With teens, talk is the most valuable treatment tool
How to ask the right questions to get the real answers about sex, drugs and other issues
From the July/August 1997 ACP Observer, copyright © 1997 by the American College of Physicians.
By Jennifer Fisher Wilson
A 16-year-old patient with chronic abdominal pain is referred to your gastroenterology practice for a diagnosis. You perform a wide range of tests and find nothing. You refer her to a subspecialist for a second opinion, which also turns up nothing. More referrals follow and you are at a loss, until you finally discover that the patient is extremely distressed over her family life. Could this psychological factor—not a disease—be the real cause of her stomachaches?
J. Dennis Fortenberry, ACP Member, has seen similar scenarios played out repeatedly since he began taking care of teenagers. As an adolescent medicine subspecialist at the University of Indiana's Children's Hospital in Indianapolis, he says that teens are especially vulnerable to psychological and social stresses. From his training in internal medicine, however, he knows that internists have limited experience treating teens and so may often have difficulty identifying such problems.
But one look at the statistics shows how important these social stresses can be: 80% of what kills teens—homicide, suicide and injury—is preventable, according to the Society of Adolescent Medicine. The suicide rate has tripled among 10- to 14-year-olds and doubled among 15- to 19-year-olds in the past 20 years. In addition, the adolescent population was the only age group that had a rising death rate during the '80s, almost all of which was due to behavioral risks.
At an Annual Session presentation on adolescent medicine, where the above statistics were presented, Gail B. Slap, FACP, past-president of the Society of Adolescent Medicine and professor of medicine at the University of Pennsylvania in Philadelphia, said that getting at underlying social problems can be a tough job. "Adolescence presents one of the greatest challenges to physicians," Dr. Slap said. "Adolescent health's major risks are behavioral and environmental, but there's very little emphasis on these during most medical exams."
Since so few teen deaths are disease-related—cardiovascular disease and cancer, the two most prevalent diseases in teens, account for only about 11% of deaths among adolescents—physicians need to spend more time talking with teen patients and less time doing physical exams. "Don't spend your whole visit looking in the adolescent's ear," Dr. Slap said. "Talk to that patient about risks."
For internists, the message is clear: Don't wait until all clinical causes have been ruled out before exploring social and behavioral issues. "An internist may be likely to overlook anything that isn't relevant to the patient's direct condition, like abdominal pain," Dr. Fortenberry said. "It's really helpful to remember that adolescents usually have other things going on in their lives that affect their health."
How to talk to teens
Identifying those issues, however, means overcoming some obstacles. For one, there's the age and cultural gap between teens and physicians. "To deal with the challenges of adolescent medicine patients, it's best to have lots of practice," Dr. Fortenberry said. Barring that, he suggested internists rely on common sense and a sense of humor when interviewing teenagers—as well as the skills they've sharpened in treating their adult patients.
"When internists see a patient, they quickly begin to compile a mental list of what disorders they have to think hard about with this patient based on patient age, past history, ethnic background and family history," said David M. Siegel, MD, an internist and pediatrician who subspecializes in adolescent medicine at the University of Rochester. "With adolescents, it's not that different from other populations. It's just that the group of conditions that you aim toward covering is different because the population has other risks."
These conditions include injury from substance abuse and cigarette smoking, eating disorders, sexuality, violence, depression and suicide. It is during the teen years that such risks and risky behaviors tend to emerge, according to Dr. Siegel.
To better talk about these issues while taking a history, Kenneth R. Ginsburg, MD, a pediatrician and educator specializing in adolescent medicine at the University of Pennsylvania, suggested following the SHADESS model, which stands for School, Home, Activities, Drugs, Emotions, Safety and Sexuality. He explained the SHADESS model at the Annual Session workshop on adolescent medicine.
For example, Dr. Ginsburg said, no matter how little time you have to take a history and physical, always ask a teenager how school is going. "It's the marker for life," he explained. "If the patient's answer implies a change, follow up and ask, 'So are you happy? Who do you talk to at school?' " If the patient indicates recent changes at school such as a drop in grades or decreased attendance, Dr. Ginsburg said, be on the lookout for a deeper problem causing the change. Also ask about the patient's home life and social activities, which can shed light on a patient's well-being, Dr. Ginsburg said.
The SHADESS model also covers drug use, sexuality and emotions. Although teens may be uncomfortable discussing these topics, Dr. Ginsburg advised doctors to persist. "If you don't ask, they're unlikely to spontaneously disclose this information to you," he said. To help loosen up the conversation, use generic questions such as "Who do you spend time with?" instead of asking about a boyfriend or girlfriend. Listen to the answer carefully, and if it is vague or generic, take note. Statistics have shown that gay youths are up to six times more likely to commit suicide than heterosexual youths.
Pointed questions about sex, drugs or emotions may simply be too intimidating for patients. To encourage patients to answer questions about such topics, be careful how you ask about them.
"Asking lots of yes and no kinds of questions really turns the conversation into a one-way interaction," Dr. Siegel said. "If you do that, the unspoken message is 'I'm not really interested in you telling me a whole lot about what's going on with you. I just want you to answer the questions.' And if you mix in with that [the question], 'Are you using drugs?', it's very easy for them to say no," Dr. Siegel said.
Instead, Dr. Siegel suggested physicians preface questions with the following type of introduction: "You and I both know there are a number of health-related things we should talk about today, and I know you came to me today to know if your health is OK." By setting up an interview this way, physicians can provide a rationale for the history-taking while implying that they have experience treating teenagers.
Dr. Fortenberry suggested a similar technique for making teen patients feel comfortable: "I often explain to the patient that I ask everybody these questions so that they don't think they've been singled out for a condition." He said this technique can be particularly effective with gay or lesbian teens, who have an especially difficult time answering questions about their social and sexual lives.
Physician insensitivity when discussing sensitive topics is inexcusable, according to Paul G. Dyment, MD, the director of student health services at the University of Louisiana. "I once referred a patient to a cardiologist for an exam and the physician said to him, 'You're not gay, are you?' " Dr. Dyment said that he apologized to the patient for the cardiologist's rudeness and never referred a patient to that physician again.
If you feel uncomfortable or unprepared interviewing teens, try having your patients fill out a written health screening questionnaire before the visit. The questionnaire may increase the efficiency of history taking.
"Giving people the opportunity to answer questions about sensitive issues on a questionnaire may prod them to focus on their health needs and it may be the setting that they're most comfortable with," Dr. Siegel said. For example, patients may feel more comfortable stating that they get depressed and cry three times a week on a questionnaire than they do talking about it.
Keeping it confidential
Although confidentiality is not always an issue for adult patients, it is a major concern for teens and their parents. Teens typically don't want their parents to know the intimate details of their sex lives and social lives. At the same time, parents want to know if their child is involved in risky behaviors.
To put both patients and parents at ease, Dr. Fortenberry suggested meeting with them somewhere outside the exam room before the examination. "It's important to establish up front the issue of confidentiality," he said. "Make it clear that your main concern is the patient."
With the parents in the room, emphasize the importance of family support and encourage teens to talk openly with parents, advised Dr. Slap. This helps parents feel included in their child's care, even though they don't accompany the child during the medical exam. "Parents need to think that their kids are safe with you and that if things get really tough, they'll be included," Dr. Slap said.
Dr. Siegel also warned physicians not to make the mistake of trying to help a patient by being a friend, an approach that often backfires. "They have peers if they want peer behavior. They want you to be an authority, and they want to believe that you have the expertise to understand what to do with the information they're giving you."
According to Dr. Ginsburg, sometimes the best treatment you can give a patient is positive support. "Be a cheerleader for kids," he said. "Praise the process of communication, not the content. Otherwise you don't get communication."
For instance, he suggested first complementing teenagers, even if it's on something like their survival skills or their honesty, and expressing that you enjoyed talking with them. Then, let them know that you're worried about them and discuss ways to modify or change their risk behaviors.
Just because kids are smarter today about dangers and risks does not mean they have the skills to deal with this knowledge, Dr. Ginsburg said.
"The reality is, you're not going to change kids' lives—the poverty, the abuse, and so forth," Dr. Ginsburg said. "But you see kids at their most vulnerable. So you have the best opportunity to help them."
Making your practice teen-friendly
- Subtlety. Place literature on sexuality, abuse and other sensitive topics in the bathroom so patients will not be embarrassed to pick it up. The bathroom may be the only place where patients are alone and feel safe examining literature and taking pamphlets.
- Convenience. Schedule office hours around teens' needs: after school or in the early morning.
- Awareness. Know your community resources so that you can refer victims of violence or abuse to available support counselors and hotlines.
- Knowledge. Keep a copy in your office of Guidelines for Adolescent Preventive Services (GAPS), which includes the AMA's standardized adolescent medicine health screening guidelines so that you can review and refer to it when necessary. GAPS is available from the AMA and accessible on the Internet: http://www.ama-assn.org/adolhlth/recomend/recomend.htm.
- Referrals. If you feel uncomfortable or unprepared to address teens' needs, refer them to a physician who specializes in adolescent medicine. For problems that are related to mental health, consider referring the patient to a mental health professional or clinical social worker who works with teens.
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