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
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 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."