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Targeting teen health

U’s adolescent health experts work to help teens survive these risk-filled years

If you are reading this page, you have lived it: The hormone-driven emotional highs and lows. The risk and resilience. The vulnerability and invincibility. The rite of passage that Carol Burnett called “one big walking pimple.”

It’s adolescence, and it’s no joke. In 2003, motor vehicle accidents, homicide, and suicide were the three leading causes of death among individuals aged 10 to 24—or 57 percent of all deaths in that age group, according to the National Adolescent Health Information Center. One in five 12th graders reported using cigarettes or taking drugs, and one in four said they were binge drinking. A new report from the Centers for Disease Control and Prevention indicates that the teen birthrate has increased for the first time since 1991.

Not surprisingly, experts in the University of Minnesota Medical School’s Division of Adolescent Health and Medicine will tell you that the teen years demand health-care professionals’ undivided attention.

“Members of this age group are not dying primarily of tumors and infectious diseases. They are dying of drinking while driving, accidents, depression, drugs, and violence,” says Nimi Singh, M.D., M.P.H., head of the adolescent medicine division and assistant professor of pediatrics. “If 80 percent of what kills people between ages 11 and 21 is emotional and behavioral, any clinician who is providing care for that population has to be looking for warning signs.”

Nimi Singh, M.D., M.P.H., head of the Department of Pediatrics's adolescent medicine division, teaches the importance of screening adolescent patients for emotional and behavioral problems and providing them with healthy coping strategies.

Singh and her colleagues have made it their mission to help teens survive these risk-filled years, and the team is training new physicians to think differently about the way they provide care for these uniquely challenging patients.

Says Singh: “We want clinicians to pick up on when a teenager is upset about a negative interaction at school, for instance, so they can help that teen learn to cope with the event emotionally rather than have him or her show up in the ER six months later because the social fallout became too much to handle.

“Anxiety, depression, poor eating habits—identifying the risky behaviors early and helping adolescents make healthy choices is the only sensible way of addressing this country’s growing challenges in adolescent health,” she says.

In fact, the University of Minnesota has been a pacesetter in teaching doctors and other health professionals to do just that. In 1978, it became one of seven academic institutions in the nation to host a federally funded interdisciplinary adolescent health fellowship program, supported by the U.S. Maternal and Child Health Bureau to train future leaders in adolescent health. And in 1988, the University’s Department of Pediatrics began requiring all of its residents to complete an adolescent health rotation—long before the Accreditation Council for Graduate Medical Education made that a mandate for all pediatric residents in 1996.

“The aim of the [adolescent health] rotation is to round out residents’ education so they become sensitive to a population that’s more independent about the health-care decisions they make,” says John Andrews, M.D., director of the pediatric residency program and associate head of education in the Department of Pediatrics.

“When you provide care to a 7-year-old, while you are holding the interests of that child in highest regard, you are also negotiating with a concerned caregiver, like a parent, to do what’s best. With adolescent patients, you need to relate more directly with them and respect their priorities.”

A memorable month

University pediatrics resident Tonya Brakey, M.D., entered her adolescent health rotation with some apprehension. Like many of her fellow residents, she was intimidated by teens. “I had this presumption that they are secretive and have a lot going on behind the scenes that they wouldn’t want to tell a doctor,” recalls Brakey. “I was concerned that when I’d talk to them, I’d look like a square or be transformed into my mother.”

But Brakey, who completed her rotation in fall 2006, found the experience to be highly rewarding. “My approach to working with youths changed fundamentally based on the training I got,” she says. “The teens were refreshing. They were funny. They were a lot more candid than I thought they would be, and they were eager to have someone listen to them and answer their questions. It was really satisfying.”

The U’s pediatric residency program packs a lot into its month-long adolescent health rotation, combining clinical assignments with training sessions, lectures, and innovative approaches to teaching communication skills.

Residents spend 20 to 25 hours a week in a variety of locations, including the Fairview Children’s Clinic affiliated with the University of Minnesota Children’s Hospital; Hennepin County Medical Center’s adolescent medicine specialty clinic; and Face to Face, a multiservice center, for disadvantaged and homeless youths.

Third-year pediatric resident John Anderson, M.D. (left), discusses a patient’s chart with John Andrews, M.D., director of the University’s pediatric residency program. The program has included an adolescent health component since 1988.

“The residents tend to move around a lot during the 30 days,” says Mae Seely Sylvester, M.S., coordinator of the rotation. “We try to give them the experience of seeing adolescents in a variety of settings.”

Two mornings a week, residents learn about such critical topics as reproductive health, mental health issues, contraception, teen pregnancy counseling, sports medicine, and gay/lesbian/bisexual/transgender youth issues.

The first two Friday afternoons of the rotation are devoted to clinical communication. Singh spends the initial hour talking about how to conduct a useful psychosocial interview, using the acronym HEADDSSS (asking about the patient’s home life; education; activities; diet;
rugs, alcohol, and tobacco; sexuality; suicidal thoughts or depression; and safety).

“The single most critical tool when working with teens in a health-care setting is the psychosocial interview, which involves connecting with young people, asking them how they are doing,” says Singh. “I tell students and residents that it’s more important than listening to their patients’ hearts.”

Often, threats to an adolescent’s health have little to do with teens’ primary reasons for visiting their doctor. “Even if a 14-year-old comes in for a refill on his asthma medications, you’ve got to do the psychosocial screening because you have no idea which young person may be struggling. The physical exam alone is not going to reveal what is putting their health at risk,” Singh says. “That’s adolescent medicine in a nutshell: identifying stressors in the life of a young person, then making sure they have healthy coping strategies for dealing with them.”

That message struck a chord with adolescent health fellow Stephanie Walters, M.D., who realized that she wanted to specialize in adolescent health when Singh spoke in one of her second-year medical school classes.

“She spoke passionately about serving teens, what the typical teen visit is like and the kind of impact we can make as physicians. I chased her down to learn more,” recalls Walters, who completed her family medicine residency in 2006. “I love the psychosocial part of medicine and the chance to sit down and hear about patients’ lives. This is the bread and butter of adolescent medicine, which cannot be said for many other specialties.”

One highlight of the rotation, the Adolescent Actors Teaching Project, allows residents to practice their interviewing skills through role playing. During the session, trained adolescent actors ages 14 to 20 come into the classroom “clinic” for predetermined reasons.

“Residents do the practice interview for 15 to 20 minutes. Then the actors provide feedback on how the interaction felt for them, what areas require improvement, what they liked and disliked, and what the residents could have done differently,” explains Sylvester. “The feedback from residents has been very positive. What I hear most often is, ‘I was anxious about role playing, but now I understand that talking to teens is doable and important.’”

The promise of youth

Amid the sobering statistics regarding adolescent health, Singh says there is much good news, too. First, clinical communication skills are easy to teach, easy to learn, and incredibly effective. Second, adolescents bounce back. “When practitioners can speak with adolescents in a respectful, nonjudgmental way, adolescents really will open up and tell you everything you need to know to provide effective care, and that puts us on a path toward the positive,” she says.

Three years ago, when Walters was talking with a 15-year-old patient during a well-care visit at a North Minneapolis clinic, she asked the teen if he had any questions about safe sex. With great enthusiasm, he described his role as a peer educator at Minneapolis North High School.

“I felt energized all day long after that visit; he had given me such a charge with his positive energy and his healthy understanding of how to protect himself and his friends,” recalls Walters. “The best part of my job has been identifying teens’ innate sense of health and wellness and focusing on those assets to help them avoid future risks—or handle current struggles.”

That’s just the lesson Singh wants to share. “What we find through our research and practice is that there is a lot of resilience built into these patients,” she says. “Tapping into that resilience—serving as a facilitator in bringing that out and then teaching others to do the same—is hands down the most rewarding, most hopeful part of my specialty.”

By Jeanne Mettner

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