The demographic landscape is shifting in the United States, a shift which is changing the distribution of patients and altering the training and practice needs of health care providers. iiZ Along with a rising proportion of elderly, it is projected that in the next decade (1990-2000) the number of youths age 12 to 17 will increase from approximately 22 million to 24 million.3 This, indeed, will require accompanying shifts in the training and practice of medical practitioners. Further concern for the pediatrician, added to the increased numbers of youths, is that the proportion of adolescents using pediatrie services is also rising.2·4'6 In its landmark report on the future of pediatrie education, the American Academy of Pediatrics declared that pediatrics was the most likely of all specialties to lead the way in the provision of adolescent health services for years to come.2 As pediatricians and other health care providers encounter a greater proportion of adolescents among their clientele, it becomes useful to examine the practice experience of physicians currently providing health care to youth, particularly examining their views of the changing nature of problems among youths, and the strategies and approaches used in addressing these problems.
Accompanying the shifting demography has been a transformation of social norms and expectations. Noted commentators have observed that, while change is endemic to modern life, the rate of change for youth is unprecedented in recent history.7'9 The confusions and pressures of modem life are reflected in the experience of our young people, which, in turn, impact on the kinds of health problems adolescents bring to health care providers. These changes in the health needs of youth were examined closely in a 1980-1981 survey of physicians then providing services to youth. This study, the Upper Midwest Regional Physicians Survey, was conducted with a representative sample of community-based pediatricians and family and general practitioners in Minnesota, Wisconsin, the Dakotas, and Iowa, and was designed to assess physicians' views of the health problems of adolescents and particular strategies for practice designed to meet the unique needs of this group. Questions related to practice addressed issues such as confidentiality of treatment and payment for services by youth, as well as the training needs of physicians in adolescent health. The sample included a 52.5% usable response rate (N=476) with good representation of the physician population.5 Data were collected by use of a mailed questionnaire. This report focuses on three components of the survey: 1) physicians' views on the changing health problems of adolescents; 2) physicians' identification of the unique practice needs of youth as clients; and 3) approaches and strategies for addressing these unique needs.
Respondents were asked about the changes they had seen in the nature of adolescent problems over the previous 5 years. Physicians' responses to this question of perceived changes fell into three categories: 1) negative or detrimental changes; 2) positive changes; and 3) no change. Two thirds of respondents reported changes in the problems and concerns brought to them by adolescents in the first category, negative changes. One fifth noted positive changes and developments, while 30% reported no change at all. (This latter group excluded physicians who had been in practice for less than 5 years so that a response of "no changes" would not serve as a proxy for insufficient time in clinical practice to have seen changes in adolescent problems and concerns.)
One third of the physicians identified increases in problems related to sexual activity: increased incidences of pregnancy, sexually transmitted diseases, and abortion. For some respondents this increase in sexually related problems was part of a more encompassing "crisis of morality." Others viewed it as a result of increased interpersonal stress, peer pressures, and shifting social norms regarding identity expression and status acquisition. As one pediatrician noted:
They are under much more pressure than before to become sexually active and to "prove" how cool and grown up they are by having intercourse. . . . There is a strong push to "grow up" faster, with irrelevant ways of demonstrating it, such as heavy sexual involvement.
(Pediatrician, town size of 5,000-10,000.)
Another, describing the shifting social norms and accompanying stress of adolescence, noted:
It's an ironic thing. There is more emphasis on self-help, self-expression, being attuned to one's feelings, etc., yet kids today are feeling more stressed, more pressured to perform, to be grown up, to act mature - and so much of it boils down to sexual intercourse, which is bewildering to so many girls when they see how personal it really is. Here norms and expectations result in the trappings of adulthood without the responsibility that goes with it. It is an unhealthy development.
(Family practitioner, town size of 50,000-100,000.)
Stress in everyday life was a second negative change noted by physicians. Fourteen percent of the respondents cited increased stress and psychological pressures evident in the daily lives of adolescents. While the sources of this stress were seen as diverse, ranging from changes in social norms and beliefs and high youth unemployment to the "failure" of individuals to cope, the results were viewed as essentially similar: adolescents are living in an environment marked by heightened tensions, pressures, and demands, with direct consequences for their mental and physical health. One general practitioner's comment aptly summarized the observations of other respondents when she noted:
They are living in a world more complex and more demanding of them (adolescents) than ever before. This is probably the most difficult time to be a teenager because of both vague and explicit demands and expectations about how to be, how to look, how to act, how to think. They have the opportunity for independent behavior and activity without having learned how to deal with it. Media messages are unhealthy, their music promotes sexual acting out as does the advertising dished out by adults; in essence we are getting from teens what we told them to be anyway. The results of this confusion and distortion are what 1 see in my office: symptoms and conditions that walk the line between physical and psychological in their etiology. This is a very disturbing development.
(General practitioner, town size of 50,000-100,000.)
A third detrimental change noted by 14% of physicians was the growing problem of chemical use by adolescents. Many linked this directly to stress and coping problems while others attributed it to "a world grown too complicated for comprehension." As one pediatrician described it:
. . . more alcohol, drug, and nicotine abuse - down into the sixth grade, brents do not give a damn - and adolescent discipline is lost. 1 can't begin to tell you the crap I've seen. It's enough to keep you up at nights.
(Pediatrician, town size of 5,000-10,000.)
Finally, 10% of respondents discussed the prevalence of parental neglect, the under-social ization of children, and the resultant antisocial attitudes and behavior among youth:
When parents stop caring about their own children these youngsters get turned loose on the schools and on society, and little can be done with them. The family, as a source of values, pride, and self-restraint, has just plain gone to hell.
(Family practitioner, metropolitan area.)
Speaking to the root of the ills of youth today, another concluded:
The saddest thing I've seen over the years has to do with the major source of all of the social problems we all know are out there. And that is the erosion of the family unit and parents taking responsibility for the upbringing of their own children. The result now is that far too many kids are confused, hostile, uncertain, and ready to kick authority in the face since they never had to learn the notion of limits and respect at home.
(Pediatrician, town size of 5,000-10,000.)
It was a minority of physicians (20%) who identified positive or beneficial changes among youth seen in their medical practice. Twelve percent of physicians reported that adolescents seemed more honest, open, expressive, and communicative, while 8% described teens as more mature, independent, knowledgeable, and informed than in previous years:
I think they are more intelligent and aware than they used to be. Not that there are not problems. But so many young people seem to want to be intelligent users of health services, and to make careful choices for themselves. They ask better questions, even critical ones, but are sharp and listen well.
(Pediatrician, metropolitan area.)
So, while some physicians did identify positive changes among adolescents, the majority cited negative, detrimental changes that are affecting the health problems of youths seen in their practices.
Unique Needs of Adolescent Patients
A second area of questions addressed the unique needs of adolescents as perceived through the physicians' practice experience. Respondents were asked whether adolescents had needs that distinguished them from other client age groups. Nearly three quarters of respondents (74%) affirmed the presence of differentiating needs of adolescent clients, while one quarter did not. Systematic content analysis of physician responses revealed that from the respondents' perspective there are four areas of need which qualitatively and/or quantitatively distinguish adolescents. The needs are for: 1) additional time; 2) an empathetic listener; 3) acknowledgment and encouragement of the adolescent's shift from dependence toward independence; and, finally, 4) confidentiality.
Adolescents need more time for interviewing, examination, and follow-up discussion of related concerns, according to 28% of the physicians in the survey. Respondents emphasized the prevalence of health worries and concerns among their adolescent patients, including higher proportions of "worried well" teens in their offices. These "worried well" were adolescents who either presented with one symptom or problem while wanting also to discuss other health concerns or bodily preoccupations, or were "presick" (no symptom) but desirous of an empathetic listener for undefined concerns and anxieties. More than children or adults, physicians viewed adolescents as needing and being desirous of clear, detailed explanations and reassurances related to their changes in emotional states, anxieties about abnormal or atypical development, and the potential impact of any number of signs or symptoms signaling actual or potential interferences with everyday life routines. As one pediatrician summarized it:
There is tremendous concern over the "meaning" of everything. A simple symptom and they want to know what it means for the future, for the football practice every night, for having to miss school, for going out with their friends. They are terrified of anything going wrong with them and exaggerate! I have to deliberately put things in a perspective because they see the slightest deviation multiplied times ten.
(Pediatrician, metropolitan area. )
Related to this issue of the time demands of adolescent clientele, 27% of physicians emphasized adolescents' need for active and empathetic listening. Recognizing the implicit sense of vulnerability in many adolescents, what Cortle called the "porous sense of self,"10 respondents stressed the importance of clearly hearing and being sensitive to both the immediate presenting health problems and the accompanying health worries of youth.
It is knowing how to listen and listen with three ears. Usually they bring in emotional problems under the "ticket" of a medical problem. You don't pick that up when you're not sitting knee to knee and really listening to the words and the meaning between, the lines. Far more than patients of any other age, they need a compassionate ear and a doctor who listens before she speaks. They usually won't say things more than once and it's the issues that really bother them that come up at the tail end of the appointment, when they're ready to talk and you've been thinking about winding it down. That's when you really have to be there.
(Pediatrician, town size of 10,000-20,000.)
One quarter of physicians identified issues in their adolescent practice experience that focused on adolescents' need for acknowledgment and encouragement in the shift from dependence to independence, a phenomenon well described in adolescent development literature.11 They noted the importance of fostering independence, mature decision-making, and active participation of the adolescent in the intervention and treatment process, which requires distinct approaches and strategies for the adolescent patient. Respondents emphasized the importance of moving teenage patients toward responsible adult status through self care, health maintenance, and rational decision-making. As one pediatrician described it:
[Adolescents must] leam to understand and rely on their own emerging selves. In the doctor-patient relationship, this means creating a partnership for health, with the adolescent's active and thoughtful participation. Eliminating passive dependence, uninformed fatalism. We must lay the ground work for responsible adult life.
(Pediatrician, metropolitan area.)
Confidentiality and privacy were identified by one fifth of the respondents as essential requirements of care for adolescent patients. Confidentiality was described as central to the adolescent developmental processes of separation and individuation of youth, this shift from dependence to independence noted earlier. Echoing the descriptions of others, a family practitioner reiterated:
Confidentiality is what permits adolescents to rise above the dependency of childhood, nearer to the status of adult. It is the foundation of independence and the patient-physician relationship, and it allows the adolescent both autonomy and the opportunity to be responsible for their decisions.
(Family practitioner, metropolitan area. )
Strategies and Approaches for Adolescent Patients
In view of physicians' knowledge of the problems and unique needs of adolescents, what are the ways in which they incorporate these understandings into their practice behavior, ie, iu their approaches and strategies for dealing with the adolescent patient? Literature addressing approaches for working with adolescent patients primarily reflects the experience and advice of individual practitioners.12,15 The goal of the Upper Midwest Regional Physicians Survey was to thematically categorize and examine an aggregate of data in order to provide a view comprised of the collective suggestions of a sample of physicians who treat adolescent patients.
This collective view of the optimum practice behavior for the care of adolescent patients can be described as the blending of two components, communication approaches and structural strategies. Communication approaches identified by the respondents related specifically to the characteristics of the interaction between physicians and adolescents, directly addressing adolescents' need for time, empathetic listening, independence, and participation. Two thirds of physicians described their response to these needs of adolescents in terms of a particular communication style. Elements of style included:
* projecting an empathetic, caring attitude that the teenage patient would recognize and trust in order to facilitate self-disclosure (36%);
* deliberately allowing for additional time to question, discuss, and clarify issues and concerns of the patient (28%); and
* adopting an objective but nonparental attitude and demeanor so that the physician could be regarded by the adolescent as a nonjudgmental source of information and advice (11%).
Structural strategies identified by the respondents were ways in which the setting could be conducive and responsive to the unique needs of adolescents, thereby promoting and facilitating the same outcomes sought by physicians who emphasized communication approaches. (Often, the overall strategy of physicians for adapting to adolescent needs was a blend of both components, communication and structural strategies. ) One third of the physicians indicated structural strategies to facilitate communication, examination, treatment, and desired outcome in their teenage patients. As one general practitioner described it, "You not only need to communicate differently; it helps to set up their whole meeting with you in certain ways so that they'll stay with you. Otherwise you might lose them along the way. I've nevet had to do this for any other age group than teenagers. "
Of the one third who reported structural strategic needs unique for adolescents, one third described distinct spatial arrangements in their office or clinic conducive to adolescents, while the remaining two thirds described strategies that made use of involvement of persons other than physician and patient, ie, other staff and family members. Spatial arrangements included the maintenance of separate waiting rooms apart from younger children and adults, examination rooms designed specifically for teens without the usual accoutrements of rooms designed for children and toddlers, and separate days for adolescent appointments. As one pediatrician noted:
Separate waiting rooms. Very important to these kids. They do not like sitting with adults looking at them (probably wondering what's wrong with them) and they feel embarrassed by younger children. I also have separate exam rooms geared for an older patient (no cute bunnies on the wall and pictures of babies about to get an injection in the nimp as horrified parents look on!). 1 try to make a space for them that is appropriate for their age and their sensitivities.
(Pediatrician, metropolitan area.)
Among those respondents who described the effective use of persons other than physician and adolescent for creating a conducive environment, one third emphasized the importance of excluding other family members from the examination process, even in the face of anxious (and sometimes persistent) parents, particularly mothers. One fifth detailed their frequent use of joint adolescent-parent conferences after the examination, depending on the condition, problem, situation, and judgment of the physician. One physician noted:
We encourage joint consultations in the office with parents and adolescents if it is warranted by the situation. Seeing the teenager alone first and then following through with bringing the parent in gives us a balanced picture of what might be going on beyond straightforward medical care needs.
(Family practitioner, metropolitan area.)
The remaining 50% of physicians who identified the use of structural strategies for addressing adolescents' unique needs discussed their collaboration with other staff members for the management of particular interpersonal and psychosocial patient problems, as well as those requiring referral to various other agencies and services and long-term complex follow-up.
As the demographic composition of physicians' clientele changes over the next decade, pediatricians in particular are expected to see a rising number of adolescents. This trend was evident in the Upper Midwest Regional Physicians Survey, in which a significant proportion of pediatricians reported an increase of adolescents in their patient population over the last 5 years. The findings of this survey afford an opportunity to sample the practice experience of physicians currently working with adolescents, in order to provide a collective view of their approaches to working with youth. In addition, these physician perspectives of the unique problems and needs of adolescents, and strategies for the provision of care conducive to this distinct age group, can offer direction for the training of practitioners who will be providing health services to youth in the future.
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