Communicating with adolescents

Part 3

  • Dr. Burnside: Mrs. Cournoyer?

    Patient: Yes.

    Dr. Burnside: It’s Dr. Burnside.

    Patient: Oh hi Dr. Burnside.

    Dr. Burnside: I’ve been doing some checking to see who could help us with Kelsey’s weight problem. Unfortunately, there’s no one here in Humphreys Harbour but there is a social worker who works in a Family Therapy Clinic in Thompsonville and it’s only 40 kilometers away; so I thought perhaps if you can bring Kelsey in I can arrange for an appointment.

    Patient: Family therapist, what’s that got to do with Kelsey’s dieting? Are you implying it’s our fault somehow?

    Dr. Burnside: Oh, no, no, no, not at all but I’ve been reading on the latest guidelines on eating disorders and family therapy is one of the recommended treatments. Kesley told me flat out she didn’t want to go but I thought perhaps if you can speak.

    Patient: Oh don’t worry about that. If this is an eating disorder she’s going.

    Dr. Burnside: Okay good. Well then, I’ll set up an appointment and send a note to the therapist.

    Patient: Great, thank you.

    Dr. Burnside: You’re welcome. Bye-bye.

Referral note

Dr. Burnside asks her assistant to call the social worker to book an appointment for Kelsey and her mother in one month. She writes a referral note for the family therapist.


Dr. Burnside
PO Box 1839
Humphrey’s Harbour, ON





Could you please see this 15 year old patient of mine who may be developing anorexia. I think some counselling might be helpful.


Thank you

W. Burnside



Consult letter

The social worker sends Dr. Burnside a consult letter which she receives three weeks after the appointment.

Dr. W. Burnside,
Main Street, Humphrey’s Harbour


Dear Dr. Burnside,

Thank you for your referral of the Cournoyer family. I met with Mrs. Cournoyer and your patient, Kelsey, on November 22. Unfortunately, the husband was unable to attend and Mrs. Cournoyer did not bring the two younger children as they would have missed school. Therefore, my assessment of the family dynamics and possibilities for therapy are somewhat incomplete.

Mrs. Cournoyer is a pleasant, well-groomed woman who seems quite concerned about her daughter’s eating disorder. She seems to be having trouble coping. She referred several times to the difficulty she is having in planning meals that will please all of the family. It may be of interest that Mrs. Cournoyer herself watches her weight carefully and in the past has gone to Weight Watchers. Kelsey seems a typical teenager. She didn’t say much, but seems to feel that she is fine and everyone is overreacting. This may be a form of denial, since her teachers have noted her grades are falling and she was told she could no longer be on the school cross-country team due to failure to maintain weight.

I am concerned about some underlying family issues, although Mrs. Cournoyer was reluctant to speak about her relationship with her husband in front of Kelsey. Mr. Cournoyer is a computer programmer who travels quite a lot and therefore leaves much of the parenting responsibilities to his wife. My sense is that he is a hard-driving person who may be rather distant and cold, except with his sons. He interacts with them primarily through sports. He plays hockey and golf and is evidently very competitive. I would sense that he is probably quite proud of his physical abilities. I asked Kelsey about her relationship with her father, to which she replied: “Well, he doesn’t beat me, if that’s what you mean.” Mrs. Cournoyer explained that Kelsey and her father have not had a good relationship since he made her remove a nose ring. He is impatient with Kelsey’s behaviour, and sees no reason why she can’t eat like everyone else. It would appear that family members are less frequently together at mealtime, as this has become a source of family distress and conflict.

I am not an expert on adolescent eating disorders, but it would not surprise me if at least part of Kelsey’s problem is related to the family dynamics. Mrs. Cournoyer has a history of eating concerns herself and the father appears to be a perfectionist, “Type A.” The mother is caring, but struggling somewhat ineffectually to deal with Kelsey and the rest of the family’s response to her problem. I think the husband may not be supportive and that this current issue has further strained a shaky marriage. I also sense that there may be financial problems. Mrs. Cournoyer indicated that her husband’s business is not going well right now.

I could address the family issues I have noted above, but only if the entire family is willing to participate in therapy. Mrs. Cournoyer seems quite uncertain that her husband would be willing or indeed could fit this into his business schedule. I have left it to her to contact me if this becomes possible. The travel issues and cost may prove insurmountable, since this service is not covered by provincial health insurance.

With regard to Kelsey, I am surprised that the entire teenaged population doesn’t have problems. Consider the barrage of media coverage of film stars, with the ideal of thinness on TV — never mind peer pressure. Body image is so important in our postmodern society. If indeed this is more than teenaged angst and a diagnosis of anorexia nervosa has been made, I can only suggest that she be referred to an academic centre for more expert treatment.

I hope that this will be helpful to you in managing this interesting and challenging family situation.

Yours sincerely,

George Palentino, BA, MSW

Reflective exercise 4

Referrals, consultations and scope of practice

Physicians do not work in isolation. While we emphasize physician-patient communication, inter- and intra-professional communication is equally important. As Lingard, et. al. (2004) indicate, “Pockets of specialty resources in the healthcare system are linked by written documents. These documents function on two levels: they are the tickets of safe passage for patients travelling to seek further care, and they are the visible currency of sanctioned co-operation among healthcare providers.” Since the sender and receiver are not face-to-face, there is no opportunity to question and clarify, as we would in talking to a patient. Thus, making our written communications clear and logical is particularly important. “To become effective intraprofessional communicators, physicians must develop a sophisticated sense of what to say and what not to say to form a story acceptable for telling in a professional context.”(Lingard, et. al. 2004)

What is “an acceptable story” varies with the context and requires the application of biomedical knowledge and clinical reasoning to that context. What all that means is that you select relevant biomedical, psychosocial and other information; interpret and integrate where necessary and then organize the information logically and insightfully. Note how this line of thinking parallels what occurs in the physician-patient encounter (see “Medical communication skills”).

The determination of relevance differs among health-care disciplines. The view of the patient and what is considered important relates to the discipline’s scope of practice. What a nurse, therapist or other health care professional is trained to do and — more importantly — what not to do is legally mandated by each province and territory as well as by local custom and circumstance. Much of the tension and disagreement between professionals from different disciplines comes from misunderstanding not only their scope of practice, but their way of understanding their practice and the health-care system. Different disciplines have different views of the way the world works. Therefore, it is important when referring and consulting that we not only know something about the work that the other professional can and should do, but that we not assume that they view the situation as we do. You will see more of this in “Exercise 5.” For more information on how the disciplines of medicine, nursing and social work interact, read Kharicha,, 2005.


Reread the referral note from Dr. Burnside to Mr. Palentino. Pretend that you are Mr. Palentino and received this note.

  • Would you know what Dr. Burnside wants?
  • Is there biomedical information that you would have liked to know?
  • Is the desired extent of Mr. Palentino’s involvement clearly indicated?
  • Is there a difference in writing a referral note to a physician or a social worker?

There is nothing to submit for this exercise. Reflect on your answers and read the suggested literature.


Now reread the consultation letter from Mr. Palentino to Dr. Burnside.

  • Notice the “flavour” of the information given.
  • How does it reflect the social worker’s view of the patient?
  • How might the letter differ if it were from a pediatrician or psychiatrist?


Read the applicable guidelines from the medical regulatory authority in your province or territory.


Next: Part 4