By Stacey Kusterbeck
An investigator studies digital tools to improve adolescents’ health, such as expanding contraceptive use or testing for sexually transmitted diseases. However, before providing an adolescent patient with one of those interventions, emergency care providers must first ask the right screening questions.
“I realized that a lot of times, providers weren’t asking these questions, even when the adolescent was probably engaging in high-risk behaviors,” says Lauren S. Chernick, MD, MSc, an associate professor of pediatrics in emergency medicine at Columbia University Irving Medical Center.
In Chernick’s experience, certain emergency care providers screened every patient, some did so sporadically, and others never did — unless it was directly related to the patient’s chief complaint. Chernick and colleagues examined emergency clinicians’ decision-making on conducting confidential conversations with adolescent patients about sensitive topics, such as substance use, sexual and reproductive health, and mental health.1
Researchers interviewed 18 emergency physicians (EPs), 11 ED nurses, five nurse practitioners, and four physician assistants across five academic pediatric EDs. “Providers had so much to say. Some got very personal with their stories, and there was a lot of emotion and frustration,” Chernick reports.
The providers talked about the need to maintain patient flow, encountering resistance from parents, dealing with limited space for private conversations, working with inadequate resources to address the patient’s stated concerns, and managing their own personal preconceptions about patients. “There was a general consensus that when relevant to the chief complaint, questions about sexual activity or substance use would be asked,” Chernick says.
Emergency care providers varied widely on whether they believed it was part of their role to ask screening questions of all adolescent patients. Chernick gives the example of a 17-year-old who presents to an ED with an ankle injury. After treating the injury, does the provider ask questions like, “Have you had unprotected sex?” or “Do you want an HIV test?” or “Do you feel like you are going to hurt yourself?”
In that case, some providers wanted to provide care focused solely on the chief complaint that brought the patient to the ED. Other respondents wanted to take a more holistic approach to the patient’s care, but struggled with obstacles. For instance, it was difficult for emergency clinicians to provide confidentiality if the parents were in the room.
“It was an internal struggle with professional identity. They wanted to be the provider that is not only there to fix the patient’s ankle, knowing that it might be the patient’s only encounter with the medical system because they don’t have a primary care provider,” Chernick says.
Many ED nurses said that asking screening questions of adolescents was part of their role. Still, connecting patients with needed follow-up and resources was a challenge. Social workers were not always available, and might be taking care of acute problems such as unhoused patients or child abuse cases. This left ED nurses unable to provide the necessary follow-up and connect adolescents with outpatient services. “The biggest barrier in the ED is time. That’s always our biggest obstacle,” Chernick says.
Digital interventions are a potential solution for those cases. For example, the tools can provide education on sexually transmitted diseases to sexually active adolescents who are not using contraception. “The challenge is how to screen and refer, without interfering with the ED flow,” Chernick concludes.
Protecting confidentiality is the primary consideration for emergency care providers discussing sensitive topics with adolescent patients, including documentation in the medical record, discharge papers, lab results, and billing, according to Cynthia J. Mollen, MD, MSCE, chief of the division of emergency medicine at Children’s Hospital of Philadelphia.
Generally, providers are required to inform parents or guardians if the adolescent patient discloses suicidal ideation, thoughts of hurting others, or abuse. Mollen says medical record documentation should include information that is directly related to the care of the patient. “Confidential conversations can be protected in the medical record through a number of ways, including the use of confidential notes that are not visible to all,” Mollen offers.
In general, providers must obtain parental consent before treating a minor. “However, every state has passed laws providing exceptions, which allow an adolescent minor to consent to their own treatment for specified medical conditions,” according to Jonathan M. Fanaroff, MD, JD, a professor of pediatrics at Case Western Reserve University School of Medicine in Cleveland. These typically include sexual, reproductive, and behavioral health issues.
Additionally, many states allow adolescents who are legally emancipated or determined to be “mature minors” to make decisions regarding their own care. “In this case, a parent would not need to be informed of what would be discussed,” Fanaroff notes.
It is important to document that the adolescent patient can provide consent and understands the risks, benefits, and alternatives of the proposed treatment.
“There still needs to be informed consent. Documentation needs to reflect that adequate informed consent was obtained,” Fanaroff stresses.
The adolescent’s confidentiality may be compromised by parental access to the electronic health record (EHR). “ED providers should mention that the parent may have access to the information in the EHR,” Fanaroff suggests.
Some EHR systems include adolescent-specific modules to address this issue. Emergency clinicians may struggle to convey these nuances to adolescents seeking reassurance that their information is private. Some adolescents directly ask providers, “Is this confidential?” or “Will you tell my parents?”
“Providers should always tell the truth to the adolescent, including situations where they are obligated to tell the parents,” Fanaroff advises.
REFERENCE
1. Chernick LS, Bugaighis M, Britton L, et al. Factors influencing the conduction of confidential conversations with adolescents in the emergency department: A multicenter, qualitative analysis. Acad Emerg Med 2023;30:99-109.
Protecting confidentiality is the primary consideration for emergency care providers discussing sensitive topics with adolescent patients, including documentation in the medical record, discharge papers, lab results, and billing. Confidential conversations can be protected in the medical record several ways, including using confidential notes that are not visible to all.
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