conversations might involve getting the teen alone to provide a safe and confidential environment. Experts recommend that physicians advise parents that they will eventually see the teen without them in the exam room. But this physician-parent conversation should occur long before the child reaches adolescence.

"Doing it at the stage where a lot of kids aren't participating in things their parents are worried about, they're a little more open to the suggestion that they need to be out of the room for part of the visit than when their kid is in a crisis," said Alison M. Warford, MD, a co-leader of the session on the adolescent office visit and the medical director of the Face to Face medical clinic for teens in St. Paul, Minn.

Facilitating a confidential discussion also can, in turn, bring to the surface one of the biggest hurdles interfering with a physician's care for these patients: a distrust of authority figures.

"One of the biggest challenges is establishing credibility," said Arlis Adolf, MD, a family physician in Denver. "It helps somewhat when you've been the kid's doc forever, but you're also kind of in the parent role."

To build trust, experts urged doctors to be honest about their expectations and what can and cannot be kept confidential. Above all, physicians should also avoid trying to appear cool and youthful -- they should be who they are. "Act your age. They're coming to you because you're an adult with knowledge," Dr. Warford said. "And they can spot a fake from a mile away."

Physicians who attended the events praised them but complained that realities make these recommendations complicated to put into practice. Time constraints, for instance, can make it difficult to get information out of often-hesitant teen patients.

"We are squeezed by managed care to make everything happen fast, and, particularly with adolescents, sitting down, talking with them, having the time for them to get to know you and trust you is a real challenge," said Jeffrey Leisring, MD, a family physician from Centerville, Ohio.

Experts say, though, that the first and biggest test in treating teens is getting them into the office. One tip -- use any visit as an opportunity to squeeze in some preventive care. In addition, physicians can reach teens by going to where they are.

"It's good that they get acne. It's good that they play soccer and that they're cheerleaders because they have to come in and get their little exam forms filled out, and we do have at least one chance to talk with them," Dr. Frank said. "But we also have to take some of the care to where the teens are -- to the school setting, to the after-school club and by being team physicians. We can be where they are and meet them on their terms."

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Tips for treating teens

Experts at the American Academy of Family Physicians scientific assembly offered doctors ways to maximize opportunities presented during an office visit to provide care and counseling and establish a physician-patient relationship with adolescents. Among them:

  • Greet the teenager first, before the adult guardian.
  • Explain to the teen's parents or guardians that they may not be in the room for the entire visit and that this is standard practice.
  • Address concerns about privacy and confidentiality.
  • Recognize that asking about sex, drugs, alcohol, smoking, eating disorders and dangerous driving may elicit information about what is most likely to impact the teen patient's health in the short term.
  • Begin the visit with the least personal questions.
  • Criticize the activity, not the patient.
  • Speak like an adult, don't try to speak like a teen.
  • Remember key differences in how medical conditions present in adolescents compared with adults or children -- for example, depression may manifest as irritability.
  • Expect to provide some preventive services during an acute care visit.
  • Don't assume anything -- whether it's the activities in which they engage or the lifestyle modifications they're willing to make.

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More shots for vaccination schedules

With next year's immunization schedule, physicians can expect changes including new vaccines and vaccine combinations.

Jonathan Temte, MD, PhD, the American Academy of Family Physicians liaison to the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, outlined some of these specifics during the AAFP's annual scientific assembly in San Francisco.

For starters, the tetravalent meningococcal conjugate vaccine, provisionally endorsed last year, will likely be officially added to the list of shots recommended for children and teens.

The combination tetanus, diphtheria and pertussis shot (Tdap), recently approved for pre-teens and adolescents, includes a lower dose of pertussis antigens than the one administered to children. It will replace the dose of tetanus and diphtheria (Td) that 11- and 12-year-olds have usually received.

"If there is a reason for the Td shot such as a puncture wound or dirty animal bite, you should use what's available. If, on the other hand, you're immunizing with Td because it's about the right time, I would hold off until Tdap is available," said Dr. Temte, who is also an associate professor of family medicine at the University of Wisconsin Medical School in Madison.

Dr. Temte predicted that within the next few years, ACIP would broaden its recommendation for hepatitis A vaccination from those living in high-risk areas to everyone in order to work toward eradication of the disease. A second dose of varicella vaccine administered in the same shot as the measles, mumps and rubella antigens is also expected to be endorsed in the near future. This combination vaccine was approved by the Food and Drug Administration in September. In addition, a new rotavirus shot should come on the market as would one for protection against the human papillomavirus.

Physicians expressed concern, however, because recommendations don't always keep up with supplies -- putting them in difficult positions when shortfalls occur. Also, many parents already complain about the number of needlesticks their children face.

"The more [disease] that we can prevent, the better," said Nancy Grossman, MD, a family physician from Crescent City, Calif. "But sometimes the moms will say, 'that's too many shots to give a little baby all at once' ... I wish that there would be more combos out there."

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Treatment tips

Here are some treatment tips from the meeting:

Countering the flu shot myth. When patients complain that they don't want to be vaccinated against influenza because they believe it gives them the flu or other side effects, physicians should respond that a true case of respiratory illness linked to the shot is next to impossible and any mild symptoms experienced are evidence that the shot is working.

"We warn patients they're going to get a sore arm for a day, and I spin it positively. I say, 'That means that you're getting protection,' " said George P. Kent, MD, clinical associate professor at the Center for Family Medicine at Stanford University in Palo Alto, Calif.

Patients should keep a food log. Evidence backing one diet over another is lacking, but data do support the effectiveness of keeping a food log when trying to lose weight and maintain the loss. "It's one of the most important things we can encourage [patients] to do," said Corey H. Evans, MD, associate clinical professor in the Dept. of Family Medicine at the University of South Florida Medical School in St. Petersburg.

Noncompliance and depression meds. About a third of patients with depression do not respond to the first attempts to treat their disorder, and part of this problem may be due to adherence issues caused by patients discontinuing their medications without telling their doctors.

"We have to tell [patients] to not stop the medication as soon as they feel better because there's a chance of relapse," said David Price, MD, director of education at the Colorado Permanente Medical Group in Denver.

Let patients decide the method. Screening for cancer of the colon and rectum is important but, with no particular strategy as yet pointing out a clear winner, patient preferences should determine how it is done.

"This needs to be individualized with your patient, and there are all kinds of reasons why someone would want one or the other," said John B. Pope, MD, professor of family medicine at Louisiana State University Health Sciences Center in Shreveport.

Cultural competency key to accurate mental illness diagnosis. Understanding the cultural factors that may affect how patients describe their mental health concerns is crucial to getting to an accurate diagnosis, according to David Satcher, MD, PhD, interim president of the Morehouse School of Medicine in Atlanta and a former U.S. surgeon general.

"African-Americans are often underdiagnosed when it comes to depression but overdiagnosed as being schizophrenic. It turns out to be a problem of communication and culture," Dr. Satcher said.

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External links

Information about lectures, presentations and other developments at the American Academy of Family Physicians 2005 Annual Scientific Assembly (link)

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