The history of adolescent medicine

Child Health Needs and the Adolescent Medicine Workforce Supply: 2020-2040

Adolescent medicine (AM) subspecialists provide primary, subspecialty, and consultative care to adolescents and young adults (AYAs). Given insufficient numbers of AM subspecialists to care for all AYAs, the workforce supports AYAs health care capacity through education, research, advocacy, and the development of policies and programs sensitive to their unique needs. A modeling project funded by the American Board of Pediatrics Foundation was developed to forecast the pediatric subspecialty workforce in the United States from 2020 to 2040 on the basis of current trends in each subspecialty. The model predicts workforce supply at baseline and across alternative scenarios, and reports results in headcount and headcount adjusted for percentage of time spent in clinical care, termed "clinical workforce equivalent." For the AM subspecialty, several scenarios were considered that modified the number of fellows and/or clinical time. The baseline model predicted low growth nationally (27% and 13% increase in total AM subspecialists and AM subspecialists per 100 000 children, respectively) and declines in AM workforce relative to population growth in census divisions with existing geographic workforce disparities. In the alternative scenarios, fellow number and clinical time changes did not significantly change predictions relative to the baseline model, but a 12.5% decrease in fellows predicted a 40% reduction in the workforce from baseline with a widening of geographic workforce disparities. On the basis of the expansive clinical and nonclinical roles of AM subspecialists and these forecasted workforce challenges, significant educational, practice, and policy changes will be necessary to bolster the supply of well-trained clinicians addressing the dynamic health care needs of AYAs.

"I can't pose a whole heap of questions that I know I don't have time to follow up"-Exploring perceptions of an adolescent transition program

BACKGROUND

Adolescent transition programs are patient education programs. They are geared towards enabling adolescents with chronic or long-term illnesses to become active partners in their health care and manage their own health. Although there is agreement about their importance, there is not an agreement on content or how they should be delivered. The study reported here was part of the first steps of an action research project.

AIM

Our aim was to explore how health professionals understand the program at our hospital, and their opinions of its implementation. This would advance our knowledge of the practice of the program to support its development.

METHODS

We conducted semi-structured individual interviews with 18 physicians and nurses. Data were analysed using qualitative content analysis. In our discussion of the generated data, we use the theory of practice architectures as a lens.

RESULTS AND DISCUSSION

We generated four themes through the analysis, namely "We are (back) at scratch", "Time is always an issue", "Getting them ready for what is to come-transition as a synonym to transfer" and "Raising topics that go beyond medical issues". Changes to a practice requires changes to the practice architectures. Practice architectures can both enable and constrain a practice. Our analysis suggests a need for a more unified perception of the program goals, the cultural-discursive arrangements. Health professionals see time as a significant barrier to implementation and changes to the material-economic arrangements are particularly called for, i.e., more time, space and staff to practice the program. These also tie into the social-political arrangements of the program.

CONCLUSION

There are arrangements in the practice architecture that currently seem to constrain the practice of the program. The practice is currently fragmented both within and across subspecialties. Efforts should be made to establish a more shared understanding of the program among health professionals. Furthermore, we should investigate how the practice of the program can be better supported.

Assessing the Gap in Adolescent Emergency Care Training for Emergency Medicine Residents: A Systematic Review

Over 1.5 million U.S. adolescents rely on emergency services for the majority of their healthcare, with increasing presentations (particularly for mental health complaints) during the coronavirus disease 2019 (COVID-19) pandemic. However, a majority of physicians practicing emergency medicine report feeling unprepared to care for adolescent patients. In turn, adolescent patients often report feeling uncomfortable or unsafe when attempting to access emergency care. Despite this deficiency, the extent to which adolescent medicine is addressed during emergency residency medical training remains unclear. Our objective in this systematic review was to identify any existing, publicly available curriculum targeted to teach adolescent emergency care during emergency medicine residency. We conducted a keyword search within the Medline Ovid, Embase, Web of Science, and Cochrane databases to identify relevant literature published between the years of 1968 and 2021; publications meeting inclusion criteria were then analyzed for content. Despite an extensive review of the existing literature, we identified no systematized curriculum and only seven individual papers describing educational efforts to promote competency in adolescent care among emergency medicine residents. Of the resources available, none provide instruction on the management of multiple adolescent presentations, nor common conditions that should be included in a more comprehensive general emergency residency curriculum. No standardized curricula exist for the instruction of relevant adolescent care in an emergency medicine residency. We conclude that the available education for emergency medicine residents is lacking in the area of adolescent care and future work is needed to identify specific competencies to target with further intervention.

Adolescent medicine training in postgraduate family medicine education: a scoping review

INTRODUCTION

Adolescents and young adults require age-appropriate healthcare services delivered by clinicians with expertise in adolescent medicine. However, resident family physicians report a low perceived self-efficacy and under-preparedness to deliver adolescent medical care. We conducted a scoping review to map the breadth and depth of the current evidence about adolescent medicine training for family medicine residents.

CONTENT

We followed Arksey and O'Malley's framework and searched seven electronic databases and key organizations' webpages from inception to September 2020. Informed by the CanMEDS-FM, we analyzed the extracted data concerning basic document characteristics, competencies and medical topics using numerical and qualitative content analysis.

SUMMARY

We included 41 peer-reviewed articles and six adolescent health competency frameworks (n=47). Most competencies taught in family medicine programs were organized under the roles of family medicine expert (75%), communicator (11.8%), and professional roles (7.9%). Health advocate and leader were rarely included (1.3%), and never scholar.

OUTLOOK

The omission of multiple competency roles in family medicine resident education on adolescents is insufficient for family physicians to deliver optimal care to adolescents. The combined efforts of family medicine stakeholders to address adolescent medicine competency gaps may positively impact the perceived competence reported by family medicine residents.

The status of adolescent medicine: building a global adolescent workforce

Remarkable public health achievements to reduce infant and child mortality as well as improve the health and well-being of children worldwide have successfully resulted in increased survival and a growing population of young people aged 10-24 years. Population trends indicate that the current generation of 1.8 billion young people is the largest in history. However, there is a scarcity of dedicated resources available to effectively meet the health needs of adolescents and young adults worldwide. Growing recognition of the pivotal roles young people play in the cultures, societies, and countries in which they live has spurred an expanding global movement to address the needs of this special population. Building an effective global workforce of highly-skilled adolescent health professionals who understand the unique biological, psychological, behavioral, social, and environmental factors that affect the health of adolescents is a critical step in addressing the health needs of the growing cohort of young people. In this review, we aim to: 1) define a global assessment of the health needs for adolescents around the world; 2) describe examples of current training programs and requirements in adolescent medicine; 3) identify existing gaps and barriers to develop an effective adolescent health workforce; and 4) develop a call for targeted actions to build capacity of the adolescent health workforce, broaden culturally relevant research and evidence-based intervention strategies, and reinforce existing interdisciplinary global networks of youth advocates and adolescent health professionals to maximize the opportunities for training, research, and care delivery.

The foundations of interdisciplinary fellowship training in adolescent medicine in the United States

The field of adolescent medicine, having developed from the specialty of Pediatrics, encompasses a holistic and developmental approach from its very origin. While its foundations were in medicine, early leaders in the field emphasized the importance of mental health care as well as nutrition, public health, and social justice. As the specialty became further established in the US with the creation of an academic society, board certification and training program accreditation, the interdisciplinary nature of adolescent medicine practice and training became formalized. This formal recognition brought with it strict guidelines with regards training and board certification. Despite the often Byzantinian training requirements, an interdisciplinary approach forms the core of adolescent medicine practice, and the incorporation of interdisciplinary training is a necessity for graduate medical education programs in the field of adolescent medicine.

A global perspective: training opportunities in Adolescent Medicine for healthcare professionals

PURPOSE OF REVIEW

The review briefly describes the current state of adolescent health globally, and highlights current educational and training opportunities in Adolescent Medicine for healthcare providers worldwide.

RECENT FINDINGS

Despite a growing body of literature demonstrating a shift toward recognizing Adolescent Medicine as a subspecialty, there are very few countries that offer nationally recognized Adolescent Medicine training programs. In recent years, several countries have begun to offer educational programming, such as noncredentialed short training programs, conferences, and online courses. Challenges, including cultural barriers, financing, and lack of governmental recognition and support, have hindered progress in the development of accredited training programs globally.

SUMMARY

It is crucial to support efforts for sustainable training programs, especially within low and middle-income countries where a majority of the world's adolescent population lives. Sharing knowledge of existing curriculums, programs, and systems will increase opportunities globally to build regional capacity, increase access to interdisciplinary services, and to implement health-promoting policies for youth worldwide.

Adolescent health in South America

Since the 1950s, a significant amount of work has been done on behalf of the comprehensive health of young people in South America. This article focuses on the regional process of training health professionals to work with this age group. There are countries in which the growth of adolescent health training has been significant, others that have made progress but still have a narrower offer of teaching activities, and a few where only very basic and limited training is available. Latin American professional associations, scientific societies, and international organizations have also contributed to the education of the adolescent health work force. Although the training in the region has advanced in some countries to the point that there is specialization in adolescent medicine, much remains to be done. Certain regional conditions have contributed to the education of providers in adolescent care. The most important has been the existence of professionals who have been highly motivated to improve the health of young people. They have worked very hard and with great commitment to achieve this goal. There have also been important obstacles to educating professionals in adolescent care. Aside from the usual lack of funding, barriers have existed in the health care system and its providers, as well as the training entities and because of certain South American conditions. Finally, this article describes the regional adolescent medicine programs and the status of recognition of this specialty, and addresses the opportunities and challenges for adolescent health training.

Opportunities and challenges in adolescent health training abroad: trainees' experience and perspective

As the global adolescent population increases and as there is enhanced recognition internationally of the unique nature of the adolescent period, the need for specialized training in adolescent medicine for international physicians becomes more apparent. There are challenges in securing placement in an adolescent medicine fellowship program, as well as, on acceptance, challenges with acculturation to a new setting, socially, academically and clinically. During fellowship, international medical graduates (IMGs) are exposed to new opportunities such as learning best-practices and being mentored by experienced advocates and clinicians in the field of adolescent health and medicine. This paper considers recommendations for improving adolescent medicine fellowship programs with a focus on IMGs.

Nicotine, adolescence, and stress: A review of how stress can modulate the negative consequences of adolescent nicotine abuse

In order to continue the decline of smoking prevalence, it is imperative to identify factors that contribute to the development of nicotine and tobacco addiction, such as adolescent initiation of nicotine use, adolescent stress, and their interaction. This review highlights the biological differences between adolescent and adults in nicotine use and resulting effects, and examines the enduring consequences of adolescent nicotine administration. A review of both clinical and preclinical literature indicates that adolescent, but not adult, nicotine administration leads to increased susceptibility for development of long-lasting impairments in learning and affect. Finally, the role stress plays in normal adolescent development, the deleterious effects stress has on learning and memory, and the negative consequences resulting from the interaction of stress and nicotine during adolescence is reviewed. The review concludes with ways in which future policies could benefit by addressing adolescent stress as a means of reducing adolescent nicotine abuse.

Knowledge of communicable and noncommunicable diseases among Karen ethnic high school students in rural Thasongyang, the far northwest of Thailand

Background

The double burden of communicable and noncommunicable diseases (NCD) is an increasing trend in low- and-middle income developing countries. Rural and minority populations are underserved and likely to be affected severely by these burdens. Knowledge among young people could provide immunity to such diseases within a community in the long term. In this study we aimed to assess the knowledge of several highly prevalent NCDs (diabetes, hypertension, and chronic obstructive pulmonary disease [COPD]) and several highly incident communicable diseases (malaria and diarrheal diseases) among Karen high school students in a rural district in far northwest of Thailand. The aim of the study is to explore information for devising life-course health education that will be strategically based in schools.

Method

A cross-sectional survey approved by the ethics committee of Boromarajonani College of Nursing Nakhon Lampang (BCNLP), Lampang, Thailand was conducted in Thasongyang, Tak province, from September 2011 to January 2012. Questionnaires for assessing knowledge regarding diabetes, hypertension, COPD, malaria, and diarrheal diseases were delivered to all 457 Karen high school students attending Thasongyang high school. A total of 371 students returned the questionnaires. Experts’ validation and split-half reliability assessment was applied to the instrument.

Results

Students’ main sources of health information were their teachers (62%), health care workers (60%), television (59%), and parents (54%). Familial risk factors of diabetes and hypertension were not known to more than two thirds of the students. Except obesity and physical inactivity, lifestyle-related risk factors were also not known to the students. Though living in a malaria-endemic area, many of the Karen students had poor knowledge about preventive behaviors. Half of the students could not give a correct answer about the malaria and hygienic practice, which might normally be traditionally relayed messages.

Conclusion

Health education and knowledge about common NCD and communicable diseases are yet to be prompted among the Karen students. A broader and more comprehensive school-based health education strategy for prevention of double burden diseases would benefit the rural minority population at the Thai-Myanmar border.

Health care professional communication about STI vaccines with adolescents and parents

Vaccination of adolescents against sexually transmitted infections (STIs) is an important prevention strategy that may reduce the global burden of disease. The World Health Organization, Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, and other national health agencies recommend the use of existing STI vaccines, and many countries have incorporated them into their routine vaccination schedule. Despite this, however, data indicate that STI vaccine uptake is suboptimal for a variety of reasons. Health care professionals (HCP) have been shown to have a strong beneficial effect on STI vaccine uptake, yet studies demonstrate that many HCPs fail to discuss or recommend them to adolescent patients. This review article focuses on HCP communication about STI vaccines with adolescents and their parents. It describes STI vaccine message content and delivery as well as the context in which HCPs formulate their messaging approach. It also examines other contextual factors that may shape communication about STI vaccines. Studies from many countries indicate that HCPs often possess misinformation about adolescents, including their sexual risk behaviors, as well as STIs, vaccine safety and efficacy, and STI vaccination recommendations. They also have misconceptions of parental barriers to STI vaccination. These may impact STI vaccine communication and have a negative influence on STI vaccine uptake. These findings highlight the critical need for improved HCP education related to adolescent health, sexuality, and STI vaccination. This may be particularly important in settings without an existing infrastructure or expertise in caring for this unique patient population.

[Historical aspects of the institutionalization of adolescent healthcare in the state of São Paulo, 1970-1990]

The article explores historical aspects of integral healthcare for adolescents in the state of São Paulo, particularly in regard to the implementation of pioneering services and programs. Against the backdrop of Brazil's social and political context during this period, it contextualizes the challenges, clashes, and difficulties that arose within the institutions involved in developing this field, from the perspectives of clinical medicine and of collective health. Grounded on documental material, the study re-examines the construction of groups of expertise and of the field of adolescent health care as part of the dialectical interplay between the construction of a new area of medical practice based on clinical work and a field of knowledge and practices in collective health based on integral health care of an interdisciplinary, inter-sectoral nature.

The Strategic Planning Committee report: the first step in a journey to recognize pediatric hospital medicine as a distinct discipline

The field of pediatric hospital medicine (PHM) has experienced phenomenal growth over the past decade. Academic contributions by pediatric hospitalists include the creation of PHM core competencies, national collaborative PHM networks for both research (the Pediatric Research in Inpatient Settings network) and quality improvement (the Value in Inpatient Pediatrics network), a robust and well-attended annual scientific meeting, and an increasing number of divisions or sections of PHM in pediatric departments across the country. Many pediatricians are choosing to pursue careers in PHM,^, and several postgraduate training programs for PHM have emerged. Similar to other generalist pediatric fields,^- the question as to how best for PHM to evolve as a distinct discipline has arisen. Several training and/or certification options are feasible and have been examined by the pediatric hospitalists who constitute the Strategic Planning (STP) Committee. The objectives of this commentary are to (1) describe the work done to investigate these options to date, (2) provide a framework for evaluating them, and (3) describe next steps. This commentary will neither justify subspecialty status for PHM, which is currently still debated within the field, nor will it compare the development of PHM as a subspecialty with other generalist fields because such a comparison is premature.

Perspectives of youths and adults improve the care of hospitalized adolescents in Spain

PURPOSE

The purpose of this study was to determine and compare the preferences and priorities of youths and adults about the best ways to improve hospitals to have an impact on the quality of life of hospitalized adolescents.

METHOD

Participants in this study were 364 adolescents between 14 and 17 years of age (96 hospitalized) and 148 adults (96 parents of patients and 52 health professionals). All the participants completed a questionnaire about their preferences and priorities with regard to hospitalization.

RESULTS

A high degree of agreement among the youths and the adults was observed, especially regarding the importance assigned to agreeableness of clinical staff to improveadolescents' experience of hospitalization. Some discrepancies also were observed. The youths granted more importance to issues related to filling in time, specifically to the leisure technology available for patients. The adults assigned more importance to the organization of the hospital stay, in particular, for adolescents to be admitted with patients of the same age and for them to receive academic support in the hospital.

CONCLUSIONS

Adolescents express a coherent perspective about the aspects that may help them feel better in the hospital that in some ways is different from the perspective of the adults who care for them.

Mapping a global agenda for adolescent health

Major changes in health are underway in many low- and middle-income countries that are likely to bring greater focus on adolescents. This commentary, based on a 2009 London meeting, considers the need for strategic information for future global initiatives in adolescent health. Current coverage of adolescent health in global data collections is patchy. There is both the need and scope to extend existing collections into the adolescent years as well as achieve greater harmonization of measures between surveys. The development of a core set of global adolescent health indicators would aid this process. Other important tasks include adapting and testing interventions in low- and middle-income countries, growing research capacity in those settings, better communication of research from those countries, and building structures to implement future global initiatives. A global agenda needs more than good data, but sound information about adolescent health and its social and environmental determinants, will be important in both advocacy and practice.

Reactions of pediatricians to refusals of medical treatment for minors

PURPOSE

Treatment refusals in pediatrics must balance parental decision-making authority and best interest. General pediatricians and subspecialists were surveyed to understand the factors that influence their responses to refusals including (1) prognosis, (2) concordance of parent-minor decision, and (3) minor autonomy.

METHODS

Of 1,120 eligible pediatricians, 421 (37.6%) randomly selected from the American Academy of Pediatrics Web-based Directory completed a survey about their reactions to refusals of treatment by parents, minors, or both in cancer scenarios with a 5-year expected overall survival of 80% or 15% for both an 11-year-old and a 16-year-old minor. Statistical analyses compared pediatrician willingness to respect a refusal and the relative importance of various factors to explain physician reasoning.

RESULTS

Pediatricians were less likely to respect refusals when prognosis was good. Pediatricians were most likely to respect a refusal when prognosis was poor and when parent and minor concurred in their decision (93%, n = 360/385 for the 16-year-old vs. 89%, n = 345/386 for the 11-year-old, p < .05). When parent-minor dyad disagreed, pediatricians were more likely to accept a refusal by a 16-year-old minor as compared with an 11-year-old (28%, n = 111/393 vs. 4%, n = 18/405 in good prognosis, p < .001; and 65%, n = 251/384 vs. 20%, n = 79/389 in poor prognosis, p < .05).

CONCLUSIONS

Pediatricians' decisions whether to respect treatment refusals for minor patients are multifactorial. When prognosis is good, best interest dominates. When prognosis is poor, parental authority is more important in younger minors, and minor autonomy is more important in older minors.

Sex, drugs, and politics: the HPV vaccine for cervical cancer

HPV is the most common sexually transmitted infection in the world. While most strains are relatively harmless, some increase a woman's risk of developing cervical cancer. This article explores the intimate, contested relationships among etiologies of cervical cancer, development and use of the new HPV vaccine, and contested notions of sexuality. We particularly focus on shifts in US health care and sexual politics, where the vaccine has animated longstanding concerns about vaccination (e.g. parental rights, cost, specialisation) and young women's bodies and behaviour. We conclude that vaccines are a distinctive kind of pharmaceutical, invoking notions of contagion and containment, and that politics shape every aspect of the pharmaceutical life course.

Adolescent otolaryngology

OBJECTIVE

To determine the pattern of disease amongst ambulatory adolescents referred to a pediatric otolaryngology outpatient department.

METHODS

Retrospective chart review of adolescents newly referred to a tertiary pediatric otolaryngology outpatient department over a 12-month period.

RESULTS

One hundred and fifteen patients were included (male 56, female 59) mean age 14.9 years. There were 36 (31%) patients who had previously required otolaryngology management for another condition, and 29 patients with complex medical conditions. Investigations, including audiology and medical imaging, were performed in 35 patients. The patients were managed surgically 34 (30%), medically 28 (24%), referred to other departments 10 (9%) had no intervention 21 (18%), while 22 (19%) failed to attend for follow up.

CONCLUSION

Ambulatory adolescent patients present with a comparable spectrum of otolaryngological problems to other pediatric age groups. These patients appear to be well managed by pediatric otolaryngologists, and there does not seem to be a need to develop a free standing adolescent otolaryngology subspecialty within tertiary pediatric otolaryngology at this time.

Patient safety problems in adolescent medical care

PURPOSE

This study estimates the annual incidence and describes the nature, types, and contributing factors involved in patient safety problems in adolescent medical care.

METHODS

This study uses data from the population-based Colorado and Utah Medical Practice Study to describe the incidence of hospital-based adverse events and preventable adverse events in adolescents and "critical incidence analysis" data reported by pediatric clinicians to elucidate the nature, types, and contributing factors in adolescent patient safety problems.

RESULTS

The incidence of adverse events in adolescents in the Colorado and Utah Medical Practice Study was 2.74 (CI 95% = 2.62-2.86), significantly higher than all other age groups of children. The incidence of preventable adverse events in adolescents was 0.95 (CI 95% = 0.65-1.25), significantly higher than that of children 1-12 years old, but not significantly different than infants. Diagnostic events were most common, followed by medication events. Services associated with the highest frequency of events were pharmacy and Family Practice. In the critical incident analysis, adolescent-specific factors contributed to 54.8% of the described patient safety problems. Discomfort with adolescents, a factor not described for other age groups of children, contributed to 17% of the adolescent patient safety problems.

CONCLUSIONS

Adolescents experience relatively high rates of patient safety problems compared with other age groups of children. Adolescents represent a defined population with a patient safety risk profile that differs from adults and younger children. The substantial contribution of adolescent-specific factors suggests that patient safety improvements, to be effective, should address adolescent-specific risks.