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Filling the Gap in Adolescent Medicine

Issue: August 2008

By: Stacy Schwan

“In the same way that children are not little adults, adolescents are not really big children, nor are they little adults either.”

– Neville Golden, M.D., Division Chief of Adolescent Medicine at Lucile Packard Children’s Hospital at Stanford

As the world of adolescence grows increasingly complex and challenging, so adolescent medicine is evolving to better meet the needs of this unique demographic.

Adolescent medicine is a subspecialty that focuses on the medical, psychosocial and cognitive developmental needs of adolescents (defined as ages 10-25 by the World Health Organization and by the Society for Adolescent Medicine). “Where it’s different from other subspecialties is that it’s a horizontal instead of a vertical one - it crosses all specialties,” says Neville Golden, M.D., Division Chief of Adolescent Medicine at Lucile Packard Children’s Hospital at Stanford.

The roots of adolescent medicine as a formal discipline can be traced to the work of J. Roswell Gallagher, M.D., who in 1951 was charged with creating the first adolescent unit at Boston’s Children’s Hospital. In an effort to fill what was then recognized as a “gap” in traditional medicine, Dr. Gallagher pioneered an interdisciplinary approach to treating the “whole patient.” Conditions the program sought to treat included contagious diseases, athletic injuries, psychological and behavioral problems, growth and glandular abnormalities, poor nutrition and obesity, acne and anemia, and learning disabilities.

The movement grew and spread to where, in 1967, there were more than 50 such programs operating in the United States and abroad; however adolescent medicine as a discipline was not officially recognized by the American Medical Association until 1977.

Today, adolescent medicine programs continue to expand in both scope and methods of delivery to address the challenges faced by modern teens. Drug and alcohol abuse, homelessness, eating disorders, and gynecological problems are just some of the issues these programs strive to mitigate. Instead of the traditional hospital setting, programs are now offered through outpatient clinics, school settings and other community locales.

The Center for Adolescent Health at Lucile Packard Children’s Hospital exemplifies what today’s adolescent medicine programs have to offer. Programs administered through the Center include:

· A Teen and Young Adult Clinic that provides comprehensive, confidential health services, including reproductive health counseling and sexually transmitted infection testing;

· A Comprehensive Eating Disorders Program that treats adolescents with anorexia nervosa, bulimia nervosa and other eating disorders;

· A Pediatric Weight Clinic that which helps overweight and obese children and teens improve their health and quality of life;

· A Pediatric and Adolescent Gynecology Clinic that cares for girls with gynecological problems or abnormalities.

One of the Center’s more notable programs is the Adolescent Health Van, or “Teen Van,” a mobile unit that provides health services for uninsured and/or homeless youths in locations throughout San Francisco, San Mateo and Santa Clara counties. One of only five such mobile units in the country, the Teen Van is staffed by a physician specializing in adolescent medicine, a nurse practitioner, a social worker, and a dietitian.

The idea is to provide an “enhanced medical home” for adolescents, says Seth Ammerman, M.D., Medical Director for the van program since it’s inception in 1996. “People who don’t have health insurance don’t have a medical home,” he explains. “Statistically, people without a medical home end up in the E.R. when they’re sick. So not having a medical home ends up in late care, expensive care and poor care, because there is no focus on prevention and early intervention.”

Treatment at the van starts by obtaining a comprehensive, confidential history. Teens may come in for one or two problems, Dr. Ammerman says, however many are discovered to have ten or twelve unmet healthcare needs. “We spend a lot of time with each kid,” Dr. Ammerman says. “Many have suffered abuse or exploitation, so building trust is a very important aspect of what we do.” The approach must work - 70-80% of the homeless and uninsured teens who visit the van once return for additional treatment.

Changes in adolescent medicine over time can be measured by the growing number of programs throughout the country, says Dr. Golden, who has been specialist in the field since 1980. “More importantly, the impact we’ve had upon adolescent health across the nation has been tremendous. For example, we’ve done a good job with pregnancy prevention, so that the rates of pregnancy in the country did stabilize. We’ve been quite effective at trying to cut down on sexually transmitted infections in adolescents. We ask questions that pick up eating disorders sooner than used to be, so we intervene much earlier, and that’s known to improve mortality and improve prognosis.”

Physicians usually come through pediatrics or general practice to the field of adolescent medicine, which requires an additional three years in training after residency. For those who persevere, however, the rewards can be tremendous. Of the many satisfactions Dr. Golden has reaped throughout his career, one of the greatest has been “having a wonderful opportunity to enter the world of someone else and to be a positive role model.”

“Two weeks ago I got a picture and a graduation card of someone who just graduated medical school,” he says, “someone who I took care of when they were younger, who went through a rocky time in their life. This person said I was an inspiration to them, and a role model for them.

“That is enough.”

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