Sensitive Subjects

Physicians Offer Advice in Counseling Adolescents

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Public Health Feature – June 2011


Tex Med. 2011;107(6):29-33.

By Crystal Conde
Associate Editor  

Every week, Hillary Boswell, MD, an obstetrician-gynecologist at The Women's Specialists of Houston at Texas Children's Hospital, talks to adolescent girls about preventing sexually transmitted diseases, birth control, and other sensitive health topics. The girls want an honest, confidential conversation with a trustworthy physician who makes them feel comfortable. Dr. Boswell specializes in the first teen gynecological visit, and adolescent girls make up about 30 percent of her patient volume.

When patients go in for their initial visit, Dr. Boswell gives them and their parents educational materials geared toward teen health, sexuality, puberty, and other areas of health. Next, she attempts to relieve any anxiety patients feel by spending some time getting to know them.

"I invest five to 10 minutes asking patients questions about their lives before getting into anything having to do with health or sensitive subjects. I try to build a rapport with the girls early on."

During her conversations, Dr. Boswell also brings up substance abuse and bullying.

"I try to get at the larger abuse issue by asking patients if anyone anywhere is trying to get them to do something they don't want to do. I also ask if they're being bullied or experimenting with drugs. Generally, I try to get the parent involved so we can all work together. If I thought the patient had a problem, I would refer her to the appropriate practitioners."

Texas Medical Association policy directs physicians who treat adolescents to give them counseling and treatment or a referral on sexual development, sexually transmitted disease, birth control, pregnancy, and substance abuse.

Tackling these once-taboo topics is vital, and Dr. Boswell says prevention and intervention – when necessary – are key. According to the Centers for Disease Control and Prevention (CDC) 2008 HIV Surveillance Report, young people aged 13 to 24 made up about 17 percent of all those diagnosed with HIV/AIDS in 2008. And a 2004 study in Perspectives on Sexual and Reproductive Health says that while 15-to-24-year-olds represent only one-quarter of the sexually active population, they account for nearly half (9.1 million) of the 18.9 million new cases of sexually transmitted infections each year.  

Subjects like sexual activity, sexually transmitted disease, substance abuse, violence, and bullying may be more familiar territory for physicians who see a large volume of adolescent patients. For those not as well versed in approaching touchy subjects with teens, resources and guidance are available.

The American Medical Association has free materials physicians can use to provide preventive care to adolescents. (See "AMA Guides Physicians in Adolescent Care.")  

Carla Ortique, MD, is a Houston obstetrician-gynecologist and a member of the TMA Committee on Child and Adolescent Health. She suggests physicians participate in seminars on adolescent health and recommends her colleagues consult the American Congress of Obstetricians and Gynecologists' (ACOG's) Tool Kit for Teen Care, Second Edition. (See "Kit Directs Physicians in Talking to Adolescents, Parents.") 


Build a Rapport With Patients

Marcel Thompson, DO, a Round Rock obstetrician-gynecologist and member of TMA's Committee on Maternal and Perinatal Health, says physicians should avoid being judgmental or making assumptions when talking to adolescents about sensitive topics. He says open-ended questions are best because they allow patients to speak freely. ACOG's Tool Kit for Teen Care gives the following examples of open-ended speech:   

  • How can we help you today?  
  • Please tell me your reasons for coming in. 
  • What have you heard about birth control pills? 
  • What would you tell your friend if she told you she was going to have sex?   

Avoid asking closed (yes/no) questions like:   

  • Are you here for birth control? 
  • Have you heard of birth control pills?  

Dr. Thompson's discussions with adolescent patients are confidential. But he says he offers to help them talk to their parents or guardians if they are comfortable doing so. 

Dr. Boswell has these suggestions for physicians when talking to adolescents about sexual health, violence, substance abuse, and other preventive health topics:   

  • Ask parents and caregivers to leave the room so you can discuss sensitive subjects and assure the patient of confidentiality. 
  • Don't perform any unnecessary pelvic exams. They are rarely necessary in adolescents and almost never required in a precoital patient. 
  • Start the conversation about experimentation with questions about the patient's peers, then move the conversation toward the patient's own experiences. 
  • Don't lecture.  
  • Ensure patients and their parents know how to contact you in the event of questions, concerns, or emergencies.  

Don't Miss Out on Prevention

Benjamin C. Lee, MD, a Dallas pediatrician and chair of TMA's Committee on Child and Adolescent Health, says two main barriers contribute to missed opportunities in preventive care for adolescent patients:  

  • The subject matters are generally taboo, and physicians, patients, and parents can be apprehensive about bringing up sensitive and private topics such as sexual activity, drug and alcohol use, and violence.
  • With a limited amount of time allocated to each appointment, an in-depth conversation in all fields may not be possible or practical.   

Dr. Lee says physicians should ask patients about sexual activity before they turn 16.

"The facts are adolescents are going through puberty at earlier ages and are faced with teenage problems before the teenage years. Doctors can begin general discussions as early as 9 to 10 years of age and bridge into more open and in-depth discussions as the child ages."

Pre-visit questionnaires help identify patient or parent concerns, he says. During the visit, Dr. Lee says, physicians should excuse the parent or guardian so the patient can speak freely and the information can remain confidential. As children grow into adolescence, Dr. Lee explains, parents' involvement in health care evolves.

"Early on, parents have total authority over a child's health care. In general, that continues during adolescence, but in some instances the child has authority over his or her individual care," he said.

For instance, the TMA Be Wise—ImmunizeSM Physician Toolkit for Adolescents says the law allows a minor to consent to medical treatment:  

  • If on active duty with the military; 
  • For diagnosing and treating any reportable infectious, contagious, or communicable disease, including all sexually transmitted diseases (this also could include some vaccine-preventable illnesses, such as hepatitis B); 
  • If unmarried and pregnant, to treat the pregnancy (other than abortion); 
  • For examining and treating addiction, dependency, or any other condition related to drug or chemical use; and 
  • For counseling for suicide prevention, chemical addiction or dependency, or sexual, physical, or emotional abuse.   

For more information, the TMA Office of the General Counsel has a white paper on Consent for Treatment of Minors. To request the white paper, contact the TMA Knowledge Center at (800) 880-7955 or (512) 370-1550, or email the TMA Knowledge Center


Make Adolescent Immunization a Priority

A discussion on adolescent health care wouldn't be complete without addressing immunization. Dr. Lee says immunization appointments give physicians a chance to talk to adolescents about important health issues. He encourages physicians to stay on top of the Advisory Committee on Immunization Practices' (ACIP's) adolescent immunization schedule [PDF].

Traditionally, pediatricians and family physicians focus their attention on ensuring that infants and young children receive every vaccine on the immunization schedule on time. Thinking about immunizing adolescents has only recently become a priority for physicians. 

Before 2005, the tetanus and diphtheria toxoids (Td) booster was the only vaccine consistently recommended for adolescents. Physicians also recommended adolescents who weren't up to date on their immunizations receive hepatitis B and measles-mumps-rubella (MMR) vaccinations. Those who hadn't contracted varicella or been vaccinated against the disease should receive a varicella vaccination, as well. 

The U.S. Food and Drug Administration (FDA) licensed the tetanus, reduced diphtheria, and acellular pertussis (Tdap) vaccine and the meningococcal conjugate (MCV4) vaccine in 2005. The following year, the FDA approved Gardasil to prevent human papillomavirus (HPV) infection and cervical cancer in women. 

With the rush of new vaccines and recommendations, TMA and the Texas Department of State Health Services (DSHS) collaborated on a statewide push to encourage adolescents to receive HPV, MMR, MCV4, Tdap, and varicella vaccinations. Efforts also include updating adolescents on their hepatitis B, hepatitis A, and polio vaccinations.  

TMA's Be Wise—Immunize Physician Toolkit for Adolescents explores barriers to vaccinating adolescents and offers solutions physicians can incorporate into their practices to boost immunization rates in this population. It includes information on:   

  • Vaccine reimbursement, 
  • Difficulty in accessing and verifying past vaccinations, 
  • Lack of confidence/self-efficacy in addressing adolescent issues, 
  • Lack of a reminder or recall system to prompt the adolescent to return for follow-up vaccinations, 
  • Increased school vaccination mandates, 
  • Simultaneous administration of multiple vaccines, 
  • Increased use of electronic vaccination records, 
  • Creation of a standard of care or protocol at each adolescent visit, 
  • Development of standing orders for vaccine practices, and 
  • Use of alternate sites for vaccinations.   

Information on conscientious objection, immunization schedules, sample minor consent forms, a list of adolescent vaccines covered by the Texas Vaccines for Children (TVFC) program, an explanation of the ordering and shipping system for TVFC participants, and DSHS adolescent immunization outreach resources round out the Physician Toolkit for Adolescents

To download the toolkit, visit the TMA website, or contact Tammy Wishard, TMA outreach coordinator, by telephone at (800) 880-1300, ext. 1470, or (512) 370-1470, or by email.

Be Wise — Immunize is a joint initiative of TMA and the TMA Alliance and receives funding through a grant from the TMA Foundation with major support from H-E-B and the TMF Health Quality Institute. The program began in 2004. 

A CDC immunization toolkit helps physicians talk to parents about adolescent vaccines. Counseling tips cover the benefits of immunizations, information about adolescent morbidity and mortality rates caused by preventable diseases, and the importance of primary prevention through immunizations. 

The communication guidance encourages physicians to:   

  • Use a consistent, simple message when discussing health and safety with adolescents and parents; 
  • Begin discussing adolescent vaccines when a child reaches age 9 to 10; 
  • Allow sufficient time to discuss with parents the benefits of vaccines, the diseases they prevent, and any risks involved; and 
  • Give the patient and/or parent a copy of the Vaccine Information Statement to take home at each visit. The statements are available on the CDC website, or you can order copies from DSHS.  

CDC also has information on the importance of vaccine administration, storage, and handling online.

The American Academy of Pediatrics (AAP) website features an adolescent immunization page with information for parents and teens, adolescent vaccine recommendations, and strategies physicians can use to increase vaccine coverage.  

Be Wise ― Immunize is a service mark of the Texas Medical Association.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.  


SIDEBAR

AMA Guides Physicians in Adolescent Care

 The American Medical Association has created materials and resources on adolescent health care and healthy lifestyles for physicians to use in their practice and professional activities. 

The Parent Package, designed to help physicians communicate important information about adolescence with parents, addresses topics such as tobacco, drug, and alcohol use; violence prevention; depression; sex; vaccinations; physical activity; and more.  

Alcohol Use and Adolescents, developed by the American College of Preventive Medicine and the AMA National Coalition for Adolescent Health, guides pediatricians in incorporating substance abuse prevention into routine and episodic office visits; understanding the signs and symptoms of substance abuse and the possibility of dual diagnoses with other mental health disorders; and serving as a community resource for smoking prevention and cessation efforts and as an advocate for evidence-based substance abuse prevention initiatives.  

The AMA's Youth Bullying resource instructs physicians on how to recognize the warning signs of victimization and to prevent bullying and intervene when necessary.  

AMA addresses violence prevention with the publication Connecting the Dots to Prevent Youth Violence: A Training and Outreach Guide for Physicians and Other Health Professionals. The tools in the publication guide physicians in integrating basic education, screening, and referral as part of their daily practice. It also encourages them to get involved in violence education and prevention in their local communities.  

To access all of these resources, visit the AMA website.   

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SIDEBAR

Kit Directs Physicians in Talking to Adolescents, Parents   

The American Congress of Obstetricians and Gynecologists (ACOG) offers the Tool Kit for Teen Care, Second Edition, to help clinicians and health care professionals care for adolescent patients. The kit features resources for adolescent assessment, CPT coding information, and educational materials on health care for girls. The kit contains a parent questionnaire, an adolescent visit questionnaire, and a new vaccine administration record for clinicians. Educational materials include pamphlets for patients, information on sexual assault prevention and screening, and fact sheets on a variety of health topics for teens and parents. 

The Talking With Teens portion of the kit guides physicians in approaching reproductive health discussions with girls. The kit includes information on using the GATHER approach when communicating with adolescents:   

  • G is for Greet: Welcome the patient in a friendly and respectful way to build trust. 
  • A is for Ask: Use open-ended questions rather than closed, narrow questions. Asking open-ended questions will help determine the patient's concerns while assessing her developmental status. 
  • T is for Tell: Respond to the teen's expressed needs and concerns. 
  • H is for Help: The physician and teen discuss alternatives, the possible outcomes, and how the teen feels about the issue. 
  • E is for Explain: The physician explains to the teen how to carry out her decision. 
  • R is for Return: Ensure that the teen has appropriate follow-up and a scheduled appointment.    

Some components of the kit are available free of charge online. Free materials include the kit's introduction, tips for making a practice adolescent-friendly, tools for adolescent assessment, CPT coding information, and ACOG educational resources. To order a complete hard copy of the kit, available for $72 for members and $85 for nonmembers, visit the ACOG bookstore online.

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