Want more young patients?

By Gail Garfinkel Weiss
Senior Editor

Older teens and twenty-somethings can be challenging and appreciative patients, and can insure a healthy practice base for years to come.

From a physician's standpoint, the young adult years are "low maintenance" times. "You see 18- to 25-year-olds for college physicals, cuts, lumps, bumps, and acute illnesses," says FP Charles Davant III of Blowing Rock, NC. "They never come in for a well visit without a form to be filled out." Or, perhaps, a need for a birth control prescription.

But low maintenance isn't always a bad thing. Many young men and women need you more than they're willing to acknowledge, says Judy Bee, a consultant with the Practice Performance Group in La Jolla, CA, and they'll appreciate having a familiar face to turn to during a medical crisis. At the same time, a diverse patient population keeps your practice from getting stale.

"You need to build a family practice from youth," says FP Steven Kamajian of Montrose, CA. "I've been at my current location for 23 years, and many of my 40-year-old patients began seeing me when they were 17."

Making your practice a magnet for younger patients does take a bit of preparation, though. Here's advice on how to do such things as expand your screening questionnaire to include queries about eating disorders and sexual identity, make your waiting room appealing, and create a buffer zone when Mom or Dad tags along on office visits.

Talking your way through the exam

An initial visit with any patient can be awkward. But with young patients, there's the added burden of their reluctance to take advice, and their conviction that they're going to live forever. "These visits are best used to let them know that help and sage advice are available if and when they realize they need it," says Davant.

Internist Alan Morrison of Fort Lauderdale emphasizes the importance of being nonjudgmental when questioning and fielding responses from youths. That doesn't mean you can't tell them, authoritatively, that certain behaviors are harmful to their health. For example, FP Craig Wax of Mullica Hill, NJ, has a few young patients who've had tongue or eyebrow piercings. "I advise against those things from a medical standpoint: risk of pain, infection, permanent disfigurement," he says.

He also makes every effort to persuade young smokers to abandon the habit. "I try to reach them with common sense, age-relevant discussions," he notes. "If, say, they're seeing me because they have a sore throat, I bring up the relationship between smoking and recurrent infections."

Indeed, with younger patients you're better off emphasizing immediate effects than long-term consequences, says David A. Birch, chair of the Department of Health Education and Recreation at Southern Illinois University at Carbondale. Some examples: "People don't like to be around smokers." "If you lose your license for drunk driving, you won't be able to spend as much time with your friends." "You risk getting tossed off the track team if you continue to use drugs."

Even if you have a screening questionnaire, don't count on the patient putting everything in writing. Internist Gregory Hood of Lexington, KY, watches for subtle clues in young adults' behavior and appearance—such as unwillingness to make eye contact, eroded dental enamel, or scars on the knuckles—that might point to eating disorders or other conditions. "Alcohol is often a discussion point," he says. "Typically they are vague on the questionnaire as to amounts. This can be a good time to discuss limits nonjudgmentally, based on medical evidence."

Wax steps in if he thinks a young patient is treating his own depression, anxiety, or ADHD with cigarettes or alcohol. "They may not have the mechanisms to look at themselves objectively. That's difficult for a person of any age, let alone someone who's just figuring out who he is."

While Hood acknowledges that "it can be a hard sell to convince this invincible age group that there are limits to what they can do to their bodies," he was able to persuade a young woman that her anxiety and insomnia were related to her drinking a case and a half of Mountain Dew a day.

Older teens experiencing their first "adult" physician encounter might be more nervous than you'd expect. FP Kelli Ward of Lake Havasu City, AZ, does what she can to maximize the comfort factor. For instance, "If an 18-year-old is coming in for her first Pap smear, I explain everything that's going to happen, go over the equipment, and talk to her throughout the exam. Once we're done I make light conversation, like, 'See, all the hype just for that!' "

Even if you can't do much for a patient medically, you can help in important ways. When one of Ward's patients—a 20-year-old male—was paralyzed in an accident, the doctor arranged for him to meet other patients with spinal cord injuries. "I wanted him to see people who were living a full life despite similar problems," she says, "and to know that there's a community out there to help support him."

Dealing with the parents

"In most states, patients 18 or older are considered adults, and therefore their health information and medical records are confidential," says Denise Sanders, an attorney with Kern Augustine Conroy & Schoppmann in Bridgewater, NJ.

As with many rules, though, there are exceptions—like when you have good reason to believe that the patient is going to hurt himself or someone else. In general, however, you need a young adult's permission before you can disclose health information to anyone—including a parent.

"I inform both the parent and the young adult that my relationship is with the latter," says internist Mary Ann Bauman of Oklahoma City. "I point out that if the young person is engaged in behaviors that I think are risky I will urge her to confide in a parent, but I won't break her confidentiality. I let the parent know that the youth needs to have a place where she can be totally honest so she can get the correct information."

If a young adult wants mom or dad in the exam room, that's fine with Bauman. Alan Morrison, too, will allow a parent in the room—but not for the entire visit. "I'll explain, 'We'll all talk together, then you're going to take a break'—I'll point to the parent—'and your son/daughter and I are going to talk for a while. Then you're going to take a break'—I'll point to the teen—'and I'm going to talk to your mom/dad.' Now everyone knows what's coming, and each person gets to speak candidly during 'break' time."

"A dicier problem," says Steven Kamajian, "is when a parent insures an adult child, gets an EOB, and insists on being told what's going on. I refuse to answer any questions, and some parents go through the roof."

If a young adult has a chronic illness and is doing well, Charles Davant sees nothing wrong with telling a parent that "Sam's managing his diabetes nicely" or "Betty's asthma is a lot better." The tough ones, he adds, "are the 21-year-old anorexic who may need involuntary hospitalization or the 24-year-old too proud to tell his parents that he can't afford the medication for his Crohn's disease."

What if a mother has a question about a youth you haven't met? Hood tells her to ask the youth to call for an appointment. "Building family relationships within a practice," Hood says, "can be one of the fun parts of medicine."

Reaching out to generations X and Y

Recruiting younger patients might mean establishing a presence on a local college campus or creating a Web site geared toward young adults. "You can develop a list of questions on the Web site with the instructions, 'Here are 15 questions you should ask yourself; if you answer Yes to more than three, we should talk'," says consultant Judy Bee.

Bee's colleague, Jeffrey J. Denning, suggests that you put magazines of interest to the younger set in your waiting room. "Not Popular Hot Rodding or Tattoo," he says, "but there are plenty of mainstream publications young patients won't expect to find in a doctor's office, like GamePro." If you're not sure which youth-oriented publications to subscribe to, Denning suggests asking the experts: "Survey under-25 patients, and give participants a two-dollar bill for their willingness to help." The currency, a popular collector's item, is available at most banks.

"I aggressively market to the teenagers who are 'aging' into adulthood in my practice," says FP Robert W. Patterson of Sanford, NC. "I send a newsletter and e-mail notes to 'my' college kids. I follow them as they enter the working world. We send birthday cards, holiday cards, and letters. When they get engaged we send a 'wedding packet,' and when they have kids we send a 'new parent' packet."

Kelli Ward woos younger patients by participating in community outreach projects, including career days at the town high school and community college. Similarly, Mary Ann Bauman reaches 3,000 to 5,000 teens each year with her "On Your Own" presentation for high school juniors and seniors about their lives after high school. "Many of the people in my practice have been through that program," she says.

Craig Wax does a weekly radio show, called "Your Health Matters," on the Rowan University radio station. He interviews health care providers and other medical experts on topics like diet, exercise, and stress management. His Web site, www.healthisnumberone.com, has several essays targeted to younger patients, including: "Alcohol and Drugs (Young Women)," "Diet/Healthy Diet," and "Drug Abuse in Teens (Prevention)."

"Remember what's most interesting to young adults: sex appeal," Denning emphasizes. "To the extent they want to be healthy and fit, it's mostly about attracting the opposite sex. By placing articles or giving short presentations on fitness, skin conditions, birth control, or weight loss you send the message that you're the expert on these issues.

"If writing is hard for you, get an English or journalism teacher to interview you and ghost the article. These folks can be culled from your patient files and, when paid a modest fee—$50 or $100—they'll become an asset to the practice and an evangelist for you in the bargain."

HEADSS up! Questions to ask young adults

Fort Lauderdale internist Alan Morrison, who specializes in treating adolescents and young adults, uses a HEADSS assessment to draw out young patients. The acronym stands for:

Home. Where do you live? With whom?

Education and Employment. Do you go to school? Where? What grade are you in? Any years repeated/classes failed? Do you have a job? Where do you work?

Activities. What do you do for fun? Are you active in sports? Do you exercise? Whom do you hang out with?

Drugs. Do you smoke cigarettes? How many a day? Do you drink alcohol? What kind and how often? What drugs have you tried? How often?

Sexual activity/identity. Are you sexually active? If so, are you using condoms? What about other forms of birth control? How many partners have you had? How old were you when you first had sex? Do you think you might be lesbian, gay, or bisexual? Has anyone ever forced you to have sex?

Suicide/depression. Do you ever feel sad or lonely? How do you handle that? Have you ever felt so bad that you thought about hurting yourself or that life wasn't worth living? How do you feel today on a scale of zero to 10, with zero meaning very sad and 10 meaning very happy?

Morrison also talks about violence. He asks patients how conflict is resolved at home and elsewhere, if they've ever been hit, or if they have access to guns. To establish a rapport, he makes casual references to the younger generation's preferred music, clothing styles, and fads. "It helps if you know things you're not supposed to know as a doctor, like the words to popular songs or this year's 'in' sneakers," he says.

It also helps to be shockproof. When a 17-year-old acknowledged that she was sexually active, Morrison segued into the "How many partners do you have?" question. "Just one," the patient answered, "I'm not into group sex anymore."

Web resources

The younger generation is totally comfortable online. If you aren't sure you'll see your young patients on a regular basis, you can suggest they at least tap into these health-related Web sites for—and about—young adults.

www.goaskalice.com
Run by Columbia University, this question-and-answer site addresses a wide range of issues, including relationships, sexuality, sexual health, fitness and nutrition, emotional health, drugs, and general health.

www.ama-assn.org/ama/pub/category/1947.html
The adolescent health section of the AMA's Web site features information on clinical and preventive services, adolescent health resources, and numerous links.

www.acha.org
This site, sponsored by the American College Health Association, has links to health-related publications and to online resources addressing HIV/AIDS, contraception and safer sex, sexual health, eating disorders, sexual identity, mental health, nutrition, sexual assault, substance use/abuse, women's health, and other issues.

www.cdc.gov/nccdphp/sgr/adoles.htmThis is the Centers for Disease Control and Prevention's "fact sheet" on adolescents and young adults. It focuses on the benefits of physical activity and on what communities can do to encourage youths to eat well and exercise.

Gail Weiss. Want more young patients?.

Medical Economics

Apr. 25, 2003;80:30.