Medical complications occurring in adolescents with anorexia nervosa

A primary care approach to adolescent health careAdolescents are generally thought to be healthy, but at least 20% of North American adolescents have a serious health problem. 1 Most adolescent morbidity and mortality are due to intentional and unintentional injuries; alcohol, tobacco, and other drug misuse; depression; unplanned pregnancies; and sexually transmitted infections. 2 These problems are often rooted in behaviors that are diagnosed not with a laboratory test or a physical examination but through open communication between the physician and the adolescent.In the past few years, several guidelines have been developed for the care of adolescents, 3-6 each emphasizing the importance of psychosocial screening.Compared with other age groups and relative to their proportion of the population, adolescents in the United States underuse the health care system.Adolescent men are less likely than young women to visit physicians.[7][8][9] They also tend to use emergency departments, free clinics, and family planning clinics as their source of primary care.Adolescents are more likely to be uninsured than any other age group.[10][11][12][13] Physicians' visits with teens are typically short, with a mean duration of 16 minutes.Counseling or education is given to teens on only 50% of visits with their physicians.Adolescents report being more concerned about their physicians' characteristics than characteristics of the site or system.Teens prefer health care professionals who are honest, knowledgeable, and experienced and who wash their hands in the teens' presence.They want physicians who treat all patients equally, who emphasize confidentiality, and who relate well to teens.14 We describe the approach to adolescent care that we use in training residents and students who rotate through the Venice Family Clinic, Los Angeles, a free clinic with more than 70,000 total visits a year.We train nurse practitioners; pharmacy students; residents from internal medicine, pediatrics, family medicine, and obstetrics and gynecology; and third-and fourth-year medical students.Our goal is to provide trainees with the tools to enable them to feel comfortable and competent interviewing and examining teens.This approach is based on the training we provide, years of practice and teaching, and the literature cited. 2 APPROACH TO ADOLESCENTSIf adolescents do not trust their physicians, they will not feel comfortable discussing sensitive health concerns.14,15 To earn this trust, the physician must be seen as an ad-vocate for the teen.Issues of consent, confidentiality, and its limits are best discussed early in the visit.14,15 A useful beginning is an initial introductory meeting with both the adolescent and parents.During this initial encounter, we establish what the parents' concerns are, obtain a family history, and ask about previous medical problems.This begins the transition from parent to teen as the medical historian.We next ask parents to wait in the waiting room so that we can speak privately with the adolescent.We interview the adolescent alone, perform a physical examination with a chaperone, and then invite the parents back into the room at the conclusion of the visit to discuss our findings.It is important for teens to establish a separate relationship with the physician.On occasion, parents may express some resistance, and we then stress the importance of an adolescent having a physician with whom the teen can confide and discuss difficult issues that may arise in the future.We reassure parents that at the end of our encounter we will invite them back into the room to discuss any remaining issues.