In his senior year, a teen got caught smoking in the woods behind school. Now he'll have to take a stop-smoking course or else not graduate.
The problem was, his parents would be mad. His peers were no help in finding a program, and he had no intention of asking school officials. So he did what few teens would feel comfortable doing. He called his personal doctor, who referred him to a smoking program, with nary a word to the folks. "He had a close relationship with Dr. Farrow," says the boy's father, Cliff Sanderlin, who heard of the crisis from his son only when it was safely past.
James Farrow, a Seattle internist, is one of a new breed of doctors (mostly pediatricians) who focus on treating teens. The specialty has sprung up in response to concern in the medical profession that adolescents need much more care than the occasional sports physical or throat culture -- the most many get once they outgrow the waiting rooms filled with babies and undersized furniture.
"I see a goodly number of teens," says Dr. Lawrence Pakula, a Timonium pediatrician.
Dr. Pakula, who has been practicing for 31 years, says teens have some common concerns. "Generally, they want to make sure that they are basically healthy," says the pediatrician, who's on staff at the Greater Baltimore Medical Center. "And they are very concerned about appearance. Acne. Weight is an issue for both males and females."
And, he says, his teen patients want to talk about issues such as sexuality, alcohol and drugs, topics that they may avoid with their parents but that affect their health greatly.
This November, the American Board of Pediatrics will recognize teens' special health-care needs when it offers the first board certification exam in adolescent medicine, testing doctors' skills at screening for and handling such issues as drug abuse, eating disorders and sexually transmitted diseases. So far, 270 doctors have applied.
Since that's still a pretty small group, the challenge for most parents remains to figure out what kind of health care their kids need and then find a doctor, specialist or not, whose approach they believe in.
The American Medical Association's Guidelines for Adolescent Preventive Services, published in 1992 for use by all primary care doctors, recommends annual checkups for teen-agers and three complete physicals between ages 11 and 21. Sexually active girls (or any female at age 18) should begin to get Pap tests for cervical cancer. Overweight teens need guidance on diet; kids whose grades plummet or who appear melancholy should be assessed for depression. (A free pamphlet summarizing the guidelines is available by calling [312] 464-5570.)
One-on-one with teens
Such delicate discussions require trust -- and this may be the tricky part for parents. Whereas a pediatrician more oriented toward young children might include Mom or Dad in every exam and chat, adolescent specialists will leave parents in the waiting room at least some of the time.
Arthur Elster, a member of the committee that developed the AMA guidelines, notes that one-on-one attention can encourage adolescents to explore issues they wouldn't at home: the insecurities they feel about their bodies and about peer pressure, for example.
And it may be the only way to get teens to share details about potentially hazardous behaviors. The Centers for Disease Control and Prevention reports that, in 1992, half of all 12- to 19-year-olds had smoked cigarettes, and 55 percent had tried alcohol.
Among 14- to 19-year-olds, 48 percent had had sex -- 16 percent with four or more partners -- and 42 percent had not used a condom the last time. How much detail is then shared with the parents is the patient's call.
It's not that adolescent doctors prefer to keep parents in the dark. Ideally, a teen-ager's folks will be supportive enough that the youngster will want them involved. A one-time experiment with cigarettes might be confidentially nipped by a talk about lung cancer and prematurely wrinkled skin. A case of chlamydia might be treated without parents' knowledge; quiet care is better, doctors reason, than the teen avoiding treatment.
When the problem is very serious -- chronic drug use, say -- a doctor might insist on letting parents know.
"I tell them that what we talk about in this room is private and rTC confidential . . . and that it will stay in this room," says Dr. Pakula, the Timonium pediatrician.
However, if someone's life or health is at risk, Dr. Pakula will talk to the parents -- after first consulting with the teen.
S. Jean Emans, adolescent medicine specialist at Children's Hospital in Boston, has the same standards. "There are times when their health is at significant risk and we would want the parents' support. If we need to break confidentiality, we would discuss it with the teen first." She routinely sets aside time to talk to parents alone.
"We may not be able to share whether their daughter or son is sexually active, but we very much like to hear their concerns," she says.
When teens don't want their folks included, the law will usually back them up. In most states, teens 14 or older can consent to treatment for sexually transmitted diseases, pregnancy, contraceptive services and drug abuse. (The laws vary widely on whether parents must be notified before an abortion.)
Some parental guidelines
Clearly, parents will want to know the policy on confidentiality and how private time will be used. A teen specialist will probe for potential problems by asking careful questions -- she won't be informing a nondating 12-year-old about methods of birth control.
The doctor may ask, for example, if the teen has a boyfriend or girlfriend or if marijuana is commonly available in school. Depending on the answers, the doctor might inquire if the boyfriend or girlfriend is a steady.
If there seems to be good reason, the questions become blunt: Are you sexually active? Have you tried marijuana? Kids who are sexually active will be counseled about birth control, sexually transmitted diseases and pregnancy. Drug and alcohol use requires further questions about the amount and frequency, as well as guidance on the dangers.
Teens will have their own yardsticks by which to measure their doctors. One young Boston native, now 21, went through three painful years following the start of her period at age 12. She bled every other week, at times doubled over in pain. Her mother took her to a man who was considered a brilliant obstetrician-gynecologist.
A doctor-patient match
But his brilliance didn't make him comfortable with a 12-year-old on the examining table. "He was a great doctor, but not for me. I don't think he was listening to what I was saying as he would have listened to an adult," says the young woman, who doesn't want to hurt his feelings by revealing her name. He chalked it up to cramps and hustled her out the door.
Finally, her mother found Dr. Emans, who, in line with the young woman's wishes, kept the mother informed every step of the way. Dr. Emans eventually called in a surgeon and two other doctors for consultation. They gathered around the examining table, looked at her face, listened -- and believed. Soon after, she had surgery for endometriosis.
She's an adult now. She hadn't, until asked, thought about leaving Dr. Emans. After a pause, she said: "I think I'll leave her when she boots me out."