December 30, 2022
While we all know that confidential care is important for caring for teenagers, a surprising number of us don’t actually spend time alone with our adolescent patients, leaving them vulnerable to health risks without our care and guidance. Join teen health expert, Dr. Katy Miller, medical director of Adolescent Medicine at Children’s Minnesota, to learn how and why confidential care is so important and what best practices to follow when providing confidential care to teenagers.
Transcript
Dr. Angela Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to The Kid Experts, where the complex is our every day. Each week, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge and perhaps change how you care for kids.
Welcome to Talking Pediatrics. I’m your host, Dr. Angela Kade Goepferd. Teenagers. They are a part of all of our practices as pediatric clinicians and some of us love engaging in the complexities of their care, and some of us shy away from these developing young adults. But what are some of the things that are critically important for us to know when it comes to caring for adolescents?
One of the things at the top of the list is confidentiality. Teenagers who reported having private time with their physicians have more positive attitudes about their healthcare providers and are more willing to discuss sensitive topics with them.
However, according to a study in the Journal of Adolescent Health in 2019, up to a third of young adults have never had a private discussion with their clinician. And the younger the adolescent, the less likely they’re having private time with their clinician. Alarmingly, only 14% of 13- to 14-year-old boys have ever had a confidential conversation with their clinician. Here to talk to us today about not only the importance of confidentiality when caring for adolescents, but how to do it well is our adolescent health kid expert, Dr. Katy Miller, the Medical Director for Adolescent Medicine at Children’s Minnesota. Katy, thanks for joining me today.
Dr. Katy Miller: Thanks for having me.
Dr. Angela Kade Goepferd: All right, let’s start out with a little about you. So, how did adolescent health become the focus of your career and why do you love caring for teenagers so much?
Dr. Katy Miller: I think teenagers are so much fun, and I know how much you love teenagers, Angela, even though your voice was dripping with disdain when you said “teenagers” at this [inaudible 00:01:59].
Dr. Angela Kade Goepferd: I do love them. I do love them.
Dr. Katy Miller: I think they’re at such a fun developmental phase in their life where what they’re going through right now and how they react to it and respond to it has the trajectory to really change how the rest of their life goes. So, I think they’re at a really vulnerable state, but also a really potentially powerful state.
Dr. Angela Kade Goepferd: Yeah, absolutely. I think that’s what I love about working with adolescents as well and they’re really smart and they’re really insightful, far more so than we probably give them credit for.
Dr. Katy Miller: Totally. And they’re really funny. They’re just really fun.
Dr. Angela Kade Goepferd: They are. So, let’s lean into confidentiality specifically. So, why is that so important and why does it matter so much for adolescents?
Dr. Katy Miller: Well, we know that adolescents who have access to confidential time with their providers will share more information, and some of that information is critically relevant to their health.
If you have a patient with sickle cell disease or cystic fibrosis or really any chronic medical condition, they should be getting private time with their doctor because they could be at risk of pregnancy, they could have a sexually transmitted infection, they could be using large quantities of marijuana or tobacco that have really important outcomes on their health. You’re not going to know about any of those things if you don’t talk to teenagers alone.
Dr. Angela Kade Goepferd: Now, I assume that primary care providers are… When they’re doing a well child visit, or if a child comes in with a complaint that might lean itself towards something that could involve sexual health, that providers are taking confidential time with their patients.
I was surprised to read that they weren’t. In your opinion, when should confidential time be offered to adolescents? At every visit, at certain visits, at well child visits in the specialist’s office? What’s your take on that?
Dr. Katy Miller: Yeah, I think there is a differentiation between primary care and specialty care. For younger adolescents around age 12, I’ll start offering… We usually do some alone time with patients. It’s a short conversation with the doctor. Nothing scary.
At age 12, I’ll say, “Are you open to that today? And if not, we’ll plan on doing it at your 13 year well check.” Once someone’s up to 14, 15, I do think that should be a part of every single visit.
So, if you are a kidney doctor, right, caring for a kid with chronic kidney disease, if you’re in hematology oncology and you have a kid with sickle cell disease, these are situations where you want to know if a patient is at risk of getting pregnant or using substances that could impact their kidney function or whatever it may be. So, I think a short check-in with adolescent patients should be part of most visits.
Dr. Angela Kade Goepferd: So, let’s talk a little bit about that, sort of best practices. So, when you’re alone with the adolescent, what are some of the things that we’re going to be asking about? What should be included in a confidential conversation?
Dr. Katy Miller: What I start by is opening the floor with what do you know about your rights to privacy or confidentiality? Is that something you’ve heard about before? And sometimes patients will give you the, “Oh, yeah, I’ve been in therapy. You can’t tell my parents unless I’m going to hurt myself,” or some variation of that. Some patients just give you a totally blank stare and have zero idea what you’re talking about. So, then I would kind of lay the groundwork.
So, as a teenage patient, you have the right to have private conversations with your doctor. I don’t share, for the most part, what we’ll talk about with your parents. The exceptions to that would be if someone’s hurting you, you’re hurting yourself, someone else is hurting you, or that has happened in the past, then we would have to talk to your parents or your guardians. We would make a plan for that. There wouldn’t be any surprises.
So, sort of teaching families what confidentiality is and what would be a reason to break confidentiality for teenage patients.
Dr. Angela Kade Goepferd: And do you explain the confidentiality just to the teenager or also to the parents before they leave the room?
Dr. Katy Miller: I usually explain it in more depth to the teenage patients. We’re in the process of making a kind of toolkit that would go out to parents and patients and providers, explaining what is and what isn’t covered. So, that’ll be a push for adolescent medicine clinic to share with everyone in 2023. But right now I focus most of my efforts on the teenage patient.
Dr. Angela Kade Goepferd: And I ask because I had a situation when I was a medical student working at a family practice clinic where I asked the mom to leave the room. And then when I went to get her from the lobby, as we were walking back, she started asking me essentially everything I had talked to her son about, which at the time, as a medical student, I was a little frazzled and not quite sure how to handle.
But it was a lesson for me that she didn’t have any expectations around confidentiality. So, I try to at least, like you said, briefly let the parents know that when they’re out of the room, what we’re talking about is going to be confidential. But I like the way that you got into more depth about what are their rights with the adolescent.
Dr. Katy Miller: And we do have signage in our adolescent medicine rooms that you have the right to private conversations with your doctor. And by that point, we usually do explain to the parents, you know, we talk to all of our patients alone and generally get very little pushback on that. When we do get pushback, I tend to hold firm and just say, “This is something that all patients have access to. We know what’s the best practice and this is what we’ll be doing.”
I’ve had a couple parents that were uncomfortable with it. One was a mom who… She felt like we were talking too long, got really worried, kind of stormed the front desk was like, “I want to know what they’re talking about.”
And then when she came back in the room, I was like, “Well, I have your daughter’s permission to share some of this. I’m really worried about how much weight she’s lost and how little she’s been eating.” And the mom was like, “Oh, yeah, I am really worried about that. That’s good. What did she tell?”
You know, so it was actually really helpful and the mom ended up being a regular patient who was very much on board with this philosophy because her child opened up in a way she might not have if the mom had been present.
Dr. Angela Kade Goepferd: So, when you’re in the room with an adolescent, you’ve explained confidentiality to them. What are sort of your agenda items during that confidential conversation that you want to be sure to get through?
Dr. Katy Miller: I’ll typically do a pretty deep social history for an adolescent, and it doesn’t need to be this deep for sub-specialists or someone where you’re really just checking in about certain risk factors. But I’ll go through my whole adolescent psychosocial assessment, not all of which is protected by confidentiality. So, some of the information I’m getting actually isn’t confidential, but it can help me build rapport and help the patient feel a little bit more comfortable. A lot of teens, if their parent is in the room, they’ll just look to their parent for the answers, that look like, “What grade am I in, mom?”
Dr. Angela Kade Goepferd: Right, right.
Dr. Katy Miller: So, I think separating them from their parents can help them speak to you more comfortably. With an adolescent social history, we start with what’s more comfortable and then we kind of move into deeper topics. So, I might start with how is school going? What school do you go to? Who do you live with? Who’s at home? Tell me about what kind of physical activity you get? Kind of covering broader strokes of social history. The meat of it and what is covered under confidentiality is sexuality, sexual health, any substance use that might be happening. And we’ll of course talk about mental health, although that gets pretty tricky with confidentiality because less is covered under minor consent with respect to mental health.
Dr. Angela Kade Goepferd: So, let’s dig into that a little bit more. So, what types of medical care and procedures are protected by adolescent confidentiality and minor consent?
Dr. Katy Miller: Yeah. So, in the state of Minnesota, adolescents can consent to their own sexual health care. So, that includes contraception, including emergency contraception. It includes pregnancy care, although we do have some restrictions on that, especially related to abortion access. Testing and treatment for sexually transmitted infections. Treatment for substance use disorder, although we can get into the weeds about mental health a little bit. Very specifically, hepatitis B screening and tuberculosis screening, those kind of fall under a public health domain that the state thought it was best to have that, be able to have adolescents consent to that on their own. Emergency care. And then short term, acute mental health health care. So, there’s some restrictions on mental health care depending on how you define short-term, acute mental health care.
Dr. Angela Kade Goepferd: And give me a little bit of your nuance for when you decide we’ve crossed the threshold into sharing with patients because obviously an acutely suicidal adolescent or someone who’s being actively harmed by an adult in their life is going to be something that’s going to need to be disclosed. But what about cutting? Or what about thoughts of self-harm? Or what about some kind of harm that happened to them in the past, but they don’t want to tell their parents about it? Can you talk through some of those trickier situations?
Dr. Katy Miller: Yeah. In terms of mental health care, I probably err on the more conservative side where, if I’m concerned about someone’s safety, if there’s significant cutting or non-suicidal self injurious behavior, if there’s thoughts of suicide and the parent is just totally unaware, I’m probably going to suggest to adolescent, I really think we should bring your parent in and chat with them about this because it sounds like it’s really affecting your health and I think you probably need some support getting this figured out.
And most adolescents will be okay with that. I’ve had one or two who are like, “I really don’t want my parents to know.” And then I think it gets a little bit into the weeds of how serious do you think the risk of harm is? Are you going to be providing medical care? I wouldn’t provide an SSRI confidentially, I would need a parent to be consenting to that treatment because I don’t think it’s really considered short term or acute. That’s more of a chronic treatment.
Dr. Angela Kade Goepferd: One other sort of question I had was around barriers to confidentiality. So, in the introduction, I talked about how despite the fact that we know adolescents deserve this confidential care, only two-thirds of them are getting it, and the younger they are, it seems the less likely they are to be getting confidential care. So, what are some of the barriers that you’re aware of that keep people from providing confidential care?
Dr. Katy Miller: There’s a lot of really challenging logistic issues. So, I think there’s the whole EMR situation. We have open notes. People may not know where to document in their medical record the confidential information they obtain. There’s insurance, explanation of benefits. So, for most patients, an explanation of benefits describing the type of care they received will go to their families.
I’ve had college students that I saw when they were legal adults, one parent’s family got a letter that said, “Now that you’re on an antidepressant, here’s what to expect.” So, the explanation of benefits and insurance piece is kind of outside of our control.
And I think there’s the provider knowledge piece. We might not feel comfortable or competent giving confidential care to teenagers. It’s sort of the setup for a high stress situation. The stakes are potentially very high. The rules vary state to state and seem to change and are kind of murky for a lot of us, and it’s just not a comfortable situation for a lot of providers. So, I think that that’s definitely a limitation, too.
Dr. Angela Kade Goepferd: Are there things that clinicians listening who are on the uncomfortable side of providing confidential care or having those conversations, are there things that they can do to be more comfortable or to become more comfortable?
Dr. Katy Miller: I think practice is the big one. So, start separating your adolescent. Doing that alone time, every time. I think a lot of people are afraid that they’ll be awkward. I am always awkward. I’m not like some expert who’s never awkward. I’m pretty universally awkward. And I think my teenage patients for the most part, sort of enjoy it a little bit, be like, “Teach me what that means,” and they’ll kind of chuckle.
Dr. Angela Kade Goepferd: Well, teenagers are awkward, so…
Dr. Katy Miller: Right. It fits, right? They’re going to be awkward. You’re going to be awkward. It’s okay. You can ask teenagers to teach you words you don’t know. It’s very educational sometimes, but just practice. Just get in there and do it. I think if your heart is in the right place and your intentions are good, most teenagers will respond really well to that. Teenagers want to be heard, they want to have a voice, and they often feel like they don’t.
Dr. Angela Kade Goepferd: And they kind of think we’re dorks to start with. I mean, it’s not like we have to go in and play it super cool and know all the lingo because we’re not fooling anybody.
Dr. Katy Miller: Exactly. No one thinks I’m cool. I guarantee you. I just had a teenage patient this morning and I was like, “Oh, what a cool sweatshirt. What national park is that?” And she looked at me with a little bit of pity and a little bit of disdain and was like, “This is a band.”
Dr. Angela Kade Goepferd: Oh, no.
Dr. Katy Miller: But she was amused, so it was okay.
Dr. Angela Kade Goepferd: Yeah, yeah.
Dr. Katy Miller: So, we’re never going to be cool. We’re never going to be totally comfortable with all of these conversations, and it’s probably okay.
Dr. Angela Kade Goepferd: One of the things that I have found that helps, too, is if your clinic has some kind of a screening form or something that you can keep confidential, that can sometimes be a jumping off point. So, in our clinic, we have a confidential adolescent form that they fill out. And so there’s some questions that are triggered on there about their sexual health, about their sexual and gender identity, about their thoughts about their body and eating. And so sometimes their answers to those, assuming we can keep that confidential, can help ease into the conversation a little bit.
Dr. Katy Miller: Yeah, it’s great if you’ve got a form that’s well done and you can kind of point to it and be like, “You know, you circled that you don’t feel safe at school, tell me what’s going on there.” That can be a good jumping off point to kind of open a difficult conversation. Or, “I see that you marked that you have a history of previous abuse. Is that something that you can tell me a little bit more about?” So, that can be a good point to open those conversations.
Dr. Angela Kade Goepferd: So, in addition to barriers to care, we talked about a few of them, explanation of benefits and the electronic medical record. I feel like I’ve been tricked a few times where I think something is going to be confidential, and then I find out later that it wasn’t. Are there common pitfalls or things that we should watch out for when we’re truly trying to provide confidential care?
Dr. Katy Miller: Yeah. So, we went over the list of what is actually considered confidential for the state of Minnesota. And if you’re listening outside of Minnesota, those rules will change state by state, but it’s relatively narrow, right? Adolescents can’t consent, for example, to their own immunizations outside of hepatitis B in our state. Adolescents can’t really consent to a well adolescent visit. Some of those really basic services, you do need a parent to consent for. There are a few exceptions to that. So, there are some adolescents that can consent to all of their medical care. Adolescents who have had a baby and are parenting a child, they can consent to their own medical care at that point, which isn’t the case in Wisconsin. When I would practice in Wisconsin, sometimes I’d have a 16-year-old patient and their child and we’d have to call the grandparent for the 16-year-old’s vaccines, right? It felt a little ridiculous.
But so here, if you’re parenting, you can consent to all of your own care. If you’re in this category of minor living apart, which is sort of Minnesota’s version of an emancipated person, so living apart from your parents, financially independent, not receiving financial support from them, then you can make your own financial decisions. But it’s a pretty high bar to reach that level. So, the scope of what is actually considered under minor consent is relatively narrow in our state.
Dr. Angela Kade Goepferd: And you mentioned that if an adolescent is living apart, financially independently, apart from their parents, they can make their own medical decisions?
Dr. Katy Miller: Correct.
Dr. Angela Kade Goepferd: What defines that? How do we decide? Is there a length of time? Is there something that defines financial independence?
Dr. Katy Miller: No, it’s pretty broadly stated, and there is some language in the statute which I don’t have in front of me, that basically allows for the fact that as long as you believe this information to be in good faith, you’re not really held accountable for whether or not it’s true. And I don’t say that as a, “Well, we should just say everyone’s a minor living apart.” I’ve used this exceptionally rarely. But if an adolescent presents information to you, you can kind of take them at their word. The times I’ve used, sort of the minor living apart clause for healthcare is minors who are runaways. So, living financially independent. I had a 16-year-old who had a job at Culver’s full-time and wanted to consent to his own medical care, hadn’t seen his parents in two years. That was kind of the perfect example. And we got a letter from the person that worked at his transitional living program kind of saying, “Yep, this patient lives alone, pays his own bills, here’s his tax statements.” So, you can see how that’s kind of an exceptional circumstance, right?
Dr. Angela Kade Goepferd: Yeah. And is there a process for minors to go through for declaring that legally? Like an emancipation procedure of some kind?
Dr. Katy Miller: My understanding is that it’s a little bit more informal than that. It was just we could say this is a minor living apart. We got some extra documentation just because we were making some high stakes medical decisions for that particular patient.
Dr. Angela Kade Goepferd: Sure.
Dr. Katy Miller: But there wasn’t a legal process or anything that the minor needed to jump through hoops for.
Dr. Angela Kade Goepferd: So, I mentioned that I’ve been tricked in the past.
Dr. Katy Miller: Yeah. What’s tricked you? This is good. This is juicy.
Dr. Angela Kade Goepferd: What has tricked me has been, so you mentioned the explanation of benefits, that’s been an area where I’ve been tricked. Billing is another area. So, for example, when a bill goes to a family, I would like to know what’s going to be showing on that bill. Is it going to say if I do STI testing, is it going to say, “Gonorrhea and chlamydia?” Or is it just going to say, “Lab charges?”
Dr. Katy Miller: It’s actually just a big scarlet letter.
Dr. Angela Kade Goepferd: Yeah.
Dr. Katy Miller: It’s just emblazoned, embroidered. No, it varies. So, if someone has Medicaid, you can feel pretty confident that they probably, most likely will not get any explanation of benefits that will disclose details. So, there’s been audits on this, and that seems to be pretty consistently true in the state of Minnesota.
Private insurance is such a wild card. So, they could do everything from be good, responsible people who don’t disclose any information, to send a letter, “Now that you’re on an SSSRI, here’s what to expect.” So, if someone has private insurance, that is something that I will talk about. I’ll talk about how the billing is going to show up for this patient. So, we’ll look at their type of insurance. If they have Medicaid or state insurance, I feel, “Okay, you probably won’t get an explanation of benefits.” We can do this care. I can protect your confidentiality with this.
Dr. Angela Kade Goepferd: Yeah.
Dr. Katy Miller: You still need to get the adolescent’s cell phone number for lab results and walk through pharmacy, which is a different potential pitfall. If you have a patient who has private insurance, there’s a pretty decent chance the policyholder would get a bill that has information about what care was provided. So, if that’s the case, I’ll often talk to adolescents about, “Well, what would that be like?” Some patients will be like, “Well, I actually think my parents would be really happy that I’m being responsible, and I think they’d be okay with it.”
That is a really different scenario than, “Well, my parents would kick me out of the house and I would need to find a new place to live.” I mean, of course there’s a whole range of options in the middle. If it’s more on the side of, “No, my parents cannot find that out, that would not be okay for me,” we’ll talk about different places that an adolescent can get care. That might look like going to Planned Parenthood. That might look like going to a sexual and reproductive health clinic that has more safeguards than what large children’s hospitals can provide, but it can actually be a safety issue. I’ve met kids who did get kicked out of their house or beat up because confidential information was disclosed inadvertently to parents.
Dr. Angela Kade Goepferd: Yeah, which is the last thing we’d want.
Dr. Katy Miller: Yeah. Not that I want to add more stress to everyone who’s stressed about this process, but the stakes are kind of high sometimes.
Dr. Angela Kade Goepferd: And you mentioned prescriptions. Give me some examples of how prescriptions can get tricky when it comes to confidentiality.
Dr. Katy Miller: So, we have wonderful outpatient pharmacists here at Children’s, but there’s a lot of pitfalls here. So, they could get a phone call from pharmacy, “Your prescription’s ready, come pick it up.” A parent could go pick up a different prescription, and that prescription is there.
If we mark a medication as confidential, in most electronic medical records, that may or may not actually transmit to the pharmacy. So, the pharmacy could have no idea that a medication is confidential.
If you want to do the safest version of providing a confidential medication, you can write a paper prescription or print it from your computer, give it to the adolescent to take to the pharmacy themselves and tell them they will need to pay cash for it, use GoodRx to find options. But if they’re using their parents’ insurance, in addition to the explanation of benefits risk, there’s also the risk that there will be some form of disclosure from a commercial pharmacy.
Dr. Angela Kade Goepferd: So, let’s do just a little bit of a recap before we close. So, I’m going to tell you what I’ve learned from you and you tell me what I missed.
Best practice would be to provide confidential care for all adolescents that we take care of, starting at around 12 or so and older. Younger, if there’s something that comes up that we feel like we need to. All well child visits, really any visit that we can, if we can get the adolescent alone, that would be ideal.
We’ve learned about the types of things that are covered under confidential care and when we’re going to need to disclose information to parents.
We’ve talked about some barriers to care. And so for those listening who want to ensure that the care that they’re providing is confidential, we’ve talked about checking your electronic medical record, understanding what type of insurance a patient has and what explanation of benefits may or may not go. Following through on a prescription that we think might be confidential and what the pitfalls might be there if it goes back to the family.
And then potentially looking at things like our forms, our screening tools, things like that. And whether they may be helping us with confidential care or potentially hurting us when it comes to confidential care.
What did we miss? Or what do you want to make sure that the clinicians who are listening know and understand about how we can best take care of teenagers in a confidential setting?
Dr. Katy Miller: Yeah. From the big, 1,000 feet away view, I think whenever you can just check in with an adolescent alone for part of the visit, ask sexual health, ask about pregnancy risk, ask about substance use, mental health, if you can do that, that will be amazing. Right?
And the little logistics piece, you can always reach out to me in adolescent clinic. You can chat with colleagues about how they’ve managed that. There are a lot of details and the devil’s in the details, but from a big picture, provide your adolescents that time to talk with you alone.
Dr. Angela Kade Goepferd: And the only thing I might add on there, and that I’ve learned in my 17 years in pediatrics and actually loving to provide care to teenagers, is another pitfall sometimes can be documentation. And while documentation is important, I would argue that the conversation is even more important. So, even if you’re just having the conversation with an adolescent, it’s getting accurate information, it’s rapport building, it’s letting them know that you’re a safe place to ask those questions. So, even if you don’t end up documenting that conversation somewhere because you’re worried about the confidentiality, I would say it’s more important just to have the conversation.
Dr. Katy Miller: And you can have little codes for yourself, right? If you don’t have the ability in whatever EMR you’re in to have a confidential note or addendum, you can write “low risk behaviors of substance use,” right? And you know in your head that means different than no behavior risk for substance use. Or have your own little code to kind of prompt yourself at future visits.
Dr. Angela Kade Goepferd: Yeah.
Dr. Katy Miller: But yeah, I think having the conversation is the really big important piece and the rest we can kind of make fall into place.
Dr. Angela Kade Goepferd: Well, Katie, thanks for joining me today. This was very illuminating. We’ll have you back again to talk about more adolescent healthcare, but really appreciate you joining.
Dr. Katy Miller: Thanks for having me.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amy Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.