The Long and the Short of It

Recently I saw an adolescent boy for a routine physical exam. As he was disrobing in the exam room, our medical assistant handed me a sealed envelope along with his chart. The envelope contained a one-page letter from his mother, asking that I address several concerns: his frequent visits to the nurse at school, recurring headaches, a question of substance abuse, self body piercing, and the discovery of a cache of gay pornographic magazines in his bedroom. I had been allotted 15 minutes in my busy afternoon schedule for this visit.

It’s a small wonder that a decade after adolescent medicine became a board certified subspecialty, it is largely shunned by doctors seeking to advance their careers—only 466 certificates in adolescent medicine were issued by the American Board of Medical Specialties from 1996 to 2005. In the same period, 2,839 were issued in geriatric medicine.

Yet despite these numbers, geriatric medicine is in no better shape, as Dr. Atul Gawande attests in his recent New Yorker article, “The Way We Age Now.” “Despite a rapidly growing elderly population,” Gawande writes, “the number of certified geriatricians fell by a third between 1998 and 2004. Applications to training programs in adult primary-care medicine are plummeting, while fields like plastic surgery and radiology receive applications in record numbers.”

Why these trends? According to Dr. Gawande, “Partly, this has to do with money—incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, most doctors don’t like taking care of the elderly.”

I would argue that the same logic follows for adolescent medicine as well. Regardless of whether you consider adolescents as pediatric, family or internal medicine patients, they all require extended office time to address their issues and concerns. This is a luxury that most high-volume private primary-care practices can not afford. And then again, as is the case with the elderly, most doctors don’t like taking care of adolescents.

What can be done to remedy the situation?

“Nothing,” according to Chad Boult, a geriatrics professor at Johns Hopkins. “It’s too late.” Gawande reports that “creating geriatricians takes years, and we already have far too few. This year, just three hundred doctors will complete geriatrics training, not nearly enough to replace the geriatricians going into retirement, let alone meet the needs of the next decade.”

“Boult believes that we still have time for another strategy: he would direct geriatricians toward training all primary-care doctors in caring for the very old, instead of providing the care themselves. Even this is a tall order—ninety-seven per cent of medical students take no course in geriatrics, and the strategy requires that the nation pay geriatricians to teach rather than to provide patient care.”

In my estimation, the same strategy may hold up for adolescents, most of whom are cared for by pediatricians. But the pediatric clinician must be willing to devote the time to care for the adolescent patient.

So, what did I do with my adolescent patient? As it turned out, he knew nothing about his mother’s note. I addressed her concerns with him, point by point. After I examined him, I discussed the results. We talked about his issues. With his permission, I spent some time conferring with his mother afterwards. She was grateful, and so was he. “I never had a physical exam like this before,” he remarked as he left.

I felt immensely satisfied for a moment, until I stepped in to see my next patients—a pair of seven-year-old twin boys with severe behavioral problems and ADHD. As I glanced at my watch before entering the exam room, I noted that I was already half an hour behind.

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