Adolescence can make or break life, but the medical
profession often ignores this crucial time of change and confusion
Getting into the head of youth
Robert Brown's patients may be obese or anorexic;
sexual innocents or infected with chlamydia; male or female; jocks or
goths; abusers of alcohol, Ecstasy, or over-the-counter drugs; tattooed,
pierced, pimpled; surly and stressed; or just mortified by their molting,
Diverse and challenging, they share at least one
common factor, which brings them to the attention of Brown and his
colleagues. They are all adolescents.
"We do dermatology, sports medicine, psychology,
gynecology, orthopedic issues, psychosocial issues, substance abuse, and
address problems of developing sexuality," said Brown, a specialist in
adolescent medicine who is chairman of pediatrics at Crozer-Chester
Medical Center, in Upland, Pennsylvania.
"We're highly trained generalists for a specific population — like
gerontologists," he said. "But either we've done a poor job of marketing
ourselves or there is something about the field."
Adolescent medicine might be expected to be booming.
The US has about 40 million people ages 10 to 19, a patient population
that experts say is vulnerable to a growing array of behavior-related
But a decade after adolescent medicine became board
certified in the US as a subspecialty, it is in little demand by doctors
seeking to advance their careers. Small wonder the public is generally
unaware of the field: according to the American Board of Medical
Specialties, only 466 certificates in adolescent medicine were issued
from 1996 to 2005. In the same period, 2,839 were issued in geriatric
Most major teaching hospitals have adolescent clinics:
pediatric residents have to spend a month in an adolescent rotation. A
few health maintenance organizations have stand-alone adolescent
clinics. Occasionally, a pediatrician in a group practice or in a
community may have a special affinity for teenagers, and be the go-to
doctor for them.
But the availability of doctors and nurse
practitioners dedicated exclusively to adolescent care is still the
exception. Their numbers are so limited that many cannot take on
adolescents as primary-care patients; the patients see them on a
temporary referral basis. Of those teenagers who are insured and who
continue to see a primary-care doctor, a vast majority remain with the
pediatricians or family doctors who have cared for them since diaperhood.
That job has become more time-consuming and complex.
"Adolescents are not big children and they're also not little adults,"
said Walter D. Rosenfeld, an adolescent medicine specialist and chairman
of pediatrics at the Goryeb Children's Hospital, in Morristown, New
They are not just a bridge population, he and many
others maintain, but their own stop in the road. During adolescence,
people need to learn how to take responsibility for their health and,
eventually, to become health care consumers, independent of their
At programs that are sensitive to adolescents, this
changing dynamic is negotiated deftly but firmly. Recently, at an eating
disorder clinic at the Goryeb Children's Center, at Overlook Hospital in
Summit, New Jersey, a nutritionist beckoned to a teenager in the waiting
area. The girl's mother stood to follow. But after the girl slipped into
the exam room, the nutritionist closed the door. "Oh, I thought I was
going in with her," the mother said to no one in particular. "Guess
not," she added with a small laugh of embarrassment.
Organizations like the American Academy of Pediatrics
and the Society for Adolescent Medicine recommend that primary-care
physicians monitor teenagers for drug and alcohol use, smoking, sexual
activity (including disease prevention and use of birth control),
physical activity, nutrition, depression, school behavior, and social
pressures. Yet various studies have shown that many pediatricians feel
inadequately prepared to address most of these issues.
A father in Indianapolis, who did not want to identify
himself to protect the privacy of his shy 12-year-old daughter, said:
"Our pediatrician is a great guy around everyday things, but he's not
adolescent-focused. He won't ask her about sex or alcohol or drugs. It's
just not in his repertoire. He's a baby doctor, oriented toward the
quickie office visit."
Because teenagers seek out doctors infrequently,
pediatricians have to grab at any opportunity to reach them, said Susan
Brill, director of adolescent medicine at the Children's Hospital at St.
Peter's University Hospital, in New Brunswick, New Jersey. "I could see
a boy with strep throat and he'll grunt at me and we'll be done in five
minutes," she said. "Or I could take a little more time to talk to him —
I might find out about sexuality issues that way. If a kid is coming in
for bronchitis, I'll get the parent out of the room and ask the kid if
he's smoking. If a kid is on a sports team and comes in with an injury,
is the pediatrician talking about weight and eating and steroid abuse?"
With so many doctors feeling underprepared to treat
teenagers and the need so critical, why no rush to those advanced
In conventional terms, the explanations for adolescent
medicine's remaining the wallflower at the subspecialty ball are
sensible enough. The fellowship is demanding: two years of additional
study for internists and family practitioners, three for pediatricians.
Yet after completing the adolescent fellowship, a
doctor's income does not markedly improve. Insurance companies still
view teenagers as large children. Though the annual checkup of a
16-year-old should take at least twice as long as that of a 6-year-old,
doctors say, the typical reimbursement is about the same.
Moreover, the field does not get much respect, at
least from other doctors (parents can be weepy with gratitude). In the
thriving world of high-tech medicine, doctors who treat adolescents are
determinedly low-tech. They listen. They observe. They do some subtle
teaching, a fair amount of diagnosing and, on the good days,
intervention, amelioration, even outright prevention.
And then there are the patients themselves. "American
society is not particularly fond of its teenagers," said John Santelli,
a professor of pediatrics and public health at Columbia University. "The
2-year-olds, everyone fawns over them. But the guy with the pin through
his nose is not cute."
A 1999 American Academy of Pediatrics study revealed
that while 22 percent of the patients seen by pediatricians were ages 12
to 18, 75 percent of the doctors surveyed did not want more adolescents
in their practice.
The meager reimbursement rates directly affect
pediatricians and family doctors. Elizabeth Panzner, a pediatrician in
Union, New Jersey, who speaks joyfully about watching a patient grow
over many years, said adolescents were nonetheless a challenge for a
busy practice. "Say there's a gynecological issue," she said. "Putting
the time factor aside, there's a financial burden which the pediatrician
would never recoup because gynecological visits are bundled into a
general pediatric office visit."
A relatively tiny, hardy, occasionally eccentric and
fervent group, adolescent-medicine specialists understand that theirs
will probably never become a much-sought-after position. Many have come
to see their mission not only in taking care of patients, but also in
researching public policy questions that affect adolescents.
And because many choose to become affiliated with
hospital programs rather than setting up fee-for-service practices, they
also teach pediatric residents and local practitioners how to exchange
critical information with teenage patients. "We can't do it alone,"
Rosenfeld, the specialist in Morristown, said. "We need to deputize
pediatricians and family practitioners, and make them our partners."
Since October, specialists in adolescent medicine in
his department have given a half-dozen lectures, including one for the
professionals at a local pediatric practice, as well as those for
pediatric residents on dating violence and eating disorders.
They have also tried direct outreach to adolescents:
last year, their blunt Web site, www.teenhealthfx.com, which has an
advisory board of teenagers, averaged nearly a quarter-million hits a
Kenneth R. Ginsburg, an adolescent-medicine specialist
at Children's Hospital of Philadelphia who trains doctors in treating
teenagers, said that when the child is 11 to 13, the doctor should
explain to both patient and parent that the visit will change: the
doctor will now spend some of it alone with the patient.
Parents need to be assured, Ginsburg said, that
although they will now be left in the dark about some of what is said in
the exam room, the doctor's goal is still the health and well-being of
The challenge, then, he and other experts say, is how
to speak with teenage patients using language that is nonjudgmental and
does not make them feel ashamed.
Leslie Sanders, an adolescent medicine specialist at
Overlook, recently gave a lecture to pediatric residents about
interviewing teenage boys. "Many pediatricians know they should be
asking, but don't know how," she said. "They might say, 'You know how to
put on a condom, don't you?' or 'After you drink, you don't get behind
the wheel, right?'"
When Ginsburg sits down with teenagers, he lays out
the deal: "They'll have a choice: they can say they don't want to talk
about this subject. They can lie to me, but if they do, I can't help
them. Then I emphasize the importance of honesty. "When the young person
tells me something I wish they weren't doing, like drugs," Ginsburg
said, "I won't praise the behavior but I'll respect the fact that
they're talking to me and looking for guidance. The kid needs to know
that my office is a place where they can get out of trouble, but not in
Doctors who choose to treat teenagers exclusively have
a special affection for them. Ginsburg's patients include the children
of intellectuals and the privileged as well as those living in shelters
and foster homes. For many of these doctors, the work has both a tinge
of personal identification and a call to social conscience. Santelli,
who is also a family planning expert, remarked: "We all have our
adolescence to live down. It was an important time to me, personally. So
I resonate when I talk to teenagers."
"Adolescence is at the intersection of fundamental issues for society:
if you make it through successfully, you're set up for life," Santelli
said. "If you don't, you could go to prison or end up in the
These doctors are also clear-eyed about their
patients. This is, after all, a patient population whose three leading
causes of death — accidents, homicide and suicide — are often related to
psychosocial problems, rather than traditional medical diagnoses.
That is why a doctor-patient relationship with the
teenager based on trust and confidentiality is so crucial, Ginsburg
said. "Adolescents are incredibly thoughtful, creative, and absolutely
challenging," he said. "They get when you're insincere really quickly.
The tough kids are not used to adults not fearing them. But if you just
love being with them, they melt. The attitude goes away because it's
just a pained, defensive posture."
May 08, 2007