Training for doctors improves screening for risk-taking in teens

Teens take risks: that is part of the nature of adolescence. Pediatricians know
that most of the health damaging, even deadly, threats to children in their
teenaged years can be prevented if teens avoid dangerous risks and habits. A
University of California, San Francisco study published in the journal
Pediatrics shows that training can increase the number of times that health
providers will put that knowledge into practice.

The study showed that a carefully-designed training program to teach
pediatricians how to talk to teenagers about risks during annual medical exams
can increase the number of teens who are screened for several risky behaviors
by an average of 16 percent. As a result, in the three HMO clinics
participating in the study, three-quarters of teens were screened for some
types of risk.
“Most teenagers are healthy,” said UCSF assistant research psychologist Julie
Lustig, PhD, lead author of the report published in the May, 2001 issue of
Pediatrics. “The leading causes of health problems and death in this age group
include motor vehicle accidents, unintentional injuries, sexually transmitted
infections and teen pregnancy. These outcomes result from unhealthy risk-taking
behaviors including use of alcohol and other substances, unsafe sexual
practices and risky vehicle use. A routine pediatric checkup provides a
wonderful opportunity for a pediatrician to ask important questions and counsel
teens about behaviors that are just beginning, potentially preventing life-long
habits from developing.”

Though national guidelines call for pediatricians to do such screening and
counseling with adolescents, Lustig said previous studies show that many
doctors’ visits go by without a conversation about risk, or with questions
about only one or two potential problems such as smoking or alcohol use. The
literature shows that pediatricians feel they lack the training and resources
to do more, she said.

The study is part of a UCSF-led research program to improve the delivery of
preventive services for adolescents. It was led by the UCSF Division of
Adolescent Medicine in cooperation with Kaiser Permanente Medical Group of
Northern California, the largest health maintenance organization in the state
and the group that cares for the largest number of adolescents. The study was
funded by a $3 million grant from The California Wellness Foundation. The
principal investigator is Charles Irwin, Jr., MD, UCSF professor of pediatrics
and chief of the division of adolescent medicine.

Irwin said that the project resulted from the UCSF group’s previous research
about teenagers’ risk-taking behavior, their willingness to trust their
physicians in confidential discussions and the methods clinicians can best use
to make an impact. “This is a prime example of what can be done to translate
the hard-won understanding of teens that the field of adolescent medicine has
gained, into programs that can impact their lives,” he said.

The UCSF researchers worked with pediatric clinics at three Kaiser Permanente
medical centers. Sixty-three pediatricians and nurse practitioners participated
in training workshops that included both education and role-playing sessions
with actors playing adolescent patients, to enhance the clinicians’ skills in
evaluating and counseling adolescents. The clinicians learned methods to talk
with teens about risk in the context of a 20- to 30-minute annual medical

Surveys of their adolescent patients showed that after training, the average
percentage of screening for alcohol use and tobacco use rose to 76 percent,
compared to 59 percent and 64 percent respectively. Screening for sexual
behavior rose from 61 percent to 75 percent; for seatbelt use from 38 percent
to 56 percent, and for helmet use from 27 percent to 45 percent. Pediatricians
also increased the number of times they offered brief counseling for some types
of risk - for example encouraging teens who were not sexually active to
continue to delay sex.
“In this study, we demonstrated that training primary care providers to
discuss risky behavior with their adolescent patients significantly improves
the delivery of preventive screening,” Lustig said. “Providers learn that
taking care of an adolescent ‘s health includes addressing their behavior.
Improving such services for adolescents is an important step in preventing
negative behavioral and health outcomes that are the leading causes of
adolescent morbidity and mortality.”

The workshops focused on five risky behaviors: seatbelt and helmet use, alcohol
and tobacco use, and sexual behavior. “Previous research has shown that
adolescents who engage in one health-damaging behavior are likely to engage in
other risky behaviors,” said Elizabeth Ozer, PhD, UCSF assistant professor of
pediatrics. She is project director and co-principal investigator of the study.
“Further, the prevalence of multiple risk behaviors increases with age.
Although it is useful to focus on specific risk areas, this clustering
indicates that we need to develop ways to help clinicians screen adolescents
for a wide variety of behaviors that can affect their health,” Ozer said.

Surveys of teenagers who saw doctors and nurse practitioners in the clinic
provided data about clinicians’ practices prior to the intervention. After the
training workshops, different teens were surveyed. In each case, the patients
were interviewed after their appointments to find out what they recalled about
conversations regarding risk. Lustig said, “One of the unique and exciting
aspects of this study is that we obtained adolescent patients’ reports of their
experiences during a visit with their providers. Most research on physician
behavior relies only upon reports from providers about their own practices. In
this study, we obtain the patient perspective, which is an important indicator
of the provider’s screening and counseling practices.”

“These results show that multifaceted training, based on previous research
about how to change behavior, improves risk-screening practices,” Ozer said.
The hypothesis of the larger ongoing study, titled “Implementing Adolescent
Preventive Guidelines,” is that not only screening but brief counseling for
risky behaviors can be significantly increased. In addition to training, the
ongoing study offers formal methods to remind clinicians and to document that
preventive services have been provided, plus additional staff resources.

Pediatrician Chuck Wibbelsman, MD, the Kaiser Permanente investigator for the
study, said the workshops have been enthusiastically received by the HMO’s
pediatric providers. As in most primary care practices, they care for children
of all ages, not just teenagers. “This study shows that many pediatrics
providers are doing a good job in caring for adolescents, but still you can
make a significant difference if you can help them be comfortable asking
questions about sensitive issues like sexuality and substance use,” Wibbelsman
said. “These workshops open a door to adolescence for our providers, a chance
for them to give teenaged patients a better quality of care.

“We not only win in quality, we should end up having healthier patients,”
Wibbelsman said. “Even if we prevent one teenaged pregnancy, or identify one
who is at risk for substance use, that will make a big difference.”

As the project continues, the researchers expect to be able to compare
adolescents whose health providers received training and extra support via the
study with those who did not. They should be able to show whether improved
training, clinical tools and support for pediatricians correlates with behavior
changes among teens such as delaying sexual initiation, using condoms, wearing
seatbelts and helmets, decreasing alcohol use, choosing not to smoke or
quitting smoking.