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Hospitalists experience 'teen angst,' express caution about treating youths

Hospitalist Management Advisor, September 1, 2006

Adolescence is a confusing time, not only for those going through it (i.e., those between the ages of 14–18), but also for hospitalists who are asked to provide hospital care to these patients, who are neither children nor adults.

If an adolescent patient is being treated for diabetes, asthma, a drug overdose, or other conditions that seem within the hospitalists’ purview, it can be difficult to explain to another physician or administrator why it might not be a good idea for a hospitalist to treat an adolescent.

“Pediatricians frequently tell me that adolescents are not little adults and that they need to be managed differently,” says O. Scott Lauter, MD, a hospitalist at Lancaster (PA) General Hospital. “We commonly hear that discussion. If they are not little adults and have their own medical issues that are distinct to that age group, then this applies to the inpatient side as well as to the outpatient side.”

Hospitalists are commonly asked to test their clinical boundaries by taking new classes of adult patients of all stripes (e.g., hip-replacement patients). However, few requests make hospitalists as uneasy as an appeal by administration or local pediatricians to care for adolescent patients.

“We’re not formally trained to treat teenagers,” says James Leyhane, MD, a hospitalist at Auburn (NY) Memorial Hospital. “I’m used to communicating with adults and seniors,” Leyhane says. Breaking bad news, reading patients’ feelings, and addressing patients’ and families’ questions and concerns are communication skills that he says he has developed by working with adults, not teenagers.

Unassigned adolescent patients

Hospitalists say they are getting requests to take younger patients because local pediatricians don’t want to take call for unassigned adolescent patients or don’t want to take time away from neonatal care to admit an adolescent patient. Administrators, confident in hospitalists’ ability to achieve results—from reducing patient complaints and readmissions to improving the hospital’s productivity and bottom line—think, “If they can do this for medicine, why not for a select group of 14- to 18-year olds?” Leyhane says.

Although all hospitalists probably find the request to treat adolescents troubling, many concede that there is some latitude on the issue, at least for older teenagers. Others take a firm position—they will treat only those aged 18 years and older.

“What’s best for the patient must drive all your decisions,” Lauter says. “Do you want doctors who don’t have the education, training, and experience and [who] didn’t treat anyone under age 18 in their residencies taking care of these patients? The simple answer is hospitalists should only take patients 18 years and up and no younger.”

Lauter says pediatricians who do not want to take unassigned adolescent patients are “guilty of cherry-picking.”

A slippery slope

Hospitalists are less likely to mention their concerns about medical treatment at the prospect of caring for adolescent patients than they are to voice concerns about malpractice, parental consent, and communicating with teenagers.

“Is it safe, is it feasible for hospitalists to take care of these older kids?” asks Christopher Skinner, MD, FACP, director of hospital medicine at Spectrum Health—Reed City (MI) Campus. “Probably yes and no.”

Hospitalists may not be familiar with juvenile rheumatoid arthritis, but they may be perfectly capable of managing asthma, appendicitis, or diabetic acidosis. “The 13-, 14-, and 15-year-old age group comes in different shapes and sizes,” says Skinner. “They mature at different levels and reach puberty at different times. There are adolescents who are physiologically adults and those who are still children, but you don’t know that until you evaluate the patient,” he says.

Although a hospitalist may be on fairly safe ground caring for a 17-year-old or even 16-year-old patient, Skinner says taking any patient under the age of 18 years can be a slippery slope. “Once you cross that line, you can always draw it lower and lower. But there’s clearly a point in pediatrics that we don’t want to dip into,” he says.

Jack Martin Percelay, MD, MPH, FAAP, a pediatric hospitalist at Hunterdon Medical Center in Flemington, NJ, says although hospitalists might not be comfortable dosing for teenagers who are small for their age, for the teenager who is a 250-lb. football player, dosing would be similar to that for an adult.

Psychosocial issues intimidating

Percelay says it’s more often the psychosocial issues that intimidate the hospitalist when treating adolescents. Unassigned patients are likely to have more psychosocial issues to sort through, he adds. He notes that teenagers are often noncompliant with the treatment plan. Also, when treating a young patient, the physician is really “working with two patients simultaneously—the patient and the parent,” he says.

Hospitalists say that although they may be well-equipped to medically manage an adolescent patient hospitalized for a drug overdose, for example—perhaps even more experienced than most pediatricians—they are not qualified to work with these patients from a psychosocial perspective.

Hospitalists must frequently work with family members when patients are not competent to make their own decisions (e.g., the son or daughter of an elderly patient or the wife or husband of a patient in a coma), but caring for adolescent patients puts hospitalists in the unfamiliar terrain of parental consent and informed consent for those under 18. What are the rules for parental consent in situations such as pregnancy, sexually transmitted diseases, and drug use? Hospitalists feel ill-equipped to navigate these thorny situations because they are accustomed to dealing directly with independent adult patients who make their own decisions. “This is setting yourself up for trouble, especially if there is a bad outcome,” says Leyhane.

Malpractice fears

Describing the ramifications of a hypothetical case with a bad outcome, Lauter says, “Can you picture what a disaster that would be in the courtroom? On the witness stand, the hospitalist would be asked, ‘Could you describe your training in pediatrics? What pediatric journals do you read?’ You wouldn’t have any leg to stand on.”

Skinner agrees. “I would cringe at the prospect of being asked those questions in court.” In fact, most hospitalists would be hard-pressed to provide hard evidence of formal training and experience in pediatrics if there was a bad outcome with a younger patient. Most hospitalists say they would feel more comfortable providing a consult on adolescent patients under the care of pediatricians. Specifically, they say they need training in caring for adolescents before taking them on as patients.

Ideally, a pediatric hospitalist should care for these patients, but if a hospital doesn’t have one, medicine-pediatric physicians (med-peds) in the community are a good alternative for treating this age group, especially those patients with chronic health issues.

Note: Med-peds receive two years of residency training in internal medicine and two years in pediatrics, instead of the typical three-year residency. They are then eligible to take board exams in both internal medicine and pediatrics and eventually pursue recertification in the two specialties simultaneously. According to the Medicine-Pediatrics Program Directors Association (www.im.org/MPPDA), two-thirds of med-peds go into primary care, with the average physician spending 75% of his or her time practicing internal medicine and 25% practicing pediatrics.

Percelay says if there is a need in the hospital for hospitalists to care for adolescents, then they should receive formal training so they feel comfortable in this role. “If you know it’s going to happen,” Percelay says, hospital privileges should be worked out in advance rather than “waiting until Friday night at 8 p.m. when everyone is out of the hospital.”