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Adolescent Health Services: Missing Opportunities
lescent medicine specialist has received extensive training in the particular health conditions and concerns of adolescents, as discussed later in this chapter and further in Chapter 5. These specialists may be more prepared than other practitioners to address multiple health problems faced by adolescents, identify specific behavioral disorders, and offer guidance on health promotion and disease prevention. But access to adolescent specialists is severely limited, since these practitioners are commonly available only in academic health centers. According to one recent estimate, just 466 certificates in adolescent medicine were issued from 1996 to 2005 (for a population of about 40 million people aged 10–19), compared with 2,839 certificates issued in geriatric medicine during the same period (Hoffman, 2007).
In addition to difficulties associated with insurance conditions and the shortage of specialists, opportunities to engage adolescents in discussions pertinent to their particular needs and circumstances and to monitor their general health status are severely constrained by a lack of continuity with a clinician or place of care, a lack of privacy, a lack of clinical awareness or skill, racial and ethnic barriers, language-related barriers, clinician and patient gender-related barriers, and a lack of time to provide comprehensive preventive care even if adolescents attend their recommended visits (Chung et al., 2006). In their review of the literature, Chung and colleagues (2006) found that fulfilling only the most conservative (i.e., evidence- and cost/benefit-based) counseling recommendations of the U.S. Preventive Care Task Force would take an average clinician nearly 40 minutes per adolescent per year. Both national surveys of pediatricians and case studies have found that insurance reimbursements are inadequate to cover the necessary time (McManus, Shejavali, and Fox, 2003; O’Connor, Johnson, and Brown, 2000).
Several group plans and managed care organizations have recognized the importance of offering primary care services tailored to the needs of adolescents. These plans and organizations tend to provide greater opportunity for adolescents and their parents to engage with providers who are specially equipped to address their concerns and are skilled in discussing sensitive health issues, such as pubertal changes, sexual activity, behavioral and mental health conditions, and substance use.
More commonly, however, providers in private office-based primary care settings believe they are inadequately trained in adolescent health, and they are uncomfortable with discussing sensitive health issues of particular concern to adolescents and their families (as discussed further in Chapter 5). Moreover, few of these providers are aware of the Guidelines for Adolescent Preventive Services (discussed in Chapter 4) or the Healthy People 2010 objectives for adolescents and young adults (described in Chapter 2) (American Medical Association, 1997; U.S. Department of Health and Human Services, 2007). They fail to recognize the importance of incorporating