Primary Care Docs Need to 'Step Up' Their Health Behavior Talks With Teens, Says Study

When Sharon Lee, M.D., of Kansas City, Kan., does physical exams on her adolescent patients, she launches her "rap." It's a talk about drugs, alcohol and sex, she says, and how it's up to the teen to make choices. But according to a recent study, she and her like-minded family medicine colleagues may be exceptions to the rule.

The study, "Adolescent Preventive Services: Rates and Disparities in Preventive Health Topics Covered During Routine Medical Care in a California Sample," says that contrary to guidelines from national agencies and professional medical organizations, primary care professionals are doing a substandard job of addressing a number of health-related issues with their adolescent patients. Those issues include tobacco, alcohol and drug use; STDs; seat belt and helmet use; violence; physical activity; and nutrition.

According to the study, which was conducted by researchers at the University of California-San Francisco and published online in the Journal of Adolescent Health in December, HHS' Healthy People 2010 public health initiative seeks to improve overall health and eliminate health care disparities by setting specific health goals for various patient populations, including adolescents. Initiating discussions about behaviors related to those health indicators is a necessary first step to meeting those goals.

"Preventive care is a crucial element of quality primary care for adolescents," say the study authors, because most morbidity and mortality in this age group derives from preventable causes. In addition, they add, many health and lifestyle behaviors established during this time can have significant health effects later.

In fact, the delivery of preventive services was "distressingly low" for all of the issues examined, except nutrition and physical activity, the study authors note.

From data collected as part of the Adolescent California Health Interview Survey during a nine-month period in 2003, the researchers selected a random subsample of 2,192 adolescents who had had a physical exam within the past six months. The adolescents, ages12-17 years, reported on whether any of nine health topics were discussed during their most recent physical exam.

Although the rates of discussion for all of the topics were low, when there were discussions, the teens most frequently talked about nutrition (76.4 percent) and physical activity (75.7 percent) with their physicians, the study says. Least frequently discussed was violence (15.4 percent).

Compared with teens ages 15-17 years, adolescents ages 12-14 years discussed safety issues more and use of substances, nutrition and STDs less. Compared with males, females talked more about exercise and STDs. And compared with white teenagers, Hispanic youths reported more discussion on most of the topics, black youths reported more discussions on nutrition, and Asian youths reported more discussions on seat belt and helmet use.

Contrary to the researchers' expectations, teens from minority, uninsured and lower-income groups reported higher rates of discussing these health topics than did white teens and those in insured and higher-income groups, the study says.

"Increased investment and effort are required to improve the delivery of preventive services, so that all adolescents may benefit from adequate knowledge about the importance of healthy behaviors across the life span," the study authors conclude.

Although the California study did not note the specialty of the participating teens' usual health care providers, some family physicians say they're in a good position to talk to teens because they know these patients' families and have built trust relationships with them.

Lee, who practices at Family Health Care in Kansas City, Kan., says 23 percent of her patient panel consists of children ages 1-18 years. She says she talks about STDs, tobacco, drugs and alcohol with teens during school physicals, and her rap goes something like this:

"You are at an age when your friends or others may try to talk you into some things that may not be healthy for you. As your doctor, I am not here to tell you what to do, but I am an adviser for you. My advice is that you really think about what you want to do regarding smoking, drugs, alcohol and sex and decide on your own without pressure. My advice is to not do anything that is dangerous for you. What do you think?"

Family physician Mary Campagnolo, M.D., of Lumberton, N.J., explains that her practice has contracts with school systems to do sports and new student physicals, and she uses those encounters to broach the topics of drug, alcohol and tobacco use. She encourages open discussions about concerns when adolescents present for health maintenance or other office visits.

"Family docs do a good job of this," Campagnolo says of these preventive health talks. "But current payment models are volume-based. And in this environment, it's difficult to take a lot of time on something that's not medically urgent. Unfortunately, many adolescents are infrequent visitors to a family physician for health maintenance, and it does take time and repeat encounters to build rapport for discussion of sensitive topics.

"Within the context of a (patient-centered) medical home health care delivery and payment system, there may be more avenues and incentives for doing this kind of counseling," she adds.