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Raising the health status of adolescents
JOURNAL OF ADOLESCENT HEALTH 2004;35:71–76
PRESIDENTIAL ADDRESS
Raising the Health Status of Adolescents ANDREA M. MARKS, M.D., F.S.A.M.
Standing before you today, I feel energized, privileged and humbled, not because I am about to become President of a huge and powerful organization, but because I am about to become President of the only national organization committed solely to improving the health and raising the health status of adolescents. Our organization and its members, from over 30 countries, not only have the potential to make a difference, but I believe we have the responsibility. I am referring to each of us in this room, and others who couldn’t make it here today, who have dedicated our careers in some way to adolescent health. There are 40 million adolescents in the United States, and many millions more around the globe, and very few of us; so our words must be clear, our voices loud, our efforts focused to let people know about the health care needs of young people, that there is such a thing as adolescent medicine and health, what it is we do, each of us in a different way and in a different place, to meet the array of complex and intriguing needs of pre-teens, adolescents and young adults, in this country and around the world. Starting this fall, SAM is introducing a double slate format for election of President and members of the Board of Directors. You will learn about the candidates and their visions in advance. Since I have been fortunate to escape such scrutiny, I feel it is my obligation, before anything else, to share with SAM members something about the person about to become your President and how it came to be that she is standing here today. So I am going to tell you a few stories about myself, a few stories about SAM, and then try to explain why SAM and I have come together on this auspicious occasion.
From the Department of Pediatrics, Mt. Sinai Medical Center and Mt. Sinai School of Medicine, New York, New York. Address correspondence to: Andrea Marks, M.D., Adolescent-Young Adult Medicine, 14 East 90th Street, New York, NY 10128.
Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
Personal Stories Elizabeth and Louis Gurlitz were my maternal grandparents. They arrived separately in New York City, as teenagers from Eastern Europe, around the turn of the 20th century. During my entire childhood and adolescence they lived upstairs from us in a small two-family house on a quiet dead-end street in Brooklyn. My grandparents owned a children’s summer camp in Connecticut, called Camp Crestwood, and except for a few months each summer, the business was run from their apartment, mostly on the kitchen table. I loved camp, even though, especially as a teenager, it was difficult to deal with being the owners’ granddaughter. One of my favorite memories of camp occurred during the winter months; even as a young child, I loved to climb upstairs and settle into a comfortable chair in my grandparents’ living room and quietly observe and listen while my grandmother interviewed prospective camp counselors, young people in their late teens and early 20s. My favorite part, after the applicant left, was to give my grandmother my thoughtful assessment of the individual. I was convinced she took my advice very seriously. One time, however, my grandmother hired a counselor I recommended against, and sure enough, he ended up fired for getting drunk at camp, an unforgivable offense. I felt vindicated. Little did I know then, I would make a career of listening to and evaluating adolescents and young adults. As a teenager, my favorite TV shows were Dr. Kildare, Ben Casey and The Fugitive. All three shows were about doctors. Occasionally a woman doctor was featured, more often as a romantic interest than a high-powered professional. Even so, or perhaps for that very reason, the media was a powerful motivator. With no doctors in my family, and the women’s movement then embodied more in my grandmother 1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2004.04.004
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than in our culture, I left for college fantasizing about becoming a doctor. Two friends I met freshman year at Bryn Mawr, who knew for certain they intended to go to medical school, convinced me that my fantasy could become reality. I was also inspired by ballet. Purely as a spectator, I was struck by the hard work, focus and commitment required to achieve the skill and splendor of an accomplished dancer. Medicine, I decided, would be my dance, an opportunity to dedicate myself to becoming highly accomplished. During one interview for medical school I mentioned that ballet had inspired me to become a doctor; the interviewer looked at me askance in puzzlement. No surprise, I got rejected from that medical school. But no problem, as I had already been accepted to Penn, where I really wanted to go, and soon joined eight terrific women and 130 very nice men in the class of ’72. Adolescent medicine had not yet arrived at The University of Pennsylvania, and even as a resident at Boston Children’s Hospital, I had no exposure to the adolescent center, founded 20 years earlier by Dr. Roswell Gallagher. Most of my patients were very sick babies and young children, but for me, the most moving and memorable were the teenagers. A 16year-old girl with cystic fibrosis asked me to pierce her ears; a 14-year-old with advanced Hodgkin’s disease refused to get out from under her covers each morning on rounds until we sang her a wake-up song; another girl on the oncology unit was profoundly withdrawn, until we convinced her parents to tell her the truth about her diagnosis and, in fact, excellent prognosis. I cared for a teenage boy with Crohn’s disease and received a rare thank you note from his private pediatrician, Dr. T. Berry Brazelton. And perhaps the most memorable of all, a boy with anorexia nervosa, a disease I knew little about then, who agreed to eat if I let him take my picture. So one day, when I met Dr. Robert Masland, Dr. Gallagher’s successor, in a hospital elevator, and he invited me to become an adolescent medicine fellow, I did not have to think too long or too hard before saying, “Yes.” Fellowships back then lasted only 1 year, and since I had a boyfriend in New York City, and heard about this great adolescent medicine program in the Bronx, I arranged a 1-month elective with Dr. Michael Cohen and his colleagues at Montefiore Hospital. The boyfriend and I broke up, but I moved to New York anyway, when Michael offered me my first attending position. Michael became my “mentor extraordinaire” in academic medicine, and invited me to attend my first SAM meeting in 1976.
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Three years later, I left Montefiore to start a new division of adolescent medicine at North Shore University Hospital, in a suburb of New York City. Curiously, the hospital had just been asked by a nearby community to establish an adolescent health center in their town, even though ample numbers of pediatricians and other health providers practiced there. Before establishing the health center, we decided to survey the adolescents, by anonymous questionnaire administered at school, to assess their health needs and willingness to utilize existing health resources. We found that these middle class suburban adolescents, with ready access to private primary health care, participated substantially in health risk behaviors and had significant unmet health care needs related, most especially, to their body image, sexuality, substance use and mental health. Yet they were reluctant to seek care for these needs from their primary physicians. The study was published in The Journal of Pediatrics in 1983 [1] with an unusual left-handed comment by the editor-in-chief, which said the paper had been the subject of considerable discussion among the editorial staff, who felt the results were important and worthy, even though the methodology of a written questionnaire administered to adolescents was problematic. This editor was uncertain if he trusted the responses of teenagers. Our little study pre-dated the Youth Risk Behavior Surveillance (YRBS) [2], AddHealth [3], and similar studies, which have come to rely on the responses of adolescents. In 1990, after 16 years in academic medicine, I left the hospital setting and full-time academia to open a private practice in New York City for patients ages 9 through 30. My research, with Martin Fisher and others, had revealed significant obstacles faced by teens seeking suitable health care, including in private practice settings. My new challenge was to design a practice both appealing to teenagers and sought by their parents. I knew it would be necessary to strike a trusting partnership with the entire family. Another aim for the practice was to care for young adults throughout their 20s. The third decade of life is one of the most intriguing and difficult in our culture; yet health care services are neither designed for, often not covered, nor consistently sought by young adults. Daunted by the realization it’s not enough to just hang out a shingle, I was inspired to actively promote my practice by a quote on a highway billboard, attributed to Dr. Martin Luther King, which read, “It’s not enough to have a good idea, you have to tell somebody.”
July 2004
There are many practice stories to tell, but I will limit myself to one that originated in the SAM office in 1999. A reporter for New York Magazine [4] contacted Edie Moore for names of adolescent specialists to interview for an article about the health care of teenage girls. When the writer called me, I was at first somewhat hesitant, since New York Magazine had done a few sensationalist articles about teens that were quite unfair. This writer, however, sounded well informed and the fine article she ultimately wrote about adolescent health care in our region quoted several SAM members. At my office, we received many inquiries and new patients as a result of this article, and what struck me was how surprised, excited and pleased the parents who called us were to learn about this “great new field of adolescent medicine and health.” In fact, several parents were health professionals themselves, yet not aware of our specialty. After 10 years solo, I am delighted to share the experience for the past few years with my colleagues, Drs. Karen Rosewater and Lauren Budow. A final personal story. Several years ago I was invited to a reunion of 40 once-close high school friends. Most of us had not seen each other in over 30 years. As I started to get ready for this event, I felt my stomach tighten, face flush and hands shake. I couldn’t decide what to wear. . .should it be a flowing 60s dress, a business suit, or casual slacks with a silk blouse? As my anxiety mounted, and puzzled by my reaction, I searched for an explanation for why I felt so tense. . .when a startling realization hit me. . . .I was 16 again, anticipating a night out with this “popular” group of high school friends. It was a valuable insight, one I am grateful for, as I am grateful to care each day for young people who feel the same way.
SAM Stories Now I would like to share with you a few stories about SAM. I hope, especially for the younger and newer members of SAM, these stories will place our organization’s work within an historical perspective. Most of these stories come from the 30th Anniversary of SAM Commemorative issue of The Journal of Adolescent Health [5], published in December 1998. It is filled with fascinating tales of historical figures, including Roswell Gallagher, Adele Hoffman, Bill Daniel, and many here today. Individual articles focus on milestones in SAM’s promotion of education and research, publications, regionalization, sup-
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port of international organizations, advocacy activities, and multi-disciplinary membership. Dr. Roswell Gallagher is credited with the vision of starting the first adolescent health program at Boston Children’s Hospital in 1951. He also established the first fellowship in adolescent medicine in1953. Shortly thereafter, one of his first trainees, Felix Heald, left Boston for Washington, DC and developed the Adolescent Seminars, sponsored by the Children’s Bureau, on topics ranging from nutrition to minors’ rights. The socio-cultural trends of the 1960s heightened public awareness of the medical needs of youth, and a group of health professionals recognized the need to define an intellectual and research basis for the field of adolescent medicine. The first Adolescent Medicine Newsletter, created in February 1965, edited by Dale Garell, makes reference to a new kind of education for physicians—a need to broaden our view of what creates the “disease” of adolescents. Three years later, SAM was formally established in Washington, DC on April 28, 1968, exactly 2 weeks after the assassination of Dr. Martin Luther King, 5 weeks before the killing of Robert Kennedy, and a few months before Chicago burned during the Democratic Convention. SAM’s original set of goals during this historic period were: • To improve the quality of health care for adolescents • To encourage the investigation of normal growth and development during adolescence • To study those diseases that affect adolescents • To increase communication among health professionals who care for adolescents • To foster and improve the quality of training of those individuals providing health care to adolescents SAM was established by academically based physicians to provide a forum for information, exchange and collegiality. The 263 charter members of SAM were 100% physicians and 83% male. However, a letter sent by Dale Garell to charter members stated, “Will you please send me a list of prospective members for the Society, i.e., individuals who are actively involved in Adolescent Medicine. . .such as psychologists, social workers, public health nurses, etc. We are very anxious to have their support and also to recognize their efforts in behalf of adolescents.” SAM’s first Annual Meeting was held in Chicago in 1971, in conjunction with the American Academy
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of Pediatrics. By this time there were 28 adolescent medicine fellowship programs, with curricula based on the invention of the individual program director. In 1972, SAM’s Education Committee met to establish a “core of required information for the medical student, house officer, fellow and academic trainee and to make recommendations for the continuing education of practitioners.” This initiative would soon become relevant to addressing the 1976 finding of the first Task Force on Pediatric Education, that 66% of recent graduates of pediatric training programs felt inadequately trained in adolescent medicine. In 1979 the Executive Committee of SAM clarified the Society’s mission with a focus statement: “The major focus of the Society for Adolescent Medicine is to promote the development, synthesis, and dissemination of scientific and scholarly knowledge unique to the developmental and health care needs of adolescents.” In 1980 the Journal of Adolescent Health Care was launched at a time when SAM was striving for academic identity and credibility. SAM’s first independent Annual Meeting, at a place and time separate from the American Academy of Pediatrics, was in Denver in 1985. After initial inquiries by SAM members in 1986, sub-specialty board approval through the American Board of Pediatrics came in 1991 and the first certifying examination was given in 1994. The first SAM regional chapter was started in New York in 1969; the second in Washington, DC in 1974. Others slowly followed in the Southeast, New Jersey, the Northwest and Northern California. Currently there are 17 regional chapters, including the International Chapter, of varying size, function, and interest, reflective of their members. From its inception, SAM was envisioned to be a multi-disciplinary organization. However, prior to federal funding in 1978 of six inter-disciplinary training programs in adolescent health, SAM’s membership was 94% physicians. These six and other programs expanded their faculty to include nurses, psychologists, social workers and dietitians. The percent of physician members of SAM has gradually dropped. Today, 79% of SAM’s 1352 members are physicians. In 1985, Sheridan Phillips presented a paper at the SAM annual meeting entitled, ”How Inter-disciplinary is SAM?” She found that in 1979, 41% of papers presented at the annual meeting had inter-disciplinary authorship (defined as “not all physician authors”), and by 1983, the number rose to 83%. This
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year, 85% of papers and posters are inter-disciplinary, indicating a consistent trend of collaborative research by SAM members. In 1987 the International Association of Adolescent Health (IAAH) was founded with the support of international and U.S. members of SAM. In 1995 IAAH and SAM held its first historic and memorable joint Annual Meeting and Youth Health Assembly in Vancouver. Appropriately, the story of SAM has been one of steady growth and development, from its birth in the 1960s, to its early identity phase in the 1970s, academic and regional expansion in the 1980s, heightened dialogue of multi-disciplinary issues in the 1990s, and arrival into the new millennium as a mature organization. SAM has successfully promoted excellence in research, training of health professionals, and collaboration among professionals of diverse disciplines. SAM’s five goals today [6] are much broader than in 1968. They are: • To promote communication and collaboration among professionals of all disciplines involved in adolescent health • To promote excellence in research related to adolescent health and to disseminate research results • To promote public and professional awareness of health-related needs of adolescents and of strategies to address those needs • To promote and foster access to quality adolescent health-related services • To promote availability of special adolescent health training
Raising the Health Status of Adolescents I believe we have to do a better job with goals three and four. To address these goals, SAM’s leadership and members must place a greater emphasis and higher priority on communication, advocacy and the financial resourcefulness of SAM, and its members. Our specialty is 53 years old and our organization is heading toward 40. This is no time for a mid-life crisis. Despite our age and maturity, most people out there, including parents, teens, youth workers, educators, students considering a health career, health professionals in other fields, and policymakers have never heard of adolescent medicine and health, or don’t quite understand or value what we do. Which brings me to why I am standing here today. . .how my own story and the story of SAM
July 2004
come together. I neither sought this job and honor, nor ever expected it to be offered. When I “got the call,” my initial reaction was, “No way do I have the time,” and asked for some time to think about it. “OK, you have 3 days,” I was told. So I consulted with two young people who know me well, and they said, “Mom, you have to do it!” And I said to myself, quoting John Lennon’s ironic lyric, written just before he was shot, “Life is what happens while you are busy making other plans.” So with the strong urging of my children, Gillian and Jordana, and more reserved encouragement from my husband, David, I am here today for one reason: Adolescent medicine and health is a great idea, yet a best kept secret. I challenge us all to work hard to transform this truth. Roswell Gallagher’s brainstorm has changed the lives and improved the health of numerous teens, whom we and our colleagues over the past half-century have had the good fortune to know and care for. Those of us who care for preteens, adolescents and young adults are forever charmed by their wisdom, resilience, openness, neediness, sadness, anger, and complexity. Every day, I ask myself, “What would have happened to this young person if he or she hadn’t made it to my office. . .or to your office?” It’s not that we are smarter than others, it’s just that we like them, and have the training and experience and desire to hear them and to understand their world. The Maternal and Child Health Policy Research Center, with input from many SAM members, recently published an excellent report entitled, “Is the Health Care System Working for Adolescents?” [7] The report cited various reasons why the answer to their question was a resounding “No.” But the two most important reasons it is not working well, they concluded, is too few teen-friendly sites of care, and shortages of providers to care for adolescents. I am not about to suggest that SAM alone or any one of us can fix such large problems, but we can and must play a role. Two ad hoc SAM committees recently addressed these concerns from different perspectives, but reached many of the same conclusions. The outstanding reports of Richard Kreipe’s Adolescent Health Work Force [8] and Carol Ford’s Young Professionals in Adolescent Health [9] committees both emphasized that all members of SAM need to take responsibility locally to be positive and nurturing role models, to create and sustain interest in adolescent medicine and health. In short, we all need to promote our field. I propose that each of us, in our own community and institution, devote some energy each day to
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telling someone about our work. With intellect and enthusiasm, we can make adolescent medicine and health come alive for a parent, a teen, a medical student, a graduate student, a colleague, a policymaker, a philanthropist, and best of all perhaps, a reporter for a newspaper, magazine or TV station. We can give talks, write articles and letters to the editor, or letters to senators, develop brochures, handouts and websites, write books, have lunch, dinner or coffee with someone influential or someone we hope to influence. We need to strive simultaneously to increase the demand for our expertise and to increase the supply of health professionals to meet it. And each time we speak out we should identify ourselves as an adolescent medicine or adolescent health specialist, so that our field becomes known. The fact that many of us are board-certified medical sub-specialists doesn’t necessarily carry the appropriate prestige or financial reward. In December, a series of e-mails on the SAM listserv addressed the question of salary. Limited data suggested that adolescent medicine base salaries may be lower than in general pediatrics and family medicine at the same rank. If this is, in fact, the case, why? I believe that advocating for adolescents and adolescent health professionals in all disciplines are inseparable obligations. In addition, we should consider avenues short of 3-year fellowships for the training of health professionals in a diversity of disciplines; to meet the aspirations of those wishing to become experts in adolescent medicine or health and others who are simply “adolescent-friendly.” Our salaries may seem low, but our experiences are enriching. We embrace the intricacies, ambiguities, and exasperations of our work, whether we are nurses, doctors, or psychologists, . . .practitioners, researchers, or administrators, . . .working in academia or a rural community. In fact, the nature of all of our work, regardless of our primary discipline, is innately and inherently inter-disciplinary, which is why we find it so fascinating, stimulating, and appealing. The strength of SAM comes from the variety and diversity of our perspectives and expertise; debate among us is healthy and enriching; but our power comes from the beliefs which unite us. Because we are a mature family now, we must contain our sibling rivalries and celebrate each of our unique contributions toward a common cause. Finally, I would like to comment on the joy of giving. You may have noticed that two SAM committees have become inactive; the Finance Committee and the Development Committee. To oversee
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SAM’s investments we have employed an investment counselor. To address development, your Board has also begun to seek professional input. Over the years, I have often heard members say, “SAM should do this, and SAM should do that.” I agree with you. As the SAM stories illustrate, we can feel enormously proud of SAM’s accomplishments; yet there are many roads to travel. Because SAM’s financial resources are modest, we must consider ideas and our own generosity to enhance SAM’s ability to develop initiatives on behalf of young people. Because SAM is relatively small and very friendly, I ask you to stand up, step forward, give me, or a Board member, or a committee or SIG chair, a call or send an e-mail; volunteer to do “this or that” when the passion strikes you. Your generosity and efforts on behalf of SAM’s work are sought and appreciated. Thank you for listening, and for this great honor. Our knowledge and vision are necessary but not sufficient to bring about change. We need to set clear objectives, develop strategies, and possess the political will. Together we can raise the health status of adolescents.
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References 1. Marks A, Malizio J, Hoch J, et al. Assessment of health needs and willingness to utilize health care resources of adolescents in a suburban population. J Pediatr 1983;102:456 –60. 2. Youth Risk Behavior Surveillance System, National Center for Chronic Disease Prevention and Health Promotion, CDC. www.cdc.gov/nccdphp/dash/yrbs. 3. The National Longitudinal Study of Adolescent Health (Add Health); Available at: http://www.cpc.unc.edu/addhealth. Accessed April 3, 2004. 4. Brenna S. The Silent Treatment. New York Magazine February 8, 1999;32:38 – 42. 5. Brown RC, Cromer BA, Brookman RR, Moore E. The Society for Adolescent Medicine: The first thirty years. Introduction. J Adolesc Health 1998;23:133–74. 6. The Society for Adolescent Medicine. Available at: http:// www.adolescenthealth.org. Accessed April 3, 2004. 7. McManus MA, Shejavali KI, Fox HB. Is the health care system working for adolescents? Maternal & Child Health Policy Research Center, 2003. Available at: http://www.mchpolicy. org. Accessed April 3, 2004. 8. Kreipe RE. Adolescent Health Work Force Ad hoc Committee Report. The Society for Adolescent Medicine, 2002. Available at: http://www.adolescenthealth.org. Accessed April 3, 2004. 9. Ford CA. Young Professionals in Adolescent Health Ad hoc Committee Report. The Society for Adolescent Medicine, 2003. Available at: http://www.adolescenthealth.org. Accessed April 3, 2004.
PRESIDENTIAL ADDRESS
Raising the Health Status of Adolescents ANDREA M. MARKS, M.D., F.S.A.M.
Standing before you today, I feel energized, privileged and humbled, not because I am about to become President of a huge and powerful organization, but because I am about to become President of the only national organization committed solely to improving the health and raising the health status of adolescents. Our organization and its members, from over 30 countries, not only have the potential to make a difference, but I believe we have the responsibility. I am referring to each of us in this room, and others who couldn’t make it here today, who have dedicated our careers in some way to adolescent health. There are 40 million adolescents in the United States, and many millions more around the globe, and very few of us; so our words must be clear, our voices loud, our efforts focused to let people know about the health care needs of young people, that there is such a thing as adolescent medicine and health, what it is we do, each of us in a different way and in a different place, to meet the array of complex and intriguing needs of pre-teens, adolescents and young adults, in this country and around the world. Starting this fall, SAM is introducing a double slate format for election of President and members of the Board of Directors. You will learn about the candidates and their visions in advance. Since I have been fortunate to escape such scrutiny, I feel it is my obligation, before anything else, to share with SAM members something about the person about to become your President and how it came to be that she is standing here today. So I am going to tell you a few stories about myself, a few stories about SAM, and then try to explain why SAM and I have come together on this auspicious occasion.
From the Department of Pediatrics, Mt. Sinai Medical Center and Mt. Sinai School of Medicine, New York, New York. Address correspondence to: Andrea Marks, M.D., Adolescent-Young Adult Medicine, 14 East 90th Street, New York, NY 10128.
Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
Personal Stories Elizabeth and Louis Gurlitz were my maternal grandparents. They arrived separately in New York City, as teenagers from Eastern Europe, around the turn of the 20th century. During my entire childhood and adolescence they lived upstairs from us in a small two-family house on a quiet dead-end street in Brooklyn. My grandparents owned a children’s summer camp in Connecticut, called Camp Crestwood, and except for a few months each summer, the business was run from their apartment, mostly on the kitchen table. I loved camp, even though, especially as a teenager, it was difficult to deal with being the owners’ granddaughter. One of my favorite memories of camp occurred during the winter months; even as a young child, I loved to climb upstairs and settle into a comfortable chair in my grandparents’ living room and quietly observe and listen while my grandmother interviewed prospective camp counselors, young people in their late teens and early 20s. My favorite part, after the applicant left, was to give my grandmother my thoughtful assessment of the individual. I was convinced she took my advice very seriously. One time, however, my grandmother hired a counselor I recommended against, and sure enough, he ended up fired for getting drunk at camp, an unforgivable offense. I felt vindicated. Little did I know then, I would make a career of listening to and evaluating adolescents and young adults. As a teenager, my favorite TV shows were Dr. Kildare, Ben Casey and The Fugitive. All three shows were about doctors. Occasionally a woman doctor was featured, more often as a romantic interest than a high-powered professional. Even so, or perhaps for that very reason, the media was a powerful motivator. With no doctors in my family, and the women’s movement then embodied more in my grandmother 1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2004.04.004
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than in our culture, I left for college fantasizing about becoming a doctor. Two friends I met freshman year at Bryn Mawr, who knew for certain they intended to go to medical school, convinced me that my fantasy could become reality. I was also inspired by ballet. Purely as a spectator, I was struck by the hard work, focus and commitment required to achieve the skill and splendor of an accomplished dancer. Medicine, I decided, would be my dance, an opportunity to dedicate myself to becoming highly accomplished. During one interview for medical school I mentioned that ballet had inspired me to become a doctor; the interviewer looked at me askance in puzzlement. No surprise, I got rejected from that medical school. But no problem, as I had already been accepted to Penn, where I really wanted to go, and soon joined eight terrific women and 130 very nice men in the class of ’72. Adolescent medicine had not yet arrived at The University of Pennsylvania, and even as a resident at Boston Children’s Hospital, I had no exposure to the adolescent center, founded 20 years earlier by Dr. Roswell Gallagher. Most of my patients were very sick babies and young children, but for me, the most moving and memorable were the teenagers. A 16year-old girl with cystic fibrosis asked me to pierce her ears; a 14-year-old with advanced Hodgkin’s disease refused to get out from under her covers each morning on rounds until we sang her a wake-up song; another girl on the oncology unit was profoundly withdrawn, until we convinced her parents to tell her the truth about her diagnosis and, in fact, excellent prognosis. I cared for a teenage boy with Crohn’s disease and received a rare thank you note from his private pediatrician, Dr. T. Berry Brazelton. And perhaps the most memorable of all, a boy with anorexia nervosa, a disease I knew little about then, who agreed to eat if I let him take my picture. So one day, when I met Dr. Robert Masland, Dr. Gallagher’s successor, in a hospital elevator, and he invited me to become an adolescent medicine fellow, I did not have to think too long or too hard before saying, “Yes.” Fellowships back then lasted only 1 year, and since I had a boyfriend in New York City, and heard about this great adolescent medicine program in the Bronx, I arranged a 1-month elective with Dr. Michael Cohen and his colleagues at Montefiore Hospital. The boyfriend and I broke up, but I moved to New York anyway, when Michael offered me my first attending position. Michael became my “mentor extraordinaire” in academic medicine, and invited me to attend my first SAM meeting in 1976.
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Three years later, I left Montefiore to start a new division of adolescent medicine at North Shore University Hospital, in a suburb of New York City. Curiously, the hospital had just been asked by a nearby community to establish an adolescent health center in their town, even though ample numbers of pediatricians and other health providers practiced there. Before establishing the health center, we decided to survey the adolescents, by anonymous questionnaire administered at school, to assess their health needs and willingness to utilize existing health resources. We found that these middle class suburban adolescents, with ready access to private primary health care, participated substantially in health risk behaviors and had significant unmet health care needs related, most especially, to their body image, sexuality, substance use and mental health. Yet they were reluctant to seek care for these needs from their primary physicians. The study was published in The Journal of Pediatrics in 1983 [1] with an unusual left-handed comment by the editor-in-chief, which said the paper had been the subject of considerable discussion among the editorial staff, who felt the results were important and worthy, even though the methodology of a written questionnaire administered to adolescents was problematic. This editor was uncertain if he trusted the responses of teenagers. Our little study pre-dated the Youth Risk Behavior Surveillance (YRBS) [2], AddHealth [3], and similar studies, which have come to rely on the responses of adolescents. In 1990, after 16 years in academic medicine, I left the hospital setting and full-time academia to open a private practice in New York City for patients ages 9 through 30. My research, with Martin Fisher and others, had revealed significant obstacles faced by teens seeking suitable health care, including in private practice settings. My new challenge was to design a practice both appealing to teenagers and sought by their parents. I knew it would be necessary to strike a trusting partnership with the entire family. Another aim for the practice was to care for young adults throughout their 20s. The third decade of life is one of the most intriguing and difficult in our culture; yet health care services are neither designed for, often not covered, nor consistently sought by young adults. Daunted by the realization it’s not enough to just hang out a shingle, I was inspired to actively promote my practice by a quote on a highway billboard, attributed to Dr. Martin Luther King, which read, “It’s not enough to have a good idea, you have to tell somebody.”
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There are many practice stories to tell, but I will limit myself to one that originated in the SAM office in 1999. A reporter for New York Magazine [4] contacted Edie Moore for names of adolescent specialists to interview for an article about the health care of teenage girls. When the writer called me, I was at first somewhat hesitant, since New York Magazine had done a few sensationalist articles about teens that were quite unfair. This writer, however, sounded well informed and the fine article she ultimately wrote about adolescent health care in our region quoted several SAM members. At my office, we received many inquiries and new patients as a result of this article, and what struck me was how surprised, excited and pleased the parents who called us were to learn about this “great new field of adolescent medicine and health.” In fact, several parents were health professionals themselves, yet not aware of our specialty. After 10 years solo, I am delighted to share the experience for the past few years with my colleagues, Drs. Karen Rosewater and Lauren Budow. A final personal story. Several years ago I was invited to a reunion of 40 once-close high school friends. Most of us had not seen each other in over 30 years. As I started to get ready for this event, I felt my stomach tighten, face flush and hands shake. I couldn’t decide what to wear. . .should it be a flowing 60s dress, a business suit, or casual slacks with a silk blouse? As my anxiety mounted, and puzzled by my reaction, I searched for an explanation for why I felt so tense. . .when a startling realization hit me. . . .I was 16 again, anticipating a night out with this “popular” group of high school friends. It was a valuable insight, one I am grateful for, as I am grateful to care each day for young people who feel the same way.
SAM Stories Now I would like to share with you a few stories about SAM. I hope, especially for the younger and newer members of SAM, these stories will place our organization’s work within an historical perspective. Most of these stories come from the 30th Anniversary of SAM Commemorative issue of The Journal of Adolescent Health [5], published in December 1998. It is filled with fascinating tales of historical figures, including Roswell Gallagher, Adele Hoffman, Bill Daniel, and many here today. Individual articles focus on milestones in SAM’s promotion of education and research, publications, regionalization, sup-
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port of international organizations, advocacy activities, and multi-disciplinary membership. Dr. Roswell Gallagher is credited with the vision of starting the first adolescent health program at Boston Children’s Hospital in 1951. He also established the first fellowship in adolescent medicine in1953. Shortly thereafter, one of his first trainees, Felix Heald, left Boston for Washington, DC and developed the Adolescent Seminars, sponsored by the Children’s Bureau, on topics ranging from nutrition to minors’ rights. The socio-cultural trends of the 1960s heightened public awareness of the medical needs of youth, and a group of health professionals recognized the need to define an intellectual and research basis for the field of adolescent medicine. The first Adolescent Medicine Newsletter, created in February 1965, edited by Dale Garell, makes reference to a new kind of education for physicians—a need to broaden our view of what creates the “disease” of adolescents. Three years later, SAM was formally established in Washington, DC on April 28, 1968, exactly 2 weeks after the assassination of Dr. Martin Luther King, 5 weeks before the killing of Robert Kennedy, and a few months before Chicago burned during the Democratic Convention. SAM’s original set of goals during this historic period were: • To improve the quality of health care for adolescents • To encourage the investigation of normal growth and development during adolescence • To study those diseases that affect adolescents • To increase communication among health professionals who care for adolescents • To foster and improve the quality of training of those individuals providing health care to adolescents SAM was established by academically based physicians to provide a forum for information, exchange and collegiality. The 263 charter members of SAM were 100% physicians and 83% male. However, a letter sent by Dale Garell to charter members stated, “Will you please send me a list of prospective members for the Society, i.e., individuals who are actively involved in Adolescent Medicine. . .such as psychologists, social workers, public health nurses, etc. We are very anxious to have their support and also to recognize their efforts in behalf of adolescents.” SAM’s first Annual Meeting was held in Chicago in 1971, in conjunction with the American Academy
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of Pediatrics. By this time there were 28 adolescent medicine fellowship programs, with curricula based on the invention of the individual program director. In 1972, SAM’s Education Committee met to establish a “core of required information for the medical student, house officer, fellow and academic trainee and to make recommendations for the continuing education of practitioners.” This initiative would soon become relevant to addressing the 1976 finding of the first Task Force on Pediatric Education, that 66% of recent graduates of pediatric training programs felt inadequately trained in adolescent medicine. In 1979 the Executive Committee of SAM clarified the Society’s mission with a focus statement: “The major focus of the Society for Adolescent Medicine is to promote the development, synthesis, and dissemination of scientific and scholarly knowledge unique to the developmental and health care needs of adolescents.” In 1980 the Journal of Adolescent Health Care was launched at a time when SAM was striving for academic identity and credibility. SAM’s first independent Annual Meeting, at a place and time separate from the American Academy of Pediatrics, was in Denver in 1985. After initial inquiries by SAM members in 1986, sub-specialty board approval through the American Board of Pediatrics came in 1991 and the first certifying examination was given in 1994. The first SAM regional chapter was started in New York in 1969; the second in Washington, DC in 1974. Others slowly followed in the Southeast, New Jersey, the Northwest and Northern California. Currently there are 17 regional chapters, including the International Chapter, of varying size, function, and interest, reflective of their members. From its inception, SAM was envisioned to be a multi-disciplinary organization. However, prior to federal funding in 1978 of six inter-disciplinary training programs in adolescent health, SAM’s membership was 94% physicians. These six and other programs expanded their faculty to include nurses, psychologists, social workers and dietitians. The percent of physician members of SAM has gradually dropped. Today, 79% of SAM’s 1352 members are physicians. In 1985, Sheridan Phillips presented a paper at the SAM annual meeting entitled, ”How Inter-disciplinary is SAM?” She found that in 1979, 41% of papers presented at the annual meeting had inter-disciplinary authorship (defined as “not all physician authors”), and by 1983, the number rose to 83%. This
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year, 85% of papers and posters are inter-disciplinary, indicating a consistent trend of collaborative research by SAM members. In 1987 the International Association of Adolescent Health (IAAH) was founded with the support of international and U.S. members of SAM. In 1995 IAAH and SAM held its first historic and memorable joint Annual Meeting and Youth Health Assembly in Vancouver. Appropriately, the story of SAM has been one of steady growth and development, from its birth in the 1960s, to its early identity phase in the 1970s, academic and regional expansion in the 1980s, heightened dialogue of multi-disciplinary issues in the 1990s, and arrival into the new millennium as a mature organization. SAM has successfully promoted excellence in research, training of health professionals, and collaboration among professionals of diverse disciplines. SAM’s five goals today [6] are much broader than in 1968. They are: • To promote communication and collaboration among professionals of all disciplines involved in adolescent health • To promote excellence in research related to adolescent health and to disseminate research results • To promote public and professional awareness of health-related needs of adolescents and of strategies to address those needs • To promote and foster access to quality adolescent health-related services • To promote availability of special adolescent health training
Raising the Health Status of Adolescents I believe we have to do a better job with goals three and four. To address these goals, SAM’s leadership and members must place a greater emphasis and higher priority on communication, advocacy and the financial resourcefulness of SAM, and its members. Our specialty is 53 years old and our organization is heading toward 40. This is no time for a mid-life crisis. Despite our age and maturity, most people out there, including parents, teens, youth workers, educators, students considering a health career, health professionals in other fields, and policymakers have never heard of adolescent medicine and health, or don’t quite understand or value what we do. Which brings me to why I am standing here today. . .how my own story and the story of SAM
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come together. I neither sought this job and honor, nor ever expected it to be offered. When I “got the call,” my initial reaction was, “No way do I have the time,” and asked for some time to think about it. “OK, you have 3 days,” I was told. So I consulted with two young people who know me well, and they said, “Mom, you have to do it!” And I said to myself, quoting John Lennon’s ironic lyric, written just before he was shot, “Life is what happens while you are busy making other plans.” So with the strong urging of my children, Gillian and Jordana, and more reserved encouragement from my husband, David, I am here today for one reason: Adolescent medicine and health is a great idea, yet a best kept secret. I challenge us all to work hard to transform this truth. Roswell Gallagher’s brainstorm has changed the lives and improved the health of numerous teens, whom we and our colleagues over the past half-century have had the good fortune to know and care for. Those of us who care for preteens, adolescents and young adults are forever charmed by their wisdom, resilience, openness, neediness, sadness, anger, and complexity. Every day, I ask myself, “What would have happened to this young person if he or she hadn’t made it to my office. . .or to your office?” It’s not that we are smarter than others, it’s just that we like them, and have the training and experience and desire to hear them and to understand their world. The Maternal and Child Health Policy Research Center, with input from many SAM members, recently published an excellent report entitled, “Is the Health Care System Working for Adolescents?” [7] The report cited various reasons why the answer to their question was a resounding “No.” But the two most important reasons it is not working well, they concluded, is too few teen-friendly sites of care, and shortages of providers to care for adolescents. I am not about to suggest that SAM alone or any one of us can fix such large problems, but we can and must play a role. Two ad hoc SAM committees recently addressed these concerns from different perspectives, but reached many of the same conclusions. The outstanding reports of Richard Kreipe’s Adolescent Health Work Force [8] and Carol Ford’s Young Professionals in Adolescent Health [9] committees both emphasized that all members of SAM need to take responsibility locally to be positive and nurturing role models, to create and sustain interest in adolescent medicine and health. In short, we all need to promote our field. I propose that each of us, in our own community and institution, devote some energy each day to
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telling someone about our work. With intellect and enthusiasm, we can make adolescent medicine and health come alive for a parent, a teen, a medical student, a graduate student, a colleague, a policymaker, a philanthropist, and best of all perhaps, a reporter for a newspaper, magazine or TV station. We can give talks, write articles and letters to the editor, or letters to senators, develop brochures, handouts and websites, write books, have lunch, dinner or coffee with someone influential or someone we hope to influence. We need to strive simultaneously to increase the demand for our expertise and to increase the supply of health professionals to meet it. And each time we speak out we should identify ourselves as an adolescent medicine or adolescent health specialist, so that our field becomes known. The fact that many of us are board-certified medical sub-specialists doesn’t necessarily carry the appropriate prestige or financial reward. In December, a series of e-mails on the SAM listserv addressed the question of salary. Limited data suggested that adolescent medicine base salaries may be lower than in general pediatrics and family medicine at the same rank. If this is, in fact, the case, why? I believe that advocating for adolescents and adolescent health professionals in all disciplines are inseparable obligations. In addition, we should consider avenues short of 3-year fellowships for the training of health professionals in a diversity of disciplines; to meet the aspirations of those wishing to become experts in adolescent medicine or health and others who are simply “adolescent-friendly.” Our salaries may seem low, but our experiences are enriching. We embrace the intricacies, ambiguities, and exasperations of our work, whether we are nurses, doctors, or psychologists, . . .practitioners, researchers, or administrators, . . .working in academia or a rural community. In fact, the nature of all of our work, regardless of our primary discipline, is innately and inherently inter-disciplinary, which is why we find it so fascinating, stimulating, and appealing. The strength of SAM comes from the variety and diversity of our perspectives and expertise; debate among us is healthy and enriching; but our power comes from the beliefs which unite us. Because we are a mature family now, we must contain our sibling rivalries and celebrate each of our unique contributions toward a common cause. Finally, I would like to comment on the joy of giving. You may have noticed that two SAM committees have become inactive; the Finance Committee and the Development Committee. To oversee
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SAM’s investments we have employed an investment counselor. To address development, your Board has also begun to seek professional input. Over the years, I have often heard members say, “SAM should do this, and SAM should do that.” I agree with you. As the SAM stories illustrate, we can feel enormously proud of SAM’s accomplishments; yet there are many roads to travel. Because SAM’s financial resources are modest, we must consider ideas and our own generosity to enhance SAM’s ability to develop initiatives on behalf of young people. Because SAM is relatively small and very friendly, I ask you to stand up, step forward, give me, or a Board member, or a committee or SIG chair, a call or send an e-mail; volunteer to do “this or that” when the passion strikes you. Your generosity and efforts on behalf of SAM’s work are sought and appreciated. Thank you for listening, and for this great honor. Our knowledge and vision are necessary but not sufficient to bring about change. We need to set clear objectives, develop strategies, and possess the political will. Together we can raise the health status of adolescents.
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References 1. Marks A, Malizio J, Hoch J, et al. Assessment of health needs and willingness to utilize health care resources of adolescents in a suburban population. J Pediatr 1983;102:456 –60. 2. Youth Risk Behavior Surveillance System, National Center for Chronic Disease Prevention and Health Promotion, CDC. www.cdc.gov/nccdphp/dash/yrbs. 3. The National Longitudinal Study of Adolescent Health (Add Health); Available at: http://www.cpc.unc.edu/addhealth. Accessed April 3, 2004. 4. Brenna S. The Silent Treatment. New York Magazine February 8, 1999;32:38 – 42. 5. Brown RC, Cromer BA, Brookman RR, Moore E. The Society for Adolescent Medicine: The first thirty years. Introduction. J Adolesc Health 1998;23:133–74. 6. The Society for Adolescent Medicine. Available at: http:// www.adolescenthealth.org. Accessed April 3, 2004. 7. McManus MA, Shejavali KI, Fox HB. Is the health care system working for adolescents? Maternal & Child Health Policy Research Center, 2003. Available at: http://www.mchpolicy. org. Accessed April 3, 2004. 8. Kreipe RE. Adolescent Health Work Force Ad hoc Committee Report. The Society for Adolescent Medicine, 2002. Available at: http://www.adolescenthealth.org. Accessed April 3, 2004. 9. Ford CA. Young Professionals in Adolescent Health Ad hoc Committee Report. The Society for Adolescent Medicine, 2003. Available at: http://www.adolescenthealth.org. Accessed April 3, 2004.