Modules

Communicating with adolescents

Part 2

Dr. Burnside refers Kelsey to the dietician at the local hospital Diabetic Clinic. While she works primarily with diabetics, Dr. Burnside hopes that she can give Kelsey some advice about proper eating habits.

Kelsey comes back to Dr. Burnside a month after the first visit, this time accompanied by her mother. The two are clearly angry with each other.

  • Dr. Burnside: Well Kelsey, your BMI has now gone from 19 to 18. That’s not really the direction you want it to go.

    Beth: Doctor, you told me that Kelsey had to eat more and I have been trying. But she just refuses! I mean, I’ve been cooking special foods, I’ve been trying to follow the plan that the dietitian gave us but she just ignores it.

    Kelsey: I eat as much as I want and need. You can’t force me.

    Dr. Burnside: Hold on now, let’s not get angry.

    Kelsey: I’m not angry! I’m old enough to make my own decisions about how I want to look and what I want to eat.

    Beth: Not if you behave like this, young lady! Look, you are still our daughter and as long as you are living under our roof you will do as we say!

    Dr. Burnside: Please, please, please! This isn’t getting us anywhere. Mrs. Cournoyer, do you think you could bring your husband in and I could have a talk with …

    Beth: Listen, I can handle this without my husband! I’m sorry. But look, he’s out of town and …

    Kelsey: Always.

    Beth: And he works out of town on business. And he just doesn’t understand. And well, Kelsey and he haven’t been getting along very much lately. And when the cross-country coach phoned …

    Kelsey: Mom!

    Beth: … to tell us that he was suspending her from the team because he caught her throwing up, and because she hasn’t been maintaining her weight …

    Kelsey: Mom!

    Beth: … my husband went ballistic!

    Dr. Burnside: Well, listen, listen please. Mrs. Cournoyer I …

    Kelsey: He’s always siding with my brothers. And you should hear them talking about food at the dinner table.

    Beth: Well at least they eat.

    Kelsey: Well, when anyone’s actually there.

    Dr. Burnside: Look, look, look, look I know that you want what’s best for your daughter. But Kelsey if trying to eat isn’t working out, and you’re not able to do it by yourself, then maybe we need to talk to somebody who has a better understanding of eating to help us. I’m not an expert. I don’t know all the answers. And maybe if I brought an outside person in, they could really help. Now I have to see what resources are available to us, but maybe if we brought in a psychologist or a social worker, somebody that would talk to you. If you would agree to that, and someone to talk to you, either alone or with your parents.

    Beth: Yeah, yeah that’s good.

    Kelsey: I don’t, there’s nothing wrong with me! I don’t need someone to tell me what to do.

    Beth: See that?

    Kelsey: I eat healthy, I eat enough!

    Beth: This is what I have to deal with, all the time!

    Dr. Burnside: Okay, yes. Mrs. Cournoyer I think it would be best if you could give us a moment alone, maybe if I talk to Kelsey by herself that would be helpful.

    Beth: You listen to the doctor, do you hear me young lady?

    (Beth leaves the room)

    Dr. Burnside: Well, Kelsey, it seems like you and your mother, you and your parents, don’t always see eye to eye.

    Kelsey: They’re always telling me what to do and criticizing me.

    Dr. Burnside: Well you’re growing up. And it’s understandable that you fight sometimes. But I’m not so sure you appreciate how serious this whole eating problem is. Can you explain to me why you’re afraid of eating?

    Kelsey: I’m not afraid! I do eat, just not what they want me to.

    Dr. Burnside: Well, yes, but there’s …

    Kelsey: I don’t want to … get fat. Okay my mom, she goes to Weight Watchers too, she watches her weight.

    Dr. Burnside: There’s a difference between healthy eating and being too thin. And you are too thin. Whether you think so or not! Now I really hope you’ll agree to meet with somebody. Maybe even somebody who can help you and your parents to get along.

    Kelsey: I don’t need that stuff.

    Dr. Burnside: Well I think that you do, and I’m the doctor. And I’m going to tell your mother that that’s what’s best for you!

  • Oh boy I lost it there. But I’m not sure how to help this kid. I’m not really comfortable talking with adolescents, and they seem like a really dysfunctional family. I remember the father. A real “Type A.” No wonder Kelsey doesn’t get along with him. I mean, I could look up how to manage an eating disorder, but will she comply? I could sure use some help.

Reflective exercise 2

In previous modules we have considered two of the components of consent: voluntariness and information exchange. In this exercise we will look at the third, that of competence/capacity, specifically in children and adolescents. We will also consider confidentiality as it applies in these age groups.

Commentary

Informed consent in adolescents is a special case of this common bioethical issue, requiring particular thoughtfulness in the physician due to differences in the physician-patient relationship between adults and children or adolescents. The assessment of competence, or capacity in legal terms, is more problematic in children and adolescents. They mature at different rates, and their values and ability to appreciate future events change with time. Their ability to understand and appreciate situations varies more with the specific circumstances than it does in adults. Therefore, the designation “mature minor” also varies with circumstance, not age. A 10 year old may very well be able to understand and agree to treatment for an ear infection, but perhaps not the options involved in cancer treatment.

An additional difficulty is related to the anorexia itself. Part of the disease is a denial of need for treatment. That, and the fact that a nutritionally starved brain may not be functioning normally, make determination of competence in a patient like Kelsey very difficult. The idea of resistance to, rather than refusal of treatment, may be helpful, as noted in MacDonald (2002). One cannot fall back on legalities although there are provincial and territorial differences in legal age of consent. In practice, a person of any age is deemed capable unless shown to be incapable.

The ethical issues regarding confidentiality are somewhat clearer. Assuming Kelsey is competent, she has the same right to confidentiality as anyone else. Dr. Burnside was quite correct in asking to speak alone with his patient, but he probably should have taken the opportunity to discuss confidentiality with Kelsey. He could ask, and would probably receive, her permission to include her mother in treatment discussions. However, if she refuses, what should he do?

A final issue is Dr. Burnside’s loss of control, resulting in his angry outburst. This probably reflects his discomfort and sense that he cannot handle the situation. It is much easier to talk to the mother, as we shall see later. Should he have apologized to Kelsey? At least he is aware of his feelings and actions. Self-awareness is an important part of communication skills and physicians who feel that they are always emotionally and value-neutral are deluding themselves. Knowledge of one’s limitations and willingness to seek help are part of expected professional behaviour.

The following literature addresses the issues of consent and confidentiality with adolescents:

Reflective exercise 3

Email etiquette

Dr. Burnside decides to seek help from a colleague, whom he emails.

Electronic communication has become almost universal in professional life. While it has many advantages, it can also cause unanticipated problems if social norms or rules are not followed. Assuming that you use email for either personal and/or professional reasons, think about the following questions:

  • Have you ever received an email from someone you know that caused an emotional response like anger or irritation? How did you respond?
  • Have you ever opened a junk or spam email by mistake because of the subject line entry?
  • Have you ever deleted an email because of its subject line that you later found you should have opened?
  • Have you ever sent or received an email that also went to unexpected recipients?
  • Have you ever deleted or failed to read an email because it was too long?

Now read the emails between Dr. Burnside and his colleague.

TO: hhalgen@yellhoo.com
FROM: w.burnside@hottalk.com
Subject: problem patient—a terrible teen!

Hi Harvey,

I hope your new practice is going well. How’s the office working? Things are certainly busy here since you left. I now have to do 2 Emerg shifts a week how are your wife and kids. Is Josh getting used to a new school? I remember you being conxcerned. Shirley sends her regards to you and your wife.

Anyway—I wonder if you can help me. I have a family with a 15 year old girl who may have anorexia. The Mother is a none-coper, and the father seems absent most of the time, –I wonder what he’s up to sometimes, and of course, the girl is denying any problems. Typical frustrating kid to try to talk to. I can’t seem to gert through to her, but then most of my practice is a good deal past 50! Ha ha The dietician in our diabetic clinic gave her a diet, but I don’t think that made an impression. I don’t quite know what to do next, and I’m not even sure that she isn’t right—maybe she isn’t sick. I remembered you had a similar case—what did you do?

All the best,
Wally

Reply email

Nice to hear from you, Wally. My wife and kids are doing fine, thanks, and the practice is growing by the day.

It sounds like you have an interesting case on your hands. Teens can be really hard to communicate with. I’m finding out with my own. I remember the case you refer to. But it was an adult—a young woman with bulimia. I sent her to a social worker who did psychological counselling. You might try that, especially if there is family conflict. I don’t know about the resources in your area, but I guess that there is no one at your clinic. Try http://findasocialworker.ca. That will give you who is out there in private practice.

Good luck,
Harvey

Email subject lines

  • What do you think of the subject line of Wally’s email?
  • If you did not know the sender well, would you open it?
  • What message does it convey about Wally’s attitude toward adolescents?

 

Exercise

  • Rewrite the subject line of Wally’s email.
  • Rethink the body of the message and consider privacy issues.
  • Is the email address personal or an office address?
  • If it is a personal address, who may read this email? List as many as you think.
  • If the email address is the office address, who may read it? List as many as you think.
  • Why might nobody read the email if sent to the office?

There is nothing to submit for this exercise.

Body of email messages: content issues

Think about the following questions before completing the last part of this exercise:

  • Wally combines personal and professional content in his email. Is this acceptable?
  • If so, what kinds of personal notes, greetings, etc. are appropriate in professional communications? How long should they be?
  • Wally makes some remarks about Kelsey and her family. Think about whom else may see this, even if names are not mentioned. (Imagine that Harvey’s assistant is in the same Weight Watchers club as Mrs. Cournoyer and overhears her talking about her daughter’s problems.)
  • How much and what kind of information does Wally need to give Harvey?
  • What do you think of the writing technique (spelling, grammar, etc.)? What might the recipient of a sloppy email think about the sender?
  • Is Harvey under any legal or moral obligation to the patient for having given advice?

Exercise
Having read the resource literature and thought about the questions:

  • Rewrite Wally’s email.
  • Look up the online resource Harvey suggested or a similar resource for your area.

There is nothing to submit for this exercise.


 

Next: Part 3

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