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Update on adolescent health care in pediatric practice
JOURNAL OF ADOLESCENT H E A L T H 1996;19:394-400
ORIGINAL ARTICLE
Update on Adolescent Health Care in Pediatric Practice MARTIN FISHER, M.D., NEVILLE H. GOLDEN, M.D., RACHEL BERGESON, M.D., ALAN BERNSTEIN, M.D., DEBORAH SAUNDERS, M.D., MARCIE SCHNEIDER, M.D., MICHELE SEITZ, M.D., AND WARREN SEIGEL, M.D.
Purpose: To determine current adolescent health care practices of pediatricians and evaluate whether changes have taken place during the past decade. Methods: A questionnaire completed by 101 pediatricians in 1985 was abbreviated and adapted by the Committee on Youth of Chapter 2, District II of the American Academy of Pediatrics and sent to 1,633 members of the Chapter in June 1993. Results: Forty-three percent of the 436 respondents in 1993 were female, 43% _< 40 years of age and 53% were in private practice. Most accept new patients _> 16 years of age (76%), continue to see patients ~ 19 years of age (63%), and interview adolescents without their parents (86%). Although between one-third and two-thirds of respondents report having equipment for gynecologic examinations, most indicate they are "not entirely comfortable" treating adolescent issues and therefore refer to others for management. Between one-quarter and onehalf indicate they are "very interested" in learning more about adolescent issues and an additional 40-50% are "somewhat interested." Obstacles to providing adolescent care include: "image as a baby doctor" (65%), fear that parents would object (61°), no separate hours (57°), difficulty in providing confidential care (56%), and difficulty in charging appropriate fees (47%). Females and younger pediatricians are more comfortable with some
From the North Shore University Hospital-Cornell University Medical College, Manhasset, New York; Schneider Children's Hospital, Albert Einstein College of Medicine, New Hyde Park, New York; State University of New York at Stony Brook, Stony Brook, New York; NYLCare, Jackson Heights, New York; Nassau County Medical Center, East Meadow, New York; and Coney Island Hospital, Brooklyn, New
York, USA. Address reprint requests to: Martin Fisher, M.D., Division of Adolescent Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. Manuscript accepted May 6, 1996. 1054-139X/96/$15.00 PII S1054-139X(96)00161-5
aspects of gynecologic care and more likely to be satisfied with the adolescent care they are providing. There were few differences between responses in 1993 and 1985. Conclusions: Few of the pediatricians surveyed provide comprehensive care to adolescent patients. Future policy decisions and medical education must respond to these realities in pediatric practice. © Society for Adolescent Medicine, 1996.
KEY
WORDS:
Adolescence Pediatricians Health care
In 1978, the Task Force on Pediatric Education reported that training in adolescent medicine was insufficient to provide the knowledge base and clinical skills necessary for most pediatricians to appropriately manage the health needs of their adolescent patients (1). Since that time, efforts have been underway to provide training in adolescent medicine for both residents and practicing pediatricians, and several studies have evaluated the comfort and selfperceived competence of pediatricians in providing adolescent care (2-7). Each of these studies has found major deficiencies in the ability of pediatricians to provide comprehensive adolescent health care. As managed care begins to impact on the practice of pediatrics, it is time to evaluate whether improvements have been made in approaches to adolescent health care and to consider what further steps need be taken to ensure that pediatricians meet the health
© Society for Adolescent Medicine, 1996 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
December 1996
care needs of adolescents. In this report, we present the results of a 1993 survey of pediatricians, compare them with findings of a similar study in 1985, and discuss implications of the results of these studies for adolescent care in pediatric practice.
Methods An anonymous, six-page questionnaire was mailed by the American Academy of Pediatrics (AAP, Elk Grove Village, IL) in June 1993 to the 1,633 members of Chapter 2, District II. The Chapter includes four counties, two of which are boroughs of New York City (Brooklyn and Queens) and two of which are in suburban Long Island (Nassau and Suffolk). Respondents were asked to return the questionnaire in an enclosed, self-addressed, stamped envelope. Completed questionnaires were received from 436 pediatricians. As determined from the list of Chapter members, the 27% who responded did not differ by age or sex from those who did not respond. The questionnaire was abbreviated and adapted by the Committee on Youth of Chapter 2, District II from that developed by Marks et al. in 1985 (6). The 1993 questionnaire included forced-choice questions on personal demographic data and practice characteristics, office and clinical practices pertinent to adolescents, involvement and interest in adolescent issues, perceived obstacles to respondents' provision of care to adolescents, and interest in further training in adolescent medicine. The questionnaire required approximately 10 minutes to complete. We did not ask in the 1993 survey whether participants had also completed the 1985 survey. Data from the 1993 questionnaire were computer tabulated (Data Ease, Version 4.2) and analyzed for all 436 pediatricians, as well as for subsets of respondents by age, sex, practice characteristics, and county. Results were compared to the 1985 data collected from 101 pediatricians in Nassau and Suffolk counties who practiced general pediatrics at least 50% of the time, 87% of whom were board certified in pediatrics (6). Standard contingency table analyses were performed and statistical significance of differences assessed by Chi-square analyses between subsets of 1993 and 1985 data.
Results Personal and Practice Characteristics
Personal and practice characteristics of respondents to the 1993 and 1985 surveys are presented in Table
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1. Differences by practice (general vs. subspecialty), location (New York City vs. Long Island), and year (1993 vs. 1985) can be deduced from this table. Forty-three percent of respondents to the 1993 questionnaire were _< 40 years of age and female. Fifty-eight percent were from Nassau and Suffolk Counties (Long Island), and 42% were from Brooklyn and Queens (New York City). Fifty-three percent of respondents were in private practice, and 47% in a prepaid group, clinic, or hospital-based practice. Males were more likely (p < .05) than females to be in private practice; older and younger pediatricians were equally likely to be in private practice. Demographic data did not differ significantly for the 1993 respondents by practice (general vs. subspecialty) or location (New York City vs. Long Island), although respondents to the 1985 questionnaire were more often older, male, and in private practice. Over three-quarters of respondents to the 1993 survey accept new patients -> 16 years of age, over one-half retain patients beyond 19 years of age, and 40% indicate that at least 10% of patients in their practice are -> 16 years of age. Pediatricians whose practices were -> 50% general pediatrics reported having more adolescent patients, those on Long Island continued to see more patients beyond 19 years of age, while those in 1985 accepted fewer new patients >- 16 years of age but retained more of their patients > 19 years of age. Respondents to the 1993 questionnaire indicated they were seeing similar numbers of adolescents (ages 11-21 years) as they were seeing 5 years earlier, but were seeing larger numbers of young adults (-> 21 years of age) now compared to 5 years ago. Eighty-six percent of respondents in 1993 report that they interview adolescents alone, compared to 83% in 1985, while 39% of 1993 respondents said they prefer younger patients, significantly greater (p < .01) than the 25% in 1985 who said they prefer younger patients. Between one-third and two-thirds of 1993 respondents report having the various pieces of equipment necessary for gynecologic examinations. Pediatricians in New York City (Brooklyn and Queens) are more likely than those in Long Island (Nassau and Suffolk Counties) to report having a pelvic examination table, vaginal speculae, Papanicolaou (Pap) smear materials, and testing for gonorrhea/chlamydia; Long Island pediatricians in 1993 were more likely than those in 1985 to have a pelvic examination table (p ~ .01) but not the materials necessary for a gynecologic examination. Many pediatricians report having pamphlets and magazines for adolescents while few have either adolescent hours or a separate
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JOURNAL OF ADOLESCENT HEALTH Vol. 19, No. 6
T a b l e 1. Personal, Practice, and Office Characteristics of Pediatricians R e s p o n d i n g to 1993 and 1985 S u r v e y s Year Respondents
1993 All pediatricians
Location
New York City & Long Island N = 436 %
Number Demographics Age -< 40 years Sex: female Nassau/Suffolk counties Private practice Adolescent patients New patients ~ 16 y.o. Old patients ~ 19 y.o. -> 10% of practice 16 y.o. Interviews adolescents alone Prefers younger patients Office equipment Pelvic exam table Vaginal speculums Pap smear materials Gonorrhea / chlamydia testing Pregnancy tests Health pamphlets for teens Adolescent magazines Adolescent hours Adolescent waiting area
1993 -> 50% general pediatrics New York City & Long Island N = 334 %
1993 -> 50% general pediatrics Long Island
1985 -> 50% general Long Island
N = 180 %
N = 101 %
43 43 58 53
40 39 57 62
44 37 100 77
24* 19" 100 88*
76 63
74 61
71 72
68 78*
40 86 39
48 86 41
52 83 38
47 83 25*
59 45 33 49
57 43 30 46
51 34 24 37
41" 32 21 40
52 64 54 19 12
51 66 56 17 11
49 69 63 16 9
-62 60 9 5
* p < .01 (1985 vs. 1993, general pediatrics -> 50% on Long Island).
waiting room. These reports did not differ by practice, l o c a t i o n , o r y e a r .
I n v o l v e m e n t and Interest in A d o l e s c e n t Issues R e s p o n d e n t s to t h e 1993 s u r v e y w e r e a s k e d to i n d i cate their comfort level ("comfortable", "not entirely comfortable", "not comfortable") in managing 10
adolescent-oriented conditions and their interest in learning more ("very interested", "somewhat intere s t e d " , " n o t i n t e r e s t e d " ) a b o u t t h o s e c o n d i t i o n s (Tab l e 2). A m o n g t h o s e i s s u e s w i t h w h i c h r e s p o n d e n t s were not comfortable, the largest numbers indicated they immediately refer patients for management of p r e g n a n c y (45%), c o n t r a c e p t i o n (35%), a n o r e x i a n e r v o s a (34%), o r s u b s t a n c e u s e (29%). B e t w e e n o n e -
T a b l e 2. I n v o l v e m e n t and Interest in A d o l e s c e n t Issues (N = 436 R e s p o n d e n t s to 1993 Survey)
Menstrual dysfunction Sexually transmitted disease Pregnancy Contraception Depression, truancy, psychosocial problems Obesity Alcohol / substance use Anorexia nervosa Disturbances in pubertal development Scoliosis
Not Comfortable (Immediately Refer) %
Not Entirely Comfortable %
Comfortable (Manage on Own) %
Very Interested %
Somewhat Interested %
Not Interested %
14 21 45 35 24
56 34 45 37 61
30 45 10 28 15
48 45 27 38 36
41 45 46 45 52
11 10 27 17 12
6 29 34 16 12
47 58 55 63 70
49 13 11 21 18
48 37 37 50 39
42 48 46 42 47
10 15 17 8 14
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third and two-thirds of all respondents reported that they were "not entirely comfortable" treating each of the 10 issues. Fewer than 20% of respondents said they were comfortable managing issues related to anorexia nervosa, substance use, psychosocial problems, scoliosis, and the initial management and decision making involved in adolescent pregnancy. From 20-50% said they were comfortable managing pubertal and menstrual disturbances, contraception, sexually transmitted disease, and obesity. In total, over 70% of respondents indicated they were "not at all" or "not entirely" comfortable managing any of the 10 issues, with the exceptions of obesity and sexually transmitted disease. These responses are similar to those of the 1985 survey in which many respondents indicated they were comfortable managing obesity (63%), but few were comfortable managing anorexia nervosa (22%), primary amenorrhea (20%), school truancy (15%), possible pregnancy (11%), birth control (10%), or alcohol use (6%) (6). As might be expected, those in the 1993 study who had a pelvic examination table, speculae, PAP smear materials, and chlamydia/gonococcus testing materials were more likely (p < .01) to report being comfortable managing issues of sexually transmitted disease, contraception, and pregnancy. Between one-quarter and one-half of 1993 respondents indicated they were very interested in learning more about each of the issues listed in Table 2. An additional 40-50% said they were somewhat interested. Fewer than 20% said they were not interested in learning more about each of the issues, with the exception of pregnancy (27%). In 1985, fewer respondents indicated they were very interested in having more involvement with obesity (23%), anorexia nervosa (13%), primary amenorrhea (27%), school truancy (14%), possible pregnancy (15%), birth control (23%), and alcohol use (4%); while larger numbers of respondents indicated they were not interested in more involvement with each of these issues (6). Direct comparison of the 1993 and 1985 data for these questions are not possible, since interest in additional learning (asked in 1993) and interest in additional involvement (asked in 1985) are not equivalent concepts. Obstacles to Care and Interest in Further Training
Respondents to the 1993 survey were asked to choose from a checklist those issues they consider to be the greatest obstacles to their providing comprehensive health care to adolescents (Table 3). Their
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image as baby doctors (65%), concern that parents would object to certain types of care (61%), lack of separate hours for adolescents (57%), difficulty in providing confidential care (56%), and inability to charge appropriate fees (47%) were considered to be mild or severe obstacles. Similar numbers of respondents considered these issues to be obstacles to care in the 1985 survey (6), and there were no differences by practice characteristics or location in the 1993 survey (Table 3). Approximately one-half of all 1993 respondents said they were satisfied providing only routine care to their adolescent patients, while 15% felt they were already providing adolescent-oriented care. Onequarter said they were not satisfied with the care they were providing and were interested in receiving additional training, while 11% were not satisfied but not interested in more training. In contrast, smaller numbers of 1985 respondents were satisfied with providing only routine care (36%), with similar numbers indicating that they provided adolescent-oriented care (17%). Among 1993 respondents who wanted to further their training, many were interested in a newsletter (43%), lecture series (41%), or 1-day Continuing Medical Education (CME) course (41%), while others expressed interest in a longer CME course (27%), mini-fellowship (24%), or reading list (21%). Smaller numbers of 1985 respondents were interested in each of these methods of potentially increasing knowledge and skills in adolescent medicine. Respondents to the 1993 survey identified several roles for the local Committee on Youth of the AAP, with the major role being that of education of pediatricians (75% of respondents). Other roles included advocacy for adolescents (64%) and pediatricians (49%), education of adolescents (57%), and providing resources (e.g., books, pamphlets, reference lists) for pediatricians (61%). Differences by Sex and Age
Compared to their male counterparts, the 43% of respondents who were female were less likely (p .01) to be practicing general pediatrics or in private practice. Female pediatricians were more likely to have equipment for gynecologic examinations but less likely to see new patients beyond 16 years of age and other patients beyond 19 years of age. Female pediatricians were more likely to prefer younger patients; less likely to consider fees and "image as a baby doctor" as obstacles to care; more comfortable managing pregnancy, substance use, and scoliosis;
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Table 3. Perceived Obstacles to Care and Interest in Further Training of Pediatricians Responding to 1993 and 1985 Surveys Year Respondents
1993 All pediatricians
Location
N e w York City a n d L o n g Island N = 436
Number Obstacles to adolescent care I m a g e as baby doctor Parents w o u l d object N o separate h o u r s Confidential care A p p r o p r i a t e fees Satisfaction with adolescent care Satisfied, p r o v i d e s routine care Satisfied, provides adolescent care N o t satisfied, interested in training N o t satisfied, not interested in training Type of training desired Newsletter Lecture series Mini-fellowship Reading list 7-day CME** 1-day CME Role for AAP*** C o m m i t t e e on Youth Educate pediatricians A d v o c a t e for adolescents Provide resources Educate adolescents Advocate for pediatricians
%
1993 -> 50% general pediatrics N e w York City a n d L o n g Island N = 334
%
1993 ~ 50% general pediatrics L o n g Island
1985 ~ 50% general pediatrics L o n g Island
N = 180
N = 101
%
%
65 61 57 56 47
64 63 58 57 51
67 61 51 56 50
62 54 52 43* 48
49 15 25 11
48 11 30 11
49 16 23 12
36* 17 30 17
43 41 24 21 27 41
45 42 27 23 20 43
44 42 21 22 30 43
-25 15 12 11" 9*
75 64 61 57 49
75 63 61 55 50
80 64 63 55 52
------
* p < .05 (1985 vs. 1993, general pediatrics -> 50% on L o n g Island). ** CME = c o n t i n u i n g medical education. *** A A P = A m e r i c a n A c a d e m y of Pediatrics.
and more interested in learning about menstrual dysfunction. Female pediatricians were more likely to be satisfied with the care they were providing to adolescents, and if not satisfied, were less interested in receiving training. The 43% of respondents who were --- 40 years of age were more likely (p < .01) to be female and less likely to be in private practice. Younger pediatricians had more equipment for gynecologic examinations and were more comfortable managing sexually transmitted diseases, pregnancy, and contraception. Younger pediatricians were also more satisfied with the care they were providing to adolescents and less interested in further training.
Discussion In comparing data from two surveys in the same geographic region 8 years apart, respondents in 1993
were younger, more likely to be female, and less likely to be in private practice than respondents in 1985. These differences may reflect changes in pediatric practice from the 1980s to the 1990s, as well as differences in membership of the American Academy of Pediatrics, whose mailing list was used for the 1993 survey, and local pediatric societies, whose mailing lists were used in 1985. Despite these differences, as well as on-going efforts to increase education in adolescent medicine, there were no changes in practice characteristics as they apply to teenagers during the 8 years. Age cut-offs did not change, adolescents -> 16 years of age continue to represent less than 10% of patients in the majority of pediatric practices, and equipment for gynecologic examinations is still not commonly available in most offices (although more offices apparently now have pelvic examination tables). A study performed in Pittsburgh in 1990 reported similar results, as did several
December1996
other studies in the 1980s (2,3,7). It should be noted that in both the 1985 and 1993 studies the response rates were low. We believe that those who responded represent pediatricians most interested in adolescent issues. The actual provision of health care to adolescents may therefore be even less than these surveys indicate. The pediatricians in each of these recent studies have provided information that may indicate why there has been little change over nearly a decade. A series of practical concerns, including image, fears of parental objections, and difficulties with hours, confidentiality, and fees, continue to be cited as obstacles to care. It is clear that despite the AAP having defined the purview of pediatrics as extending through age 21 years (8,9), continuing medical education courses and published suggestions and reassurances (10-14), pediatricians are not making significant change. Data from this current study suggest that this lack of change may result from lack of motivation for pediatricians to change their practices to better accommodate adolescent patients and their more complicated needs. Perhaps this is because there has been no specific economic incentive developed to do so, and as managed care patients occupy a greater percentage of the pediatrician's panel, this may become even more problematic. Full risk arrangements with capitation as the principal mechanism for reimbursement make it increasingly more difficult to receive approval for annual visits with the adolescent as well as for the increased time required to provide comprehensive care in the private office. Further, health plans may not recognize the need for provision of certain procedures, such as pelvic examinations, by pediatricians rather than gynecologists. Finally, with the advent of specialty boards in adolescent medicine, it will become an imperative to educate health maintenance organizations (HMOs) to recognize this field as a subspecialty of pediatrics. Although few pediatricians (15%) in the current survey believed they were providing "total adolescent care," only 25% more said they were interested in additional training. Larger numbers of 1993 than 1985 respondents said they were satisfied "being involved with the routine medical problems" of their adolescent patients, while somewhat fewer expressed an interest in further training. Perhaps reflecting ambivalence about their responses, more pediatricians in 1993 chose specific topics of training activities they would desire and 75% said that the role of the Committee on Youth should be the education of pediatricians. This ambivalence is further demonstrated when
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levels of comfort and interest in managing specific issues are analyzed. Pediatricians express greatest concern and least competence about managing patients with common problems related to sexuality, eating disorders, and substance use (2-6,15-17). Although most respondents indicated being "somewhat" or "very" interested in learning more about these and other issues, results of both surveys make it unlikely that additional education will be sufficient to change practice approaches to these problems. Instead, we suggest that there be a change in what is expected of pediatricians who provide adolescent health care and that continuing education efforts be oriented toward that change. Specifically, we believe that only those pediatricians with a specific interest and expertise in adolescent issues should manage their gynecologic and mental health needs, while all pediatricians should be trained to screen for the health risk behaviors and warning signs that underlie these needs. Several recent trends may help bring about these changes (18). It is hoped, for example, that pediatricians will increasingly rely on adolescent medicine specialists, who have the interest and willingness to overcome the barriers to care and deal comfortably and competently with these issues, to help manage the gynecologic and mental health needs of their patients. Alternatively, pediatricians can develop relationships with gynecologists and mental health professionals in their communities (19,20). The recently published Guidelines for Adolescent Preventive Services (GAPS) by the American Medical Association, and Bright Futures by the United States Departntlent of Health and Human Services, as well as several reviews on this topic, are aimed at helping pediatricians develop these skills (21-24). It is our hope that pediatricians will develop confidence in asking the appropriate questions so that future surveys will reflect needed change. That the 43% of respondents to this survey who were younger and female expressed greater confidence in managing sexuality-related issues is a hopeful sign that such change may occur and that increasing numbers of pediatricians will be able to provide all screening services recommended by the GAPS and Bright Futures reports, including PAP smears and testing for sexually transmitted diseases in sexually active adolescents. This survey involved only a small fraction of the pediatricians practicing in the United States. We recommend that additional surveys be performed to evaluate how pediatricians in other areas, as well as other specialties and disciplines, are managing the complex issues of adolescent health.
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References 1. The Future of Pediatric Education. A report by the Task Force on Pediatric Education. Evanston, IL., 1978. 2. Resnick MD. Use of age cutoff policies for adolescents in pediatric practice: report from the Upper Midwest Regional Physician Survey. Pediatrics 1983;72:420-7. 3. Orr DP, Weiser SP, Dian DA, Maurana CA. Adolescent health care: perceptions and needs of the practicing physician. J Adotesc Health Care 1987;8:239-45. 4. Neinstein LS, Shapiro JR. Pediatrician's self-evaluation of adolescent health care training, skills, and interest. J Adolesc Health Care 1986;7:18-21. 5. Blum R. Physicians' assessment of deficiencies and desire for training in adolescent care. J Med Education 1987;62:401-7. 6. Marks A, Fisher M, Lasker S. Adolescent medicine in pediatric practice. J Adolesc Health Care 1990;11:149-53. 7. Bradford J, Lyons W. Adolescent medicine practice in urban Pittsburgh--1990. Clin Pediatrics 1992;31:471-77. 8. Council on Child Health. Age limits of pediatrics. Pediatrics 1972;49:463. 9. Council on Child Health. Age limits of pediatrics. Pediatrics 1988;51:736. 10. Long WA. Treating teens for fun--and profit. Contemporary Pediatrics 1991;8:31-48. 11. Shapiro E. Obstacles to adolescent care in general practice. Adol Med State Art Rev 1991;2:389-96. 12. Lopez RI. Obstacles to adolescent care: economic issues. Adol Med State Art Rev 1991;2:415-28. 13. Williams RL. The office setting for adolescent care: concerns of physicians, patients and parents. Adol Med State Art Rev 1991;2:381-8.
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14. Fisher M. Parents' views of adolescent health issues. Pediatrics 1992;90:335-41. 15. Nussbaum MP, Shenker IR, Feldman JG. Attitudes versus performance in providing gynecologic care to adolescents by pediatricians. J Adol Health Care 1989;10:203-8. 16. Beatty ME, Lewis J. Adolescent contraceptive counselling and gynecology: a deficiency in pediatric office-based care. Conn Med 1994;58:71 8. 17. Klitsner IN, Brook GM, Neinstein L, MacKenzie R. Adolescent health care in a large multispecialty prepaid group practice: who provides it and how well are they doing? West J Med 1992;156:628-32. 18. Klein JD, McAnarney ER. Adolescent medicine. JAMA 1993; 270:186 -7. 19. Grace E. Incorporating adolescent gynecology into a general practice. Adolesc Med State Art Rev 1991;2:397-406. 20. Fisher M. Adolescent sexuality: overview and implications for the pediatrician. Pediatrics Annals 1991;20:285-9. 21. Elster AB, Kuznets NJ. AMA Guidelines for Adolescent Preventive Services: Recommendations and Rationale. Baltimore, Maryland: Williams and Wilkins, 1994. 22. Green M, ed. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, VA: National Center for Education in Maternal and Child Health, 1994. 23. Marks A, Fisher M. Health assessment and screening during adolescence. Pediatr 1987;(supp])80:135-58. 24. Cromer BA, McLean CS, Heald FP. A critical review of comprehensive health screening in adolescents. J Adolesc Health 1992;13:1S-65S.
ORIGINAL ARTICLE
Update on Adolescent Health Care in Pediatric Practice MARTIN FISHER, M.D., NEVILLE H. GOLDEN, M.D., RACHEL BERGESON, M.D., ALAN BERNSTEIN, M.D., DEBORAH SAUNDERS, M.D., MARCIE SCHNEIDER, M.D., MICHELE SEITZ, M.D., AND WARREN SEIGEL, M.D.
Purpose: To determine current adolescent health care practices of pediatricians and evaluate whether changes have taken place during the past decade. Methods: A questionnaire completed by 101 pediatricians in 1985 was abbreviated and adapted by the Committee on Youth of Chapter 2, District II of the American Academy of Pediatrics and sent to 1,633 members of the Chapter in June 1993. Results: Forty-three percent of the 436 respondents in 1993 were female, 43% _< 40 years of age and 53% were in private practice. Most accept new patients _> 16 years of age (76%), continue to see patients ~ 19 years of age (63%), and interview adolescents without their parents (86%). Although between one-third and two-thirds of respondents report having equipment for gynecologic examinations, most indicate they are "not entirely comfortable" treating adolescent issues and therefore refer to others for management. Between one-quarter and onehalf indicate they are "very interested" in learning more about adolescent issues and an additional 40-50% are "somewhat interested." Obstacles to providing adolescent care include: "image as a baby doctor" (65%), fear that parents would object (61°), no separate hours (57°), difficulty in providing confidential care (56%), and difficulty in charging appropriate fees (47%). Females and younger pediatricians are more comfortable with some
From the North Shore University Hospital-Cornell University Medical College, Manhasset, New York; Schneider Children's Hospital, Albert Einstein College of Medicine, New Hyde Park, New York; State University of New York at Stony Brook, Stony Brook, New York; NYLCare, Jackson Heights, New York; Nassau County Medical Center, East Meadow, New York; and Coney Island Hospital, Brooklyn, New
York, USA. Address reprint requests to: Martin Fisher, M.D., Division of Adolescent Medicine, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030. Manuscript accepted May 6, 1996. 1054-139X/96/$15.00 PII S1054-139X(96)00161-5
aspects of gynecologic care and more likely to be satisfied with the adolescent care they are providing. There were few differences between responses in 1993 and 1985. Conclusions: Few of the pediatricians surveyed provide comprehensive care to adolescent patients. Future policy decisions and medical education must respond to these realities in pediatric practice. © Society for Adolescent Medicine, 1996.
KEY
WORDS:
Adolescence Pediatricians Health care
In 1978, the Task Force on Pediatric Education reported that training in adolescent medicine was insufficient to provide the knowledge base and clinical skills necessary for most pediatricians to appropriately manage the health needs of their adolescent patients (1). Since that time, efforts have been underway to provide training in adolescent medicine for both residents and practicing pediatricians, and several studies have evaluated the comfort and selfperceived competence of pediatricians in providing adolescent care (2-7). Each of these studies has found major deficiencies in the ability of pediatricians to provide comprehensive adolescent health care. As managed care begins to impact on the practice of pediatrics, it is time to evaluate whether improvements have been made in approaches to adolescent health care and to consider what further steps need be taken to ensure that pediatricians meet the health
© Society for Adolescent Medicine, 1996 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
December 1996
care needs of adolescents. In this report, we present the results of a 1993 survey of pediatricians, compare them with findings of a similar study in 1985, and discuss implications of the results of these studies for adolescent care in pediatric practice.
Methods An anonymous, six-page questionnaire was mailed by the American Academy of Pediatrics (AAP, Elk Grove Village, IL) in June 1993 to the 1,633 members of Chapter 2, District II. The Chapter includes four counties, two of which are boroughs of New York City (Brooklyn and Queens) and two of which are in suburban Long Island (Nassau and Suffolk). Respondents were asked to return the questionnaire in an enclosed, self-addressed, stamped envelope. Completed questionnaires were received from 436 pediatricians. As determined from the list of Chapter members, the 27% who responded did not differ by age or sex from those who did not respond. The questionnaire was abbreviated and adapted by the Committee on Youth of Chapter 2, District II from that developed by Marks et al. in 1985 (6). The 1993 questionnaire included forced-choice questions on personal demographic data and practice characteristics, office and clinical practices pertinent to adolescents, involvement and interest in adolescent issues, perceived obstacles to respondents' provision of care to adolescents, and interest in further training in adolescent medicine. The questionnaire required approximately 10 minutes to complete. We did not ask in the 1993 survey whether participants had also completed the 1985 survey. Data from the 1993 questionnaire were computer tabulated (Data Ease, Version 4.2) and analyzed for all 436 pediatricians, as well as for subsets of respondents by age, sex, practice characteristics, and county. Results were compared to the 1985 data collected from 101 pediatricians in Nassau and Suffolk counties who practiced general pediatrics at least 50% of the time, 87% of whom were board certified in pediatrics (6). Standard contingency table analyses were performed and statistical significance of differences assessed by Chi-square analyses between subsets of 1993 and 1985 data.
Results Personal and Practice Characteristics
Personal and practice characteristics of respondents to the 1993 and 1985 surveys are presented in Table
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1. Differences by practice (general vs. subspecialty), location (New York City vs. Long Island), and year (1993 vs. 1985) can be deduced from this table. Forty-three percent of respondents to the 1993 questionnaire were _< 40 years of age and female. Fifty-eight percent were from Nassau and Suffolk Counties (Long Island), and 42% were from Brooklyn and Queens (New York City). Fifty-three percent of respondents were in private practice, and 47% in a prepaid group, clinic, or hospital-based practice. Males were more likely (p < .05) than females to be in private practice; older and younger pediatricians were equally likely to be in private practice. Demographic data did not differ significantly for the 1993 respondents by practice (general vs. subspecialty) or location (New York City vs. Long Island), although respondents to the 1985 questionnaire were more often older, male, and in private practice. Over three-quarters of respondents to the 1993 survey accept new patients -> 16 years of age, over one-half retain patients beyond 19 years of age, and 40% indicate that at least 10% of patients in their practice are -> 16 years of age. Pediatricians whose practices were -> 50% general pediatrics reported having more adolescent patients, those on Long Island continued to see more patients beyond 19 years of age, while those in 1985 accepted fewer new patients >- 16 years of age but retained more of their patients > 19 years of age. Respondents to the 1993 questionnaire indicated they were seeing similar numbers of adolescents (ages 11-21 years) as they were seeing 5 years earlier, but were seeing larger numbers of young adults (-> 21 years of age) now compared to 5 years ago. Eighty-six percent of respondents in 1993 report that they interview adolescents alone, compared to 83% in 1985, while 39% of 1993 respondents said they prefer younger patients, significantly greater (p < .01) than the 25% in 1985 who said they prefer younger patients. Between one-third and two-thirds of 1993 respondents report having the various pieces of equipment necessary for gynecologic examinations. Pediatricians in New York City (Brooklyn and Queens) are more likely than those in Long Island (Nassau and Suffolk Counties) to report having a pelvic examination table, vaginal speculae, Papanicolaou (Pap) smear materials, and testing for gonorrhea/chlamydia; Long Island pediatricians in 1993 were more likely than those in 1985 to have a pelvic examination table (p ~ .01) but not the materials necessary for a gynecologic examination. Many pediatricians report having pamphlets and magazines for adolescents while few have either adolescent hours or a separate
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T a b l e 1. Personal, Practice, and Office Characteristics of Pediatricians R e s p o n d i n g to 1993 and 1985 S u r v e y s Year Respondents
1993 All pediatricians
Location
New York City & Long Island N = 436 %
Number Demographics Age -< 40 years Sex: female Nassau/Suffolk counties Private practice Adolescent patients New patients ~ 16 y.o. Old patients ~ 19 y.o. -> 10% of practice 16 y.o. Interviews adolescents alone Prefers younger patients Office equipment Pelvic exam table Vaginal speculums Pap smear materials Gonorrhea / chlamydia testing Pregnancy tests Health pamphlets for teens Adolescent magazines Adolescent hours Adolescent waiting area
1993 -> 50% general pediatrics New York City & Long Island N = 334 %
1993 -> 50% general pediatrics Long Island
1985 -> 50% general Long Island
N = 180 %
N = 101 %
43 43 58 53
40 39 57 62
44 37 100 77
24* 19" 100 88*
76 63
74 61
71 72
68 78*
40 86 39
48 86 41
52 83 38
47 83 25*
59 45 33 49
57 43 30 46
51 34 24 37
41" 32 21 40
52 64 54 19 12
51 66 56 17 11
49 69 63 16 9
-62 60 9 5
* p < .01 (1985 vs. 1993, general pediatrics -> 50% on Long Island).
waiting room. These reports did not differ by practice, l o c a t i o n , o r y e a r .
I n v o l v e m e n t and Interest in A d o l e s c e n t Issues R e s p o n d e n t s to t h e 1993 s u r v e y w e r e a s k e d to i n d i cate their comfort level ("comfortable", "not entirely comfortable", "not comfortable") in managing 10
adolescent-oriented conditions and their interest in learning more ("very interested", "somewhat intere s t e d " , " n o t i n t e r e s t e d " ) a b o u t t h o s e c o n d i t i o n s (Tab l e 2). A m o n g t h o s e i s s u e s w i t h w h i c h r e s p o n d e n t s were not comfortable, the largest numbers indicated they immediately refer patients for management of p r e g n a n c y (45%), c o n t r a c e p t i o n (35%), a n o r e x i a n e r v o s a (34%), o r s u b s t a n c e u s e (29%). B e t w e e n o n e -
T a b l e 2. I n v o l v e m e n t and Interest in A d o l e s c e n t Issues (N = 436 R e s p o n d e n t s to 1993 Survey)
Menstrual dysfunction Sexually transmitted disease Pregnancy Contraception Depression, truancy, psychosocial problems Obesity Alcohol / substance use Anorexia nervosa Disturbances in pubertal development Scoliosis
Not Comfortable (Immediately Refer) %
Not Entirely Comfortable %
Comfortable (Manage on Own) %
Very Interested %
Somewhat Interested %
Not Interested %
14 21 45 35 24
56 34 45 37 61
30 45 10 28 15
48 45 27 38 36
41 45 46 45 52
11 10 27 17 12
6 29 34 16 12
47 58 55 63 70
49 13 11 21 18
48 37 37 50 39
42 48 46 42 47
10 15 17 8 14
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third and two-thirds of all respondents reported that they were "not entirely comfortable" treating each of the 10 issues. Fewer than 20% of respondents said they were comfortable managing issues related to anorexia nervosa, substance use, psychosocial problems, scoliosis, and the initial management and decision making involved in adolescent pregnancy. From 20-50% said they were comfortable managing pubertal and menstrual disturbances, contraception, sexually transmitted disease, and obesity. In total, over 70% of respondents indicated they were "not at all" or "not entirely" comfortable managing any of the 10 issues, with the exceptions of obesity and sexually transmitted disease. These responses are similar to those of the 1985 survey in which many respondents indicated they were comfortable managing obesity (63%), but few were comfortable managing anorexia nervosa (22%), primary amenorrhea (20%), school truancy (15%), possible pregnancy (11%), birth control (10%), or alcohol use (6%) (6). As might be expected, those in the 1993 study who had a pelvic examination table, speculae, PAP smear materials, and chlamydia/gonococcus testing materials were more likely (p < .01) to report being comfortable managing issues of sexually transmitted disease, contraception, and pregnancy. Between one-quarter and one-half of 1993 respondents indicated they were very interested in learning more about each of the issues listed in Table 2. An additional 40-50% said they were somewhat interested. Fewer than 20% said they were not interested in learning more about each of the issues, with the exception of pregnancy (27%). In 1985, fewer respondents indicated they were very interested in having more involvement with obesity (23%), anorexia nervosa (13%), primary amenorrhea (27%), school truancy (14%), possible pregnancy (15%), birth control (23%), and alcohol use (4%); while larger numbers of respondents indicated they were not interested in more involvement with each of these issues (6). Direct comparison of the 1993 and 1985 data for these questions are not possible, since interest in additional learning (asked in 1993) and interest in additional involvement (asked in 1985) are not equivalent concepts. Obstacles to Care and Interest in Further Training
Respondents to the 1993 survey were asked to choose from a checklist those issues they consider to be the greatest obstacles to their providing comprehensive health care to adolescents (Table 3). Their
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image as baby doctors (65%), concern that parents would object to certain types of care (61%), lack of separate hours for adolescents (57%), difficulty in providing confidential care (56%), and inability to charge appropriate fees (47%) were considered to be mild or severe obstacles. Similar numbers of respondents considered these issues to be obstacles to care in the 1985 survey (6), and there were no differences by practice characteristics or location in the 1993 survey (Table 3). Approximately one-half of all 1993 respondents said they were satisfied providing only routine care to their adolescent patients, while 15% felt they were already providing adolescent-oriented care. Onequarter said they were not satisfied with the care they were providing and were interested in receiving additional training, while 11% were not satisfied but not interested in more training. In contrast, smaller numbers of 1985 respondents were satisfied with providing only routine care (36%), with similar numbers indicating that they provided adolescent-oriented care (17%). Among 1993 respondents who wanted to further their training, many were interested in a newsletter (43%), lecture series (41%), or 1-day Continuing Medical Education (CME) course (41%), while others expressed interest in a longer CME course (27%), mini-fellowship (24%), or reading list (21%). Smaller numbers of 1985 respondents were interested in each of these methods of potentially increasing knowledge and skills in adolescent medicine. Respondents to the 1993 survey identified several roles for the local Committee on Youth of the AAP, with the major role being that of education of pediatricians (75% of respondents). Other roles included advocacy for adolescents (64%) and pediatricians (49%), education of adolescents (57%), and providing resources (e.g., books, pamphlets, reference lists) for pediatricians (61%). Differences by Sex and Age
Compared to their male counterparts, the 43% of respondents who were female were less likely (p .01) to be practicing general pediatrics or in private practice. Female pediatricians were more likely to have equipment for gynecologic examinations but less likely to see new patients beyond 16 years of age and other patients beyond 19 years of age. Female pediatricians were more likely to prefer younger patients; less likely to consider fees and "image as a baby doctor" as obstacles to care; more comfortable managing pregnancy, substance use, and scoliosis;
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Table 3. Perceived Obstacles to Care and Interest in Further Training of Pediatricians Responding to 1993 and 1985 Surveys Year Respondents
1993 All pediatricians
Location
N e w York City a n d L o n g Island N = 436
Number Obstacles to adolescent care I m a g e as baby doctor Parents w o u l d object N o separate h o u r s Confidential care A p p r o p r i a t e fees Satisfaction with adolescent care Satisfied, p r o v i d e s routine care Satisfied, provides adolescent care N o t satisfied, interested in training N o t satisfied, not interested in training Type of training desired Newsletter Lecture series Mini-fellowship Reading list 7-day CME** 1-day CME Role for AAP*** C o m m i t t e e on Youth Educate pediatricians A d v o c a t e for adolescents Provide resources Educate adolescents Advocate for pediatricians
%
1993 -> 50% general pediatrics N e w York City a n d L o n g Island N = 334
%
1993 ~ 50% general pediatrics L o n g Island
1985 ~ 50% general pediatrics L o n g Island
N = 180
N = 101
%
%
65 61 57 56 47
64 63 58 57 51
67 61 51 56 50
62 54 52 43* 48
49 15 25 11
48 11 30 11
49 16 23 12
36* 17 30 17
43 41 24 21 27 41
45 42 27 23 20 43
44 42 21 22 30 43
-25 15 12 11" 9*
75 64 61 57 49
75 63 61 55 50
80 64 63 55 52
------
* p < .05 (1985 vs. 1993, general pediatrics -> 50% on L o n g Island). ** CME = c o n t i n u i n g medical education. *** A A P = A m e r i c a n A c a d e m y of Pediatrics.
and more interested in learning about menstrual dysfunction. Female pediatricians were more likely to be satisfied with the care they were providing to adolescents, and if not satisfied, were less interested in receiving training. The 43% of respondents who were --- 40 years of age were more likely (p < .01) to be female and less likely to be in private practice. Younger pediatricians had more equipment for gynecologic examinations and were more comfortable managing sexually transmitted diseases, pregnancy, and contraception. Younger pediatricians were also more satisfied with the care they were providing to adolescents and less interested in further training.
Discussion In comparing data from two surveys in the same geographic region 8 years apart, respondents in 1993
were younger, more likely to be female, and less likely to be in private practice than respondents in 1985. These differences may reflect changes in pediatric practice from the 1980s to the 1990s, as well as differences in membership of the American Academy of Pediatrics, whose mailing list was used for the 1993 survey, and local pediatric societies, whose mailing lists were used in 1985. Despite these differences, as well as on-going efforts to increase education in adolescent medicine, there were no changes in practice characteristics as they apply to teenagers during the 8 years. Age cut-offs did not change, adolescents -> 16 years of age continue to represent less than 10% of patients in the majority of pediatric practices, and equipment for gynecologic examinations is still not commonly available in most offices (although more offices apparently now have pelvic examination tables). A study performed in Pittsburgh in 1990 reported similar results, as did several
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other studies in the 1980s (2,3,7). It should be noted that in both the 1985 and 1993 studies the response rates were low. We believe that those who responded represent pediatricians most interested in adolescent issues. The actual provision of health care to adolescents may therefore be even less than these surveys indicate. The pediatricians in each of these recent studies have provided information that may indicate why there has been little change over nearly a decade. A series of practical concerns, including image, fears of parental objections, and difficulties with hours, confidentiality, and fees, continue to be cited as obstacles to care. It is clear that despite the AAP having defined the purview of pediatrics as extending through age 21 years (8,9), continuing medical education courses and published suggestions and reassurances (10-14), pediatricians are not making significant change. Data from this current study suggest that this lack of change may result from lack of motivation for pediatricians to change their practices to better accommodate adolescent patients and their more complicated needs. Perhaps this is because there has been no specific economic incentive developed to do so, and as managed care patients occupy a greater percentage of the pediatrician's panel, this may become even more problematic. Full risk arrangements with capitation as the principal mechanism for reimbursement make it increasingly more difficult to receive approval for annual visits with the adolescent as well as for the increased time required to provide comprehensive care in the private office. Further, health plans may not recognize the need for provision of certain procedures, such as pelvic examinations, by pediatricians rather than gynecologists. Finally, with the advent of specialty boards in adolescent medicine, it will become an imperative to educate health maintenance organizations (HMOs) to recognize this field as a subspecialty of pediatrics. Although few pediatricians (15%) in the current survey believed they were providing "total adolescent care," only 25% more said they were interested in additional training. Larger numbers of 1993 than 1985 respondents said they were satisfied "being involved with the routine medical problems" of their adolescent patients, while somewhat fewer expressed an interest in further training. Perhaps reflecting ambivalence about their responses, more pediatricians in 1993 chose specific topics of training activities they would desire and 75% said that the role of the Committee on Youth should be the education of pediatricians. This ambivalence is further demonstrated when
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levels of comfort and interest in managing specific issues are analyzed. Pediatricians express greatest concern and least competence about managing patients with common problems related to sexuality, eating disorders, and substance use (2-6,15-17). Although most respondents indicated being "somewhat" or "very" interested in learning more about these and other issues, results of both surveys make it unlikely that additional education will be sufficient to change practice approaches to these problems. Instead, we suggest that there be a change in what is expected of pediatricians who provide adolescent health care and that continuing education efforts be oriented toward that change. Specifically, we believe that only those pediatricians with a specific interest and expertise in adolescent issues should manage their gynecologic and mental health needs, while all pediatricians should be trained to screen for the health risk behaviors and warning signs that underlie these needs. Several recent trends may help bring about these changes (18). It is hoped, for example, that pediatricians will increasingly rely on adolescent medicine specialists, who have the interest and willingness to overcome the barriers to care and deal comfortably and competently with these issues, to help manage the gynecologic and mental health needs of their patients. Alternatively, pediatricians can develop relationships with gynecologists and mental health professionals in their communities (19,20). The recently published Guidelines for Adolescent Preventive Services (GAPS) by the American Medical Association, and Bright Futures by the United States Departntlent of Health and Human Services, as well as several reviews on this topic, are aimed at helping pediatricians develop these skills (21-24). It is our hope that pediatricians will develop confidence in asking the appropriate questions so that future surveys will reflect needed change. That the 43% of respondents to this survey who were younger and female expressed greater confidence in managing sexuality-related issues is a hopeful sign that such change may occur and that increasing numbers of pediatricians will be able to provide all screening services recommended by the GAPS and Bright Futures reports, including PAP smears and testing for sexually transmitted diseases in sexually active adolescents. This survey involved only a small fraction of the pediatricians practicing in the United States. We recommend that additional surveys be performed to evaluate how pediatricians in other areas, as well as other specialties and disciplines, are managing the complex issues of adolescent health.
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