Modules

Communicating with adolescents

Part 1

  • Dr. Wallace Burnside, family physician in Humphrey’s Harbour
  • Mrs. Beth Cournoyer
  • Kelsey Cournoyer, Beth’s daughter
  • Dr. Burnside: Hello?

    Beth: Hello, uh Dr. Burnside? It’s Beth Cournoyer.

    Dr. Burnside: Oh yes, Mrs. Cournoyer. How are you?

    Beth: Oh well I’m fine, it’s Kelsey I wanted to ask you about.

    Dr. Burnside: Kelsey. I haven’t seen her in quite a while. How old is she now?

    Beth: She’ll be 15 in three months. Doctor, she’s never caused us a moment’s worry … until lately. Well, she’s changed. Moody. Nothing I do is right. I know she’s a teenager, but her grades are falling, and her teacher’s quite concerned. You know, she isn’t seeing her friends, but she stays out.

    Dr. Burnside: Uh-huh.

    Beth: And when she’s at home, she’s gone on some crazy organic diet. I can’t find any food she’ll eat. And she’s lost quite a lot of weight. She won’t talk to me, doctor. But I thought that maybe you could talk to her …

    Dr. Burnside: Well, Mrs. Cournoyer, in many respects it sounds like she’s a normal teenager, and you can’t force her to come in.

    Beth: Oh, oh I know that. But we had it out last night and she agreed to come. I’ll stay out of it, but will you see what you can do? I’m so worried she might be on drugs or involved in something she can’t handle.

    Dr. Burnside: Yes. Yes of course I’ll try. I’ll have Linda set up something in the next couple of days, okay?

    Beth: Oh great, thank you.

    Dr. Burnside: Alright bye now.

  • Dr. Burnside: So Kelsey, thanks for coming in today.

    Kelsey: Anything to get mom off my case.

    Dr. Burnside: Did your mother tell you why she wanted you to come and see me?

    Kelsey: Oh she’s just on my back about everything. Schoolwork, my weight, my clothes. But I have the right to eat what I want and wear what I want.

    Dr. Burnside: Yes well your mother did mention that you’d lost some weight and that your school marks were suffering. I can see that you’re a bit thin? How much, how tall are you?

    Kelsey: I dunno.

    Dr. Burnside: Are you as tall as your mother?

    Kelsey: I dunno.

    Dr. Burnside: Well, your mother tells me that you’ve become a vegetarian. Are you dieting?

    Kelsey: No! I’ve just decided to eat healthy. Carnivores are disgusting. You should see my little brothers.

    Dr. Burnside: Yes, well vegetables are good, but it’s important that you get enough calories and that you eat a balanced diet. Are you concerned about your weight? Or your appearance?

    Kelsey: Well, I was fat. I look better thinner.

    Dr. Burnside: Are you trying to lose even more weigh?

    Kelsey: Well I’m really watching it. I could lose a few more pounds. I’m not as thin as some of my friends.

    Dr. Burnside: Well, let’s get you up on the scale and see how much you weight right now. Is that okay?

    (after Kelsey is weighed)

    Dr. Burnside: Well Kelsey at 110 pounds and five foot five, the conversion chart says your BMI is 19. Do you know what that means?

    Kelsey: No.

    Dr. Burnside: Well looking at how you’ve been growing, I would expect you to weigh more. This means you’re underweight. I’m worried that you may be developing an eating disorder and that can be very serious. Have you heard of anorexia nervosa?

    Kelsey: Yeah, but I’m okay, I’m in control.

    Dr. Burnside: Well, I’m not sure that you are. This can be serious. You can get all sorts of physical and mental problems. You could even die. Now, I really would like you to try to eat more. I don’t care how many calories. I just need you to beef it up. Um, I’ll talk to your parents and see if they can help out, okay?

    Kelsey: Okay.

Commentary

Anyone who is on social media or reads a newspaper or watches television is aware of the North American preoccupation with weight and body image. It may seem ironic that while the preferred body is that of the thin Hollywood celebrity, the major health problem is obesity. Physicians are much more likely to be dealing with the results of that than of other eating disorders.

The lifetime prevalence of anorexia nervosa and bulimia nervosa is 1-2.5 per cent in females and 1 per cent in males. Many feel eating disorders are a cultural phenomenon related to the pervasive media coverage of celebrities. Others place them as psychiatric disorders, with or without genetic or socio-cultural factors. The important point for practicing physicians is that all adolescents, both boys and girls, should be screened for eating disorders as part of routine care.

Reflective exercise 1

Communicating with adolescents

Patient-centred communication with adolescents is basically no different from that with older patients (see The patient-centred model of physician-patient communication), but requires consciously utilizing some particular interviewing techniques. The topics discussed will also be different from those in many adult physician-patient encounters. Preventive medicine and health promotion will be major subjects in routine visits. Finally, attitude is very important in successfully connecting with adolescents.

Many physicians are uncomfortable talking with their adolescent patients; adolescents have their own culture and it can sometimes be quite foreign to the physician. Dealing with visits for a specific medical complaint, such as an earache, may seem straightforward. However, in a population that is usually healthy, what are the physician’s responsibilities to ensure continued good health? What are the barriers to providing good care to adolescents? What are the special issues a physician should think about when seeing an adolescent patient? What communication techniques can be used to obtain sufficient and accurate information from an adolescent patient? And what role should the parent play? Do adolescents mature at the same rate? How do you decide if the adolescent is capable of making their own decisions?

Think about the following issues. There are no right or wrong answers and there is nothing to submit. Simply reflect on how you might deal with these situations or discuss them with a colleague.

  • Dr. Burnside does not respond directly to Kelsey’s statement that she can “eat and wear what she wants.” Would it have helped to establish a therapeutic relationship if he had? If so, what words or phrases might he have used? What message is Kelsey sending in this statement?
  • Note the types of questions that Dr. Burnside asks. Are they primarily open or closed? How might you rephrase those questions to help Kelsey give more information?
  • Should Dr. Burnside have done a HEADSS screening at this visit? Why or why not? What additional questions, if any, do you think would have been important to ask?
  • Dr. Burnside tells Kelsey that she can die from her condition. Attempting to motivate patients by telling them of the seriousness of their illness is sometimes successful. Does the 14 year old brain appreciate such abstract future possibilities? How could you determine if Kelsey does? What about any patient with anorexia nervosa? (Read the literature in the Resources section for information about the mental state of patients with eating disorders.)
  • Dr. Burnside suggests to Kelsey that she “beef up” her caloric intake. Note Kelsey’s non-verbal response. If you make an unfortunate remark like that in talking to a patient, what would you/should you do?

 

Next: Part 2

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