Teens need to be treated differently from younger children
Host Amber Smith: Upstate Medical University in Syracuse New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.
The American Academy of Pediatrics made a policy statement recently that hospitalized adolescents have unique and essential needs that differ from those of younger pediatric patients. We'll learn more about this from two physicians from the Upstate Golisano Children's Hospital. Dr. Karen Teelin is the director of adolescent medicine at Upstate, and Dr. Jennifer Myszewski is a pediatric hospitalist.
Welcome, both of you, to "The Informed Patient."
Jennifer Myszewski, DO: Thank you for having us.
Host Amber Smith: At the Upstate Golisano Children's Hospital, what percent of patients are adolescents between the ages of 11 and 20?
Jennifer Myszewski, DO: It's a little over a third of our patients are adolescent medicine at this point. It depends on the service line. Surgery, it's a little bit higher, but for inpatient medicine in general, it's over a third.
Host Amber Smith: What are the main reasons for hospitalizations in this age group?
Jennifer Myszewski, DO: By far it is mental health. It is suicidal ideation (thinking and planning). It is aggression. It is just struggling with home life and stressors at school. Eating disorders are a part of that, but it is hugely outnumbering any other diagnosis that they would come to the hospital?
Host Amber Smith: And how long do adolescents typically stay in the hospital?
Jennifer Myszewski, DO: It depends on the diagnosis. If it's for a classically medical diagnosis -- they've had surgery, they had an infection, something like that -- the average length of stay is between two and three days. If it's for a mental health reason, it could be for much longer than that.
Host Amber Smith: Can you compare what a hospital stay is like for an adolescent compared with a younger child or toddler?
Jennifer Myszewski, DO: A lot of it is going to depend on the reasons that they're here. All patients are encouraged to have their social support there, to personalize the room, to bring in things from home that are going to make them most comfortable.
With adolescents, a lot of times that's their friends, their social network. Sometimes it's their siblings. Because of the pandemic and because of the visitor restrictions that we've had to place in the hospital, a lot of times the very people that they're closest with aren't allowed to visit in person. So we do encourage them to use their phones, use their tablets to communicate.
The caveat is if they're there for a mental health reason, sometimes those are the very things that could trigger them. And so we don't allow access unless it's supervised under specific conditions to outside communication, to the internet, because we don't want them to be triggered by outside influences. We want them to be able to focus on what it's going to take for them to get better.
Host Amber Smith: I'm curious about the rooms. Are they different sizes for the little kids versus the older kids? And do they have the same food options, for instance?
Jennifer Myszewski, DO: The rooms are the exact same. We just allow them to bring in things from home that will make them more comfortable. As far as food options, there are graduated menus based on age, so they can select options from home, depending on the reason that they're there. They could always bring in food from home or have food delivered, which is very popular.
Host Amber Smith: Are the child life specialists involved with the teens? I know they're very popular with the younger kids. Do you also have them devoted to teenagers?
Jennifer Myszewski, DO: Absolutely. They have activities for patients of all ages. They have activities that are specific to adolescents . On the hematology/oncology (cancer and blood-related conditions) floor, there's a child life room where the activities are mostly designed around adolescent patients, depending on the reason that they're admitted to the hospital. Kind of right now, with the pandemic and with isolation precautions, access to those rooms are a little bit challenging, but we do kind of encourage them to participate in all kinds of different child life.
Host Amber Smith: So it sounds like there are features in the children's hospital that were designed specifically with hospitalized teenagers or adolescents in mind.
Jennifer Myszewski, DO: Absolutely.
Host Amber Smith: Dr. Teelin, I wonder if you can speak a little bit about the stresses of hospitalized teens and how that might differ from the stresses of hospitalized children or hospitalized adults. Do they have unique stressors?
Karen Teelin, MD: Well, being hospitalized can be so stressful, regardless of the age of the child, or the adolescent, or the adult. It can be particularly stressful for adolescents because it's a challenging time in life, when your autonomy is emerging. Your identity is emerging, and you're working toward being independent, and being hospitalized feels like a little bit of that is taken away. It's so hard for hospitalized adolescents.
There's some adolescents who have chronic illnesses who have been in the hospital frequently, and it feels frustrating to them to have to answer the same questions over and over. We have a teaching hospital. We have wonderful medical students, wonderful residents (physicians in training), but some of these patients with chronic illness have answered these questions so many times. And it gets hard for them and for their parents because they truly, they know their illness very well, and their parents know their illness very, very well too.
For patients who are just there once for whether a mental health reason or an infection, an injury, it's a terrifying time. It's a life-changing time. It's an extremely stressful time. And the adolescents just don't have as much experience advocating for themselves and speaking up. They're learning to do that, and they need to be given that respect and that autonomy. And we really try to work with them to give them the space to express what they need and to communicate with us so that we can take the best possible care of them. And that's always what we aim to do.
We're in a mental health crisis right now for adolescents. That's not just locally. That's nationally and internationally. And it's been an incredible change in all children's hospitals in the proportion of adolescents admitted for mental health concerns, really from almost none 10 or 15 years ago to, on a consistent level, I would say at least 10 at a time are in our hospital, if not more, with people waiting, waiting in the emergency room. And part of that is access to outpatient care. There aren't enough trained professionals, really, out there to take care of these kids outpatient. And then also, it's the severity of their illness that, that many of them need that respite in the hospital.
Host Amber Smith: What is done to help adolescents, who have to be hospitalized, particularly maybe those with a chronic illness, so that they can maintain their regular education and recreation while they're hospitalized?
Karen Teelin, MD: Well, it's a great point you bring up because it's so disruptive to their education. You know, you miss a few days of high school, and you can really be quite far behind. And a lot of these kids, that's pretty upsetting to them, and they're worried about that, worried about school, worried about their family, and worried about their friends. So we're lucky we have a full-time educator in the hospital.
Our children's hospital was designed to meet the needs of children. And each patient has their own room. The rooms are fairly large. We have the child life specialists. We have a teenage game room. We have the family resource center, and we have child life, and we have the educator. So we certainly do everything we can to help them maintain some sense of normality and not to have them fall behind. Their health comes first, but education's extremely important, of course, and we want to do everything we can to support that.
Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Upstate's director of adolescent medicine, Dr. Karen Teelin, along with Upstate pediatric hospital medicine specialist Dr. Jennifer Myszewski.
The policy statement from the American Academy of Pediatrics says that confidentiality is important, but I know that laws vary by state. I'm curious about what the laws are like in New York state regarding medical confidentiality of teens. Dr. Myszewski?
Jennifer Myszewski, DO: So there are a number of things that families and patients should be aware of. Above the age of 12, parents do not have full access to their child's medical record. The notes are protected so that we can talk about topics like STDs (sexually transmitted diseases), sexual activity, drug use, marijuana use, in a very protected environment where information doesn't necessarily get revealed to the parents without the patient's consent.
You'll often have conversations, and the patients won't want to be honest, and that can actually be dangerous if we don't know what they're doing. So as long as we are able to say, "You know, this stays between us unless we have a concern that you're at risk of hurting yourself or hurting somebody else." And a lot of times, they will then open up and be very honest and very revealing about what's going on in their life.
We also want to make sure that we know what their home environment is, what their school environment is, so that if they are being bullied or threatened or hurt in any way, that we can offer them resources and offer them protection. And so we want to have that open line of communication. A lot of times when issues do come up, the patient has been very open with their family in the past, or maybe wants us to be the person who kind of like bridges that conversation and gets that conversation going and is that safe space where both sides can kind of react and have the initial emotional response, and then kind of settle down and say, "OK, now that we all know and we're all on the same page, this is how we're going to move forward."
Host Amber Smith: Is it a 12-year-old who gives consent for medical procedures, or do parents do that?
Jennifer Myszewski, DO: Parents still give consent for procedures. And you have to make sure that they understand all of the risks and benefits. You also explain those to the patient themselves, and they give something called "assent," where they agree that what the plan is, is something that they're willing to go through.
If there's ever a conflict where it is in the best interest of the child, and the family agrees that the patient doesn't want that procedure or doesn't want that treatment, then you have additional discussion. It's rarely the other way around, where the family doesn't want it and the patient does. That's also a discussion that we are happy to mediate and help everybody kind of come to a reasonable, acceptable conclusion and agreement.
Host Amber Smith: So does a teenager have the legal right to refuse care?
Karen Teelin, MD: I mean, the parents are the ones who legally provide the consent for care up until 18. So we will always -- you know, as Dr. Myszewski points out so well -- that assent is also important. So consent and assent are both very important. We have emerging adults with emerging autonomy, and we want to include them, and we have to include them. And they have a right to be included. As she was saying, if an adolescent declines, but their parents want the care and it's considered in their best interest medically, that's an very unusual situation. That would be very rare. But we would mediate that. We would work with them. If we are stuck, we have, we're lucky we have, an ethics team, and we have legal team access right in our hospital that are really there for us 24 hours a day, if needed. But we always work with the parents to include them.
So adolescents have a right to privacy, and it has been shown to improve their health if they're able to talk to their care providers privately. But our goal is always to include the parents and to work with the youth to include their parents. So if they're telling us something and then we ask them, "Are your parents aware?" And if they're not -- often they are, they are already aware -- but if they're not, then we say, "You know, can we help you tell them? How can we help you? How would you like to let them know?" If it's a situation where they'd truly be in danger if their parents knew, then of course we do what we can to take excellent care of them and protect them. In New York state, they do have a right to privacy for sexual and reproductive health care and, in some cases, for mental health and substance use care.
Host Amber Smith: Another thing that's mentioned in the policy statement is the suggestion that physicians and other caregivers undergo implicit bias training. What is that?
Karen Teelin, MD: Implicit bias is just bias that we all, or nearly all, of us have that we don't necessarily realize. It may be subconscious, but it does affect actions and behaviors and outcomes. And there's been a lot of attention to it recently and a lot of research, and it's very common to have implicit bias training. The goal is to make things better, not to make things worse, of course, but to make all of us aware of what our biases are, so that we can mitigate that because we want, obviously, the best possible care for everyone regardless of their gender, their race, their sexual orientation, their socioeconomic status, their nationality, etc.
Host Amber Smith: So is that something that the Golisano Children's Hospital already does?
Karen Teelin, MD: Yes. Anyone who works here has to do some training every year. We have modules (training and testing) that we do. Our hospital has a diversity, education and inclusion committee. And we're very, very active, and we do workshops where we talk through issues that have happened and ways to handle and mitigate these types of events.
Host Amber Smith: Well, before we wrap up, let's talk about how you go about transitioning an adolescent from pediatric care to adult medical care. This is something the authors of the policy statement talk about with regard to hospitalized patients, but it's also something that inevitably comes up with the healthy teens who age out of the pediatrician's office. So how do you handle this?
Jennifer Myszewski, DO: We're lucky at Golisano that we are a hospital within a hospital, so, on the pediatric floors, we tend to see patients up until the 20th birthday, sometimes a little bit longer if they have chronic medical illnesses that are typically taken care of by pediatric providers. But we have a number of providers who are trained in both pediatrics and adult medicine, and they can help link and bridge those transitions.
We also, when the patients who are in their later teens -- almost turning 18 through 20 years old -- if we need to consult a subspecialist, we'll make sure that it's an adult provider so that they have that support system and they can transition while they're still in the hospital. We also, as they're going back to their primary care provider, make sure that they have somebody who's able to transition them. There's also a couple of providers in the outpatient clinic that's associated with the hospital that specialize in transitioning patients, and Dr. Teelin, being in adolescent medicine, is one of those specialists.
Host Amber Smith: Is there a concern that people in their 20s will fall out of the habit of preventive care because they no longer are in the habit of going to a pediatrician regularly?
Jennifer Myszewski, DO: Absolutely. Being guilty of it myself, we tend to think that college-aged patients or in the late 20s use urgent care in the emergency room as their primary care provider. And so there's a lot of education and support about the need for preventative care, for keeping up on just the annual health physicals, the vaccines, the blood work, the -- if there's anything that runs in your family, making sure that you're being screened for that and followed for that as well.
So, I think it starts with the pediatrician, and it continues while in the hospital, and it continues through adolescent medicine and family practice and internal medicine, just trying to keep that continuum in their minds and in keeping their health literacy also in their minds.
Host Amber Smith: Well, Dr. Teelin, Dr. Myszewski, I really appreciate you making time for this interview.
Jennifer Myszewski, DO: Thank you so much.
Karen Teelin, MD: Thank you.
Host Amber Smith: My guests, from the Upstate Golisano Children's Hospital, have been Dr. Karen Teelin, the director of adolescent Medicine at Upstate, and Dr. Jennifer Myszewski, a pediatric hospital medicine specialist who also directs the new pediatric hospital medicine fellowship program.
"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.
Find our archive of previous episodes at upstate.edu/informed.
This is your host, Amber Smith, thanking you for listening.