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Which Adolescents Have Opportunities to Talk to Doctors Alone?

      See Related Article p. 393
      The importance of confidential adolescent health care has been explicitly acknowledged by all major health professional organizations for nearly two decades [
      • Gans J.
      Policy Compendium on Confidential Health Services for Adolescents.
      ,
      AMA Council on Scientific Affairs
      Confidential health services for adolescents.
      ]. Private conversations between adolescent patients and health care professionals are developmentally appropriate as children transition through adolescence into young adulthood, because adolescents need to learn skills to become increasingly responsible for their own health and health care. Private conversations with a health care professional also allow discussion of topics or behaviors that adolescents may not disclose or discuss in the presence of a parent. Research has consistently shown that adolescents' concerns about privacy can delay or prevent some adolescents from seeking health care, and interfere with open patient-physician communication about issues that need to be discussed because they have a major impact on adolescent health such as sexual behaviors, substance use, and mental health [
      • Jones R.K.
      • Purcell A.
      • Singh S.
      • et al.
      Adolescents' reports of parental knowledge of adolescents' use of sexual health services and their reactions to mandated parental notification for prescription contraception.
      ,
      • Reddy D.M.
      • Fleming R.
      • Swain C.
      Effect of mandatory parental notification on adolescent girls' use of sexual health care services.
      ,
      • Jackson S.
      • Hafemeister T.L.
      Impact of parental consent and notification policies on the decisions of adolescents to be tested for HIV.
      ,
      • Ford C.
      • Best D.
      • Miller W.
      Confidentiality and adolescents' willingness to consent to STD testing.
      ,
      • Thrall J.
      • McCloskey L.
      • Ettner S.
      • et al.
      Confidentiality and adolescents' use of providers for health information and for pelvic exams.
      ,
      • Sugerman S.
      • Halfon N.
      • Fink A.
      • et al.
      Family planning clinic clients: Their usual health care providers, insurance status, and implications for managed care.
      ,
      • Ford C.A.
      • Bearman P.S.
      • Moody J.
      Foregone health care among adolescents.
      ,
      • Klein J.
      • Wilson K.
      • McNulty M.
      • et al.
      Access to medical care for adolescents: results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls.
      ,
      • Meehan T.M.
      • Hansen H.
      • Klein W.C.
      The impact of parental consent onthe HIV testingof minors.
      ,
      • Ford C.
      • Millstein S.
      • Halpern-Felsher B.
      • et al.
      Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care.
      ,
      • Boekeloo B.
      • Schamus L.
      • Cheng T.
      • et al.
      Young adolescents' comfort with discussions about sexual problems with their physician.
      ,
      • Ginsburg K.
      • Slap G.
      • Cnaan A.
      • et al.
      Adolescents' perceptions of factors affecting their decisions to seek health care.
      ,
      • Nowell D.
      • Spruill J.
      If it's not absolutely confidential, will information be disclosed?.
      ,
      • Cheng T.
      • Savageau J.
      • Sattler A.
      • et al.
      Confidentiality in health care: a survey of knowledge, perceptions, and attitudes among high school students.
      ,
      • Zabin L.
      • Stark H.
      • Emerson M.
      Reasons for delay in contraceptive clinic utilization: Adolescent clinic and nonclinic populations compared.
      ,
      • 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.
      ].
      Despite the acknowledged importance of providing opportunities for private adolescent patient–clinician discussions, existing research shows that this does not occur as frequently as one might hope or expect. Two articles in this issue of the Journal of Adolescent Health make important contributions to a growing literature that describes which adolescent patients do not get private time with a health care professional, and why. Edman et al report results of secondary data analyses using the Medical Expenditure Panel Survey Child Health Supplement, which provides national estimates of health care delivered across the United States [
      • Edman J.C.
      • Adams S.H.
      • Park M.J.
      • Irwin Jr., C.E.
      Who gets confidential care? Disparities in a national sample of adolescents.
      ]. For these analyses, office records were used to determine whether adolescents between 12 and 17 years of age had been seen for routine preventive visit in the past 12 months, and caregiver interviews were used to determine whether the adolescent had spent any time alone with their healthcare provider during their most recent visit. Results show that adolescents aged 12–17 years who had a preventive visit in the previous year were more likely to have spent time alone with a clinician at their last visit than adolescents without a preventive visit. Nonetheless, even among adolescents aged 12–17 years who had an annual preventive visit, the minority (40%) had time alone with a clinician at their last visit. Young, female, and Hispanic adolescents were less likely to spend time alone with a clinician at their last visit as compared to older, male, and non-Hispanic adolescents. The highest proportion to receive time alone with a clinician at their last visit was among 17-year-old adolescents, and that proportion was barely above one-half (57%).
      O'Sullivan et al report the results of an innovative study conducted in selected communities in New York during which healthcare professionals were asked to report their own practice behaviors immediately after 215 adolescent (aged 12–18) patient visits [

      O'Sullivan L, McKee M, Rubin S, et al. Primary care providers' reports of time alone and the provision of sexual health services to urban adolescent patients: results of a prospective card study. J Adolesc Health. In press.

      ]. Of the 144 visits attended by a parent, clinicians reported that 68% involved time alone with the adolescent patient. Clinicians also reported that they on an average spent 51% of the visit privately and parents responded extremely well to being asked to leave the room. Adolescents were more likely to spend time alone if they were being seen for a scheduled physical, and if they presented with a problem that could have been related to sexual health.
      Taken together, these articles raise important issues. First, reasons that an adolescent patient does or does not have the opportunity to talk privately with a healthcare professional appear linked to reason for visit. Future research will benefit from measuring predictors and characteristics of adolescent patients' time alone with clinicians during specific types of visits. Second, whether an adolescent spends time alone with a clinician appears to vary by patient characteristic and research is needed to understand why. Why are young adolescent girls less likely to have opportunities to talk privately with clinicians as compared to young adolescent boys? Why are Hispanic adolescents less likely to have opportunities to talk privately with clinicians as compared to non-Hispanic adolescents? Third, these articles are consistent with the published data showing that opportunities for private adolescent patient–clinician discussions are not occurring as frequently as one might hope or expect.
      Whether an adolescent patient spends time alone with a healthcare professional in many situations can affect quality of health care. The U.S. Preventive Services Task Force, based on strong evidence-based reviews, recommends high-intensity behavioral counseling to prevent sexually transmitted infections among sexually experienced adolescent boys and girls, and has specific testing recommendations for chlamydia, gonorrhea, and HIV that depend on level of risk [

      US Department of Health and Human Services Agency for Healthcare Research and Quality. US Preventive Services Task Force - Child and Adolescent Health Recommendations. [Accessed Jan 19, 2010]; Available from: http://www.ahrq.gov/clinic/tfchildcat.htm.

      ]; clinicians need to be able to obtain an accurate sexual history to determine level of risk, and their ability to do so will be hampered if questions about adolescent sexual behaviors are asked in the presence of a parent. Similarly, the U.S. Preventive Services Task Force has also recently recommended screening adolescents aged 12–18 years for major depressive disorder, and accurate assessments of depression may be more likely when adolescent patients and clinicians have the opportunity to talk privately. Future research should also identify strategies to ensure that all adolescents receive the private time needed with healthcare professionals to facilitate high-quality adolescent healthcare services.

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        Adolescents' reports of parental knowledge of adolescents' use of sexual health services and their reactions to mandated parental notification for prescription contraception.
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        Impact of parental consent and notification policies on the decisions of adolescents to be tested for HIV.
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        Confidentiality and adolescents' willingness to consent to STD testing.
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      1. O'Sullivan L, McKee M, Rubin S, et al. Primary care providers' reports of time alone and the provision of sexual health services to urban adolescent patients: results of a prospective card study. J Adolesc Health. In press.

      2. US Department of Health and Human Services Agency for Healthcare Research and Quality. US Preventive Services Task Force - Child and Adolescent Health Recommendations. [Accessed Jan 19, 2010]; Available from: http://www.ahrq.gov/clinic/tfchildcat.htm.

      Linked Article

      • Who Gets Confidential Care? Disparities in a National Sample of Adolescents
        Journal of Adolescent HealthVol. 46Issue 4
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          Using the 2001–2004 Medical Expenditures Panel Survey, we examined rates of past-year adolescent time alone with a clinician by visit type, and among youths with a preventive visit, examined age, gender, and race/ethnicity differences. Youths with a preventive visit have higher rates of time alone; rates for these youths increase with age, are higher for males (42%) versus females (37%), and are lowest among Hispanics. Time alone rates are low, especially for younger females and Hispanic youths.
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