"We Have a Voice" - Mental Health, Social Media, and Sexual & Reproductive Health in Adolescents (Part I)

In this episode, Dr. Liang interviews Dr. Quinn (Adolescent Health Provider) and Alexis (Teenager) on her personal experience with navigating social media, mental health struggles, and reproductive health with her healthcare providers. 

=== Outline ===

Chapter 1: Definitions

Chapter 2: Establishing a relationship with the patient

Chapter 3: Mental health

Chapter 4: Social media

Chapter 5: Sexual and reproductive health

Chapter 6: Conclusion

=== Learning Points ===

1. First impressions are important. How you set up and frame the relationship with a teen patient will set the tone for the teen’s trust, and how much they choose to confide in you in the coming years. 
2. Instead of being prescriptive or setting limits, such as with social media, we can equip teens with the skills to reflect on their interactions. What does it mean to be kind in an online world? Is it leading to meaningful and constructive interactions? Or is it quickly becoming a detriment to someone’s identity and how they see themselves?
3. No matter the topic, using normalizing language can go a long way in empowering adolescents to share. When discussing topics included in the social history, using simple language can go a long way in avoiding misunderstandings. Remember, it might be the first time that teens are hearing these words being used.

=== Our Expert(s) ===

Sheila M. Quinn, DO, is an attending physician in the Craig-Dalsimer Division of Adolescent Medicine and the Transition to Adult Care Program at Children's Hospital of Philadelphia. Her areas of expertise include adolescent and young adult health, reproductive health, and health care transitions.

=== Toolkits and Resources ===

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=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories. 

Hosts: Addy Feibel

Producers: Helen Cai, Josh Onyango

Logo and Name: Eva Zimmerman

Editing: Helen Cai, Josh Onyango

Theme music: Josh Onyango

Other background music: Nat Keefe, TrackTribe, Geographer, Asher Fulero, Loopop, Freedom Trail Studio, Chris Haugen, Aaron Kenny, Ammil, penguinmusic, 

Instagram: @pcpearls

Twitter: @PCarePearls

Listen on your favorite podcast platforms: linktr.ee/pcpearls

Transcript

Adolescent Health I: 

Mental Health, Social Media, and Sexual & Reproductive Health

Host: Hi, welcome to Primary Care Pearls. A podcast made by learners for learners. Today: 

Alexis: Teenagers are very capable of understanding what's happening. We have a voice, we have an ability to describe what's happening within our bodies. And disregarding that feels very painful.

Host: We’re talking about adolescent health. During today's discussion, we'll focus on establishing care with adolescents and approaching the discussion of topics such as mental health, sexual and reproductive health, and - a topic that’s becoming increasingly important in our current landscape - the impact of social media.  We’ll be joined by our patient, Alexis.

Alexis: My name is Alexis and I am a student in Yale College. I have a couple of genetic disorders that I was diagnosed with towards the end of my eighth grade year. And then when I came to college, I started using the label disabled. I started using the label hard of hearing.

Host: We’ll learn more about her experience as a young child and adolescent interfacing with the healthcare system.

We’ll also be joined by Dr. Sheila Quinn.

Sheila Quinn: My name is Sheila Quinn and I am a primary care internist and adolescent medicine physician here in Philadelphia. I did my internal medicine, primary care residency up at Yale. So I'm very happy to be virtually back, if you will. And I left there to do an adolescent medicine fellowship down here in Philadelphia for the Children's Hospital of Philadelphia.

Host: Both of our interviews are facilitated by Jonathan Liang. 

Jonathan: My name is Jonathan Liang and I am an MD PhD student at the Yale School of Medicine.

Host: My name is Addy Feibel. I’m a fourth year medical school student at Yale School of Medicine and I’ll be your host for this series.

Before we get started, please know that this content is made to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you, or a loved one is suffering from anything discussed in today's episode, please be sure to discuss it with a medical expert. Now onto the show.

Definitions

Host: For some of us, the concept of adolescent health as a specialized field might be new. To kick us off, let's start by asking our expert to give us an idea of what she does as someone with a focus on working with this unique population.

Sheila Quinn: What that means and what that looks like is that now I practice a little bit of adolescent medicine and a lot of adult medicine. I see my own adult patients as an adult primary care internist. I definitely see a lot of our patients that are transitioning out of pediatrics and into adult care, coming over from CHOP and other places. And, I also do a fair amount of reproductive health and contraception, in my internal medicine practice as well.

And then formally over at CHOP, I work in our adult care and transition team, which helps transition some of our more medically complex patients out of pediatrics and into adult healthcare. So that's what a week in the life looks like for me right now.

Host: That's a fabulous introduction into this topic, and a sneak peek on what we will learn from our expert over the next couple of episodes. We'll dedicate an entire episode to transitions of care, so stay tuned.

In the meantime, let's take a moment to hear from Alexis about her own experience as a young patient, working with her pediatrician. Like with any good story, we’ll start at the beginning.

Establishing a relationship with the patient

Jonathan: Do you remember when you first met your pediatrician?

Alexis: Yeah. My insurance switched when I was eight. So I met my new pediatrician when I was eight. I remember I picked her out because on the website I thought she was the prettiest out of all the doctors, and I was like, I want a pretty doctor.

Jonathan: What was it like coming into that office for the first time?

Alexis: I was definitely very scared. I loved my prior pediatrician. She was she was a family medicine doctor, so she is my mom's doctor as well. I loved her. She helped deliver me. So she's been there since day one, so I was super scared to come into this new hospital, new place.

I had gone eight years of my life, without doing that, without changing my pediatrician. It was definitely very scary. I think immediately she assuaged those fears. Coming in, talking to me as well as my mom she was very engaged with me and that put me at ease and made me trust her. And all of these things that are still important in the doctor patient relationships. 

Jonathan: Is that the pediatrician you then followed with until you came to college?

Alexis: Yes. 

Jonathan: So how did your relationship and your visits to that pediatrician change through those 10 years?

Alexis: We definitely built a relationship, beyond the like, symptoms and talked about what are you doing at school, what are you stressed about right now? What are your goals for the future? What college do you wanna go to? And more of also being interested in my life and how that affects my health. 

I definitely built a very good relationship with her over the 10 years. One that I was very sad to leave. 

I think as I got older, I know that some of the hospital practices changed, like they started doing like questionnaires at the beginning of each yearly checkup.

I know that when I turned 12 or 13, they started doing depression and anxiety screenings . And then I also know that they did risk screenings, like abuse, substance abuse, sexual abuse, all of these things. And I filled them out alone.

Host: Mm, gotta love those screening questionnaires. Those of us in primary care will be very familiar with the important role of screening during a visit. Let's take a moment to hear from our expert on the topic of mental health in adolescents, and how she approaches the topic.

Mental health

Sheila Quinn: Mental health, by far and away, is one of the most pressing topics. It really I think was necessarily highlighted during the pandemic, though of course, it was an issue before then too.

So mental health is getting more attention and should continue to get more attention in adolescent healthcare, 

Jonathan: How do you navigate questions about mental health with teenagers? How do you break the ice there?

Sheila Quinn: I tell them what is true, which is I ask all of my patients about it. I'm not asking because I suspect anything, I’m not asking because of any certain inferences. I truly do ask all of my patients about their mental health, because it's part of their health. And I let them know that, and very often they're going to interface with screens and questionnaires see them.

They're gonna fill out a PHQ-2 or a PHQ-9 or something like that before they even get to me. So I hope they know that is a universal practice, and it's one that is highly endorsed in all of the groups of, specialties. And starting out without a label and just saying: tell me more about this questionnaire that you filled out or tell me about your mood.

How are, how's your mood? As opposed to are you depressed? Are you anxious? Because I feel like a lot of people may not categorize themselves as that. But when you give them a little bit more chance to talk, they'll use the words that are more comfortable to them to describe those similar diagnoses.

And then once, you know, whatever words we use once this diagnosis is in the room, I think just normalizing it. And again, this is not like a tactic that I really consider unique. It truly is like so many people have depression and anxiety. It's so many people, struggle with it at various points in their lives.

I let them know that. I think also using first person language, first person plural language can really help saying things like, many of us or all of us are going to struggle with this at some point in our lives. And, it's gonna hit us at different points. It's gonna last different durations of time. And, the wonderful thing is we've got increasingly effective ways of treating this. And why don't we start talking about what would be an acceptable way to think about treatment for this.

Host: Language is so key when framing the conversation about mental health. Dr. Quinn gave us a useful framework and examples of verbiage and language to use throughout the conversation. Let’s go through some of those examples again. 

First: Let the teen know that it’s your practice to ask all of your patients these questions, and that they’re not being singled out or picked on.

Second: Keep the questions open-ended. Ask broadly about mood and the questionnaire, rather than closing down on words that can connote diagnoses, such as anxiety and depression.

Third: Utilizing first person plural language can be very powerful in normalizing diagnoses. For instance: you might say that many of us struggle, or this is something that we all encounter. 

Let's hear from Alexis about her experience being on the patient end of this conversation.

Alexis: I was very early in my mental health crises. I was in fifth grade. I was 10 years old. My mental health challenges as a result of some childhood trauma, I think is why it manifested a little bit earlier in me than in most people. I was well past the point of, by the time they started asking those questions, I was on medication and I had been in therapy for two years.

My, my doctor knew. And so for all of these questions that were like, have you ever harmed yourself? Have you ever had suicidal thoughts? It's like I was answering yes to all of these questions, but it wasn't really a conversation starter because that conversation had already happened. Again, with those questions, I feel like it can be very challenging to, if you don't already have that conversation open, to feel comfortable checking that “yes” box. 

I do know, again, some of my friends have very real mental health disparities and rates of mental health crises. And so I know that for a lot of them, they did not choose to disclose that information when they were asked except one of my friends.

I know after about maybe the fourth time of it being asked did, because, they felt like they were at a point that like. Something really needed to change. And that was their way of reaching out was through their pediatrician. And they found great help in that. 

It was, again, one of those things where parents are out of the room talking about these things. They and their pediatrician made a plan of how to talk to the parents about what was gonna happen next. It was very much the teenager and pediatrician were a team. And they were very involved in the process.

It was not like, okay, now that you've said this, I need to tell your parents and they will decide what is happening. Which is, I think one of my, and one of my friends', greatest fears was that, as soon as it got out, they would be taken out of the equation.

And that loss of control is very scary when you're having mental health issues because often those mental health issues come out of feeling like you have no control in the world. Specifically for me with the trauma that I went through, it felt very much like I had no control over anything. I was searching for control. And so one of the scariest things was the idea that it would be taken away from me. 

Jonathan: Yeah, I think that is just packed with lessons. Ask early, ask often and especially in children who have had adverse childhood experiences, it sounds even the start of formal teenager-ness is a time when there might already have been a long history of these things.

Alexis: Yeah. Yeah, definitely. Ask early, ask often. I think that if I would have been asked, I probably would've checked yes, because I know that before things had gotten out of my hands, I was like searching for a way to get that help, but I didn't know how to do that. So yes it may seem really young, like 10 years old. It is really young. Those things were already happening.

Host: One thing I'll take away from Alexis's reflection is the importance of continually offering the chance for patients to discuss what they're going through--even if they might initially say no. Hence, the importance of asking often. Every visit is an opportunity for the adolescent to say yes or no to a conversation. 

On top of that, it's very important for the patient to continue to have ownership over their own health--to include them in how information is shared (whenever possible), to provide context to why the provider is asking these questions, and to empower them within a treatment plan. 

Social media

Host: Let's move on to discuss the complex world of social media, one that has become more and more linked to adolescent mental health in recent years. In June 2023, the U.S Surgeon General Dr. Vivek Murthy issued an advisory that highlighted several important factors regarding the impact of social media on youth mental health. 

First: Up to 95% of youth ages 13-17 now report using social media platforms, with over a third using them “almost constantly”.

Second: There’s growing evidence linking social media use to depression, anxiety, exposure to risks such as cyberbullying, and negative impacts on sleep and in-person relationships.

In the context of these growing concerns, let’s hear about Alexis’ personal relationship to social media and how Dr. Quinn advises her patients regarding this topic.

Jonathan: I'm curious then what your perspective is and what you tell your adolescent patients about some of the factors, outside the medical sphere that all contribute to mental health and to potentially mental health conditions, especially maybe about social media, which I think is such a big part of teenage lives sometimes for the better and sometimes for the worse.

Sheila Quinn: So there are certainly inherent evils of it. I also think the most important thing though is, I don't think it's worth fighting. Social media is going to be in our teens’ lives, in our young people's lives.

And the most important thing is just as we would, teach our teens to navigate cliques at school in the eighties and nineties and how to navigate bullying, face-to-face. A couple decades ago, equipping them with the skills and the wherewithal to, to be aware of what bullying is and, when people are safe and when people are helpful and they're unsafe and unhelpful.

It's, it comes back to, I think, basic skill sets that we equip them with, not like a permission or denial to engage with social media.

Jonathan: Right. Because being teenagers, that permission or denial doesn't necessarily mean so much to them…

Sheila Quinn: It’s not gonna get you very far.

Jonathan: What would you say would be the core tips, the advice that, any pediatrician, any family medicine provider could give to a teen who is coming into that age when they're starting to use social media?

Sheila Quinn: I think in moderation, it doesn't replace in-person interaction. It doesn't replace the sort of interactions that you're going to have as a young person and as an adult. It is a type of interaction that actually people in my generation and above are, need to learn more of and actually need to learn probably more skills.

But, I think, used in moderation and balanced with other forms of communication and other forms of friendship is fine. And also, I'm not a social media expert by any means, but certain rules of not writing anything that you wouldn't say to somebody's face and, that you wouldn't be embarrassed to show, your parents or your grandparents or something like that.

Are you treating people with respect? Is it supportive? Is it true? And, I think I'd probably stick to certain basics like that.

Jonathan: I think that makes a lot of sense. We've seen the anonymity sometimes of social media lead to behaviors that might not necessarily be what someone would do in person. 

Alexis: I grew up in rural Wisconsin. So of course my experience is not going to be comparable to a lot of peoples’. But I guess the culture that I grew up in was very focused on like work and how you could get to have a good job, to have a good family and a good life, whatever. Most of that culture did not focus on college.

And I've always been on more of the outskirts of the culture that I grew up in, I wanted to pursue higher education. I'm interested in going to law school or graduate school or something like that, which is not common where I'm from.

 And being disabled did not help. Disability is often like a very isolating thing. 

But I found the most beneficial and that would be characteristic of this time period is the internet and social media. I know that there are some very bad things about the internet and social media, especially in teenagers and informing self-worth and body image and those things. It can be very problematic. But in the world of disability, I definitely found that finding other people with this rare disease was very helpful to feel like I was not alone. That I would not, when I was diagnosed, like I thought my life was over. I was like, I'm not gonna go to college. I'm not gonna be able to have a family. I'm not gonna be able to do all these things because my health was in a really bad place. As a teenager to be told that and then be told, I probably can't have biological kids. And things like that. That's all a lot to be told at 14.

And then to go into school every day and have people, constantly reminding you that you were just told this big news was hard. But like when I went to the internet, when I found other people who had similar experiences and we shared, tips and tricks on like how to survive this symptom or what makes this better, because I often found that that community knew a lot more in terms of making my quality of life better than the specialist that I was seeing did.

So I'm very grateful that I was growing up in the late 2010s because of my access to this community. And these people were often much older, nowhere near Wisconsin. My mom was very cautious, like these are strangers on the internet, Alexis make sure you know what you're telling them.

And like I was careful. But I actually built some really good friendships of people over the internet and bonded over our shared experiences, which I know would not have been possible if I had grown up 10 years earlier.

Jonathan: I'm really encouraged to hear that you found that support network. Can you tell me more about how you got connected with that group? What platforms that you used to find them and to stay in touch?

Alexis: So I mostly found them through Instagram just like searching the diagnosis on the tags. And then of course five posts come up because no one's really using this tag. But like almost all of them were from this girl who was posting vlogs about her life with her disabilities.

And this was a time when YouTube was, the height of it's reign and like being a YouTuber was the coolest thing ever. And She had maybe 200 followers. She was not like, living off of this or anything. But from watching her videos, I felt like we had really similar experiences. I reached out to her over Instagram and she responded right away and we just kept DMing. And we don't talk super frequently anymore, but if there's ever something that I think of, I definitely don't hesitate to reach out to her. I feel like we have very similar trajectories and it's been really good to get to know her.

Jonathan: And it sounds like that initial connection brought you into a larger network of people as well. 

Alexis: Yeah, so after I met her she shared a Facebook group with me that had people with the same diagnosis. I didn't end up spending a ton of time in that group because it was mostly like 30 plus year olds Facebook is, has never really been my generation's app. So it was helpful in that seeing like there were so many other people with a similar thing, but I definitely spent more time talking to her than I spent connecting with other people in that Facebook group.

Sheila Quinn: Yeah. So I thought it was, that part was fascinating for me, I am someone who has grown up at the tail end of, I guess the, the millennial generation in that I remember the introduction of the Internet and instant messaging and things like this. I certainly lived at a time where things like, social interaction and for better or for worse happened before that and am certainly living with it now.

And I very much appreciated Alexis's reflection on how her experience would be so different if she had been diagnosed 10 years earlier. And I think that when she talked about finding support, through the Internet, I thought how lucky that is, that we can really expand, especially for someone like herself that's from this rural area in Wisconsin and now, about to go to a whole new part of the country for college.

It really expands the network for someone like that. And I've seen that happen throughout many age groups. Certainly young people are the most talented navigators and users of social media. And so I think that she really spun it as a wonderful asset to her disease journey.

And I've seen it also really helpful for parents too. Alexis talks very candidly about her mom's apprehension about her interaction with the Internet. Be careful honey, make sure you know what you're doing and things like that, which is, I think, really understandable.

And I think fast forward 10 years from that, even parents are way more comfortable with their kids engaging in support groups, but also the parents engaging in support groups too. Whether those are formal or informal relationships, or groups. And so I think I certainly am not surprised to hear that any of my patients are involved in this sort of thing. And, I encourage the positivity that comes out of it. 

Certainly we have to acknowledge that there are risks and dangers.

Host: The role of social media is changing, maybe more rapidly than we'd like to admit. I myself certainly have struggled to keep up with the new waves of apps and interfaces and the new ways that we meet and interact with each other. 

But it’s important to acknowledge both risks and benefits of these tools for our teenagers, provide them guidance on how to be safe online, and help them recognize signs that their use of social media may be impacting them negatively.

Okay, so we've talked a lot about mental health and the presence of social media--two forces that have the potential to make a huge impact on teens' lives. Let's move onto another important topic for this population: how to navigate sexual and reproductive health.

Sexual and reproductive health

Jonathan: Let's get onto reproductive health because I know that is an area that you have spent a lot of time working on. How do you break the ice on reproductive health and actually when do you break the ice on reproductive health?

Sheila Quinn: Much earlier than you'd think is the short answer. Much earlier. And I have to say, I didn't believe it until I saw it, until I started seeing 12 year olds, in my fellowship and, thinking, oh gosh, they'll never say that they're having sex. 

It's earlier than you think. And I think the earlier you start asking about it, the earlier that they know it's something that is gonna be asked during these appointments, that it's a normal place to have this asked and talked about. And to be honest, even when my patients say no, I've never been sexually active or things like that, I always say, before I move on to the next question: Okay, that's fine. Just so you know, if and when that becomes part of your life, this is a totally safe place to talk about that and to get any help related to that issue. Confidentially. So it's a, we're talking about it and this is why, and not like I'm a nosy doctor that wants to know. 

So as an internist. an adolescent doc. I don't see anyone younger than 12, so I can't say I've ever asked anyone younger than 12, but I do ask my 12 year olds, that I see. And usually it's at a time when I have asked their parents to step out of the room, but if it's a patient that really can't or doesn't want to leave their parents, I may tread a little bit more gently and ask about relationships first, crushes, and things like that. 

And then, rolling it into all my other social history questions I think is important, but I think more important than where you put it in the history, and in the interview is just explaining why you're asking, and saying things like, I'm asking this because it, it's important for me to know so that I offer certain screening for certain infections, et cetera. We also like to make sure that people are safe and being treated well in their relationships.

We talk about this in appointments going forward, that's why I'm asking. And then the next level I would say is when people are having sex, certainly we cannot assume that everybody is having, heteronormative relationships out there.

So I ask, are you having sex? Are you having sex with men, women, both, other genders? To really leave it open. And then again, why, I'm asking this because it's important for us to know what parts of your body and your partner's bodies in sex, so that we can screen appropriately.

And so do you mind telling me what parts of your body and what part your partner's bodies are used? And then I mirror that language. Unless it's profanity, I will mirror it. People have different preferences for the words the parts of their body that they want to be referred to. This comes up a lot too in our, more gender expansive patients.

And being able to reflect back to them that you're listening and that you honor the language that they wanna use,

Jonathan: So you must be learning a lot of vocabulary from your patients.

Sheila Quinn: Oh my gosh, yes. I should back up and say the number one rule here is just practicing humility. I'm still seeing 18 year olds, even though I'm getting older. They're gonna teach me things that I did not know and would not know without them. 

Jonathan: Can you say more especially about how you talk about contraception and maybe how that's evolving?

Sheila Quinn: It varies a lot depending on who I'm talking with. Certainly if I'm talking to a 35 year old patient in my adult practice versus a 16 year old patient, at the children's hospital or something, I will generally shift my verbiage a little bit.

Have adapted a couple nuances in the way I talk about it. One is saying things like period control and birth control, especially for our younger patients who may not be sexually active, and who are there with their parents, asking for treatment for menstrual disorders. Really normalizing this category of medications and broadening its use, to saying things like, especially if somebody says oh, I'm on birth control.

Okay. Are you using that for period control, actual birth control? Both. It really helps us understand how and why a patient might be wanting or using medication.

For adolescents, I really follow their lead. II will bring it into the room and I'll bring it up in conversation. If they don't wanna talk about it, I don't force it. but if they're there and they want to, or their parents want to talk about it, obviously I talk about it all day long. So it's very comfortable for me to engage with them.

I think probably relevant to this conversation today is framing it as a part of their health. So reproductive health, just like we talked about, mental health is health, reproductive health is health. Mental health is health.

And so that's one, the reason I'm asking about it. And two, especially for our patients' diseases that are on, medications that are teratogenic that could be really dangerous, for an embryo or a fetus. Making sure that's just explicitly communicated with patients upfront.

Many people don't know that. So that's one thing. Not saying you can never get pregnant, you can never reproduce. but thinking about it, in a way that says, we just, we just need to plan. I am here with you. My goal is to support your goals. And if you tell me you wanna get pregnant and you are on, I don't know, cyclosporine or something, let's get to a point where we can get you pregnant in a healthy way and I'm gonna work with you and your doctors and whatever. I think it's just important to put it on the table and not wait until people are actively trying or pregnant to talk about these things.

They deserve to have all the information as early as they want it, and need it.

Host: Something that we’ve heard Dr. Quinn touch on time and time again is the importance of providing context for your questions--for instance, explaining that the reason you are asking about sexual activity is because this is a safe space to ask for help if they have questions about it later on. By providing this context behind questions, we can do a lot to empower adolescents to better understand their own bodies, and also strengthen the relationship between the provider and the patient.

Let's listen to Alexis reflect on her own experience with these discussions during her visits to her pediatrician.

Alexis: I remember being a little bit like, why does my doctor need to know this for the like, sexual orientation thing? I was just like, I don't know. Why does she need to know? But I was also very open about it. Unlike rural Wisconsin, my family has always been open to that kind of thing, so I've been out for a long time.

But I remember hearing my friends come back from their appointments and being like, oh, I, like I just lied on it. Because they didn't feel comfortable or like similar feelings of why do they need to know? So they would just, put “straight” and then it wouldn't have to be talked about.

They did give things like we will not discuss this with your parents unless you're planning on harming yourself for others. Like that kind of thing. So like I knew that if I would have put something that I didn't want my parents to know about, like it wouldn't have been shared with them, I think that would maybe make people feel more comfortable, but they already had it. But I think still it just that is a very touchy subject.

Jonathan: I'm curious, what are the things that you might expect patients to ask themselves, and are there topics that you will routinely bring up? Because often adolescents won't want to ask about them.

Sheila Quinn: I think that things they want to know about are, the things that are affecting their daily lives that are harder to hide, I guess from like their parents and things like that. So are the things that sort of more naturally lead into the room. And this is easier too when they make an appointment because of the issue, because they're gonna tell you.

So if they make an appointment because of dysmenorrhea or abnormal uterine bleeding, they're gonna tell you about it. And those are things that affect real daily quality of life and that their parents are probably aware of and things like that. Things that they generally do not bring up on their own, but that I will definitely ask about, sex.

And even if somebody's coming to me for treatment for dysmenorrhea or heavy menses and things like that, I'm absolutely going to talk to them about it and how it can be treated with something like, many different categories of our, classic contraception and birth control medications.

When their parents are out of the room, I will say, are you also having sex? The reason I'm asking is because I will counsel you to take this medication in a much more regimented way or et cetera. Definitely bring up sex. Definitely bring up the gender of partners like we talked about, the patient's gender identity of course, which hopefully is established early on in that, in the encounter.

Gender of partners. I will bring up contraception if they don't. For sure. I will bring up safety of pregnancy if they are sexually active, especially for people with chronic diseases, on either teratogenic medications or conditions that make pregnancy more dangerous. So I'll bring that sort of thing up.

And then generally people aren't bringing up things like substance use, so I will bring that up. I'm very explicit, too, when I screen for abuse. So generally people will say, if people say are you being abused at home? It's easy to say yes or no to. Maybe I shouldn't say it's easy, but it's easier to say yes or no.

But when you really delineate what that means, is, does anybody kick, shove, push, scream at et cetera? Adolescents often need concrete questions to give you the answers that you need. They're very intelligent and can give you the information you need. And often just aren't used to the way that we ask questions in medicine. It's often their first time answering these questions.

Host: Dr. Quinn brings up a fabulous message here, which I think is really important to underscore. In medical training, we are so accustomed to what these questions in the social history mean and what medical providers refer to. But imagine that it’s your first time having these questions asked of you, and it’s a really stressful environment. Having clear, illustrative examples of what you are trying to ask will be much more informative than simple short, conceptual questions.

At the end of the day, communication is a two-way street. It's important to be able to effectively include the teen in the conversation, learn from their experiences, and work with them to understand their own care. Alexis had some reflections on this to share with us.

Jonathan: Are there things you wish doctors, whether primary care or specialists knew about teenagers in general and what it's like to be a teenager?

Alexis: I think my main thought is that teenagers are very headstrong, right? You're a teenager, you think you know everything, but within that, many teenagers are very capable of understanding what's happening. We have a voice, we have an ability to describe what's happening within our bodies. And disregarding that feels very painful when when, a physician yeah, just does not speak to you at all. Asks your parent about what medications you're taking or things that you could well vocalize yourself. It makes you feel very small and very much like you're not a part of the equation when it is your body that's being talked about. And just remember that the teenager can vocalize what's happening and can understand what you're talking about.

Obviously, this will be different with each person. I was very interested in the technicalities at the time. I thought I wanted to be a doctor and so I very much wanted to hear all of the technical words and everything. And it felt like when people would make fun analogies or things, it just felt like that wasn't the right care for me.

Perhaps, that'd be great if I was eight or, not so interested in healthcare or something but to have a physician, like just it feels belittling. And even though I know, and like even looking back, to five years ago or whatever I was very arrogant in what I thought that I knew.

And I'm sure I am now. I'm sure I'll look back in another five years and be like, wow, I was so blind to all of these things. But in the moment it feels very much like a personal attack because you wanna be seen, as an adult, you wanna be seen as capable.

I'm not a kid anymore, whatever. I'm in high school, I can drive a car. All these things. But so yeah, just recognizing that even though some things that come outta my mouth were probably really stupid. Just the way that it felt when they'd speak down to me is very characteristic of my feelings about that at the time.

Jonathan: Thank you. I think that's very good insight. Since you've spoken to, how you felt at those times, I wanna ask what you think an ideal doctor's visit would look like for you as a teenager. And I know that won't be universal for every teenager.

Alexis: Yeah. I think I'll just, I'll use an example of a time that I thought was, the ideal interaction. I saw a pediatric gastroenterologist and he was amazing. He still is amazing. But he spoke to both me and my mom, asked about the narrative behind what was happening.

Not just, like on a scale of one to 10, how many times in the past week has this happened, but more of how did I feel about that? What did that make in life difficult? How did this affect you? More of feeling like I'm an actual person going through this rather than a list of symptoms going through this.

He also was very clear about his thought process in ordering tests, medications, whatever, he was very clear, I think that, this is why I think that this would be helpful. This is why I think this would not be helpful. He even, there was like a little whiteboard on the wall and he was writing things down.

Then my mom took a picture of it and later when we were like, oh, what did he say about this? It was right there. It was very helpful. Also, for context, my mom is, I'm a first generation college student, so she did not go to college. She has really no idea of basic science. As much as I try and teach her, because I do love basic science biology and whatever. But he put both, put it in a way that she could understand in not being really interested in, the nitty gritty of it. And in a way that me, as someone who was really interested in it that we could both feel, walk away from the interaction, feeling like we understood what was happening and that we were, talked to and not talked at. So yeah, that, that was just an amazing interaction. The clear thought process, speaking to us, getting the narrative instead of just trying to extract a list of numbers.

That is my ideal doctor's visit.

Conclusion

Host: Wow. What a whirlwind tour through these topics: mental health, social media, sexual health. I think that today has also been a good reminder that teenagers go through a lot. We never know what's going on in a teen's life, and we might be surprised by the answers we receive when we ask about these topics. But, as Alexis pointed out, it's so important for the teenager to be in control of their own narrative, and the information that they provide to you. 

No matter what ages of patients you see--children, adults, older adults--we know the importance of asking about these topics. But, we might be less familiar with the mechanics of how to broach them. I myself will be listening to this episode time and time again for a nice refresher.

Here are some notes I took away from the episode, and I hope you did too.

1. First impressions are important, but especially in the context of adolescent health. How you set up and frame the relationship will set the tone for the teen's trust, and how much they choose to confide in you in the coming years. 

2. There are certain topics, such as social media, where we may not need to take the approach of being prescriptive or setting limits. Instead, we can equip teens with the skills to reflect on how they interact with social media: what does it mean to be kind in an online world? Is it leading to meaningful and constructive interactions, like building a community that is otherwise hard to find in the physical world, or is it quickly becoming a detriment to somebody's identity and how they see themselves?

3. No matter the topic, using normalizing language and reassuring adolescent patients that many people experience struggles can go a long way in empowering them to share. And, when broaching the topics included in the social history, using simple language can avoid a lot of misunderstandings--remember, it might be the first time that teens are hearing these words being used.

And that concludes our episode for today. In the next episode in the series, we'll be discussing strategies for referral to specialty care, as well as transitions to the world of adult care. 

Special thanks to our patient Alexis; Jonathan Liang, who served as our interviewer in the patient and expert interviews; and Dr. Sheila Quinn, who served as our faculty expert and provided peer review for the project. Special thanks to our producer Helen Cai as well as our faculty advisors Dr. Joshua Onyango and Dr. Katie Gielissen. 

Follow us at PC pearls on Instagram or at PCare pearls on X or Twitter to get details on show release times. Throw us a five-star review to help others find our channel. And please share the episode with friends who would find today's topic interesting. 

This is Addy Feibel with primary care pearls. Thanks for joining us. We'll catch you in the next one.

Bibliography

U.S. Surgeon General. (2023). Social media and youth mental health: The U.S. Surgeon General's Advisory. U.S. Department of Health and Human Services. https://www.hhs.gov/sites/default/files/sg-youth-mental-health-social-media-advisory.pdf

Office of Juvenile Justice and Delinquency Prevention. (n.d.). U.S. Surgeon General issues advisory on social media and youth mental health. Retrieved January 12, 2025, from https://ojjdp.ojp.gov/news/juvjust/us-surgeon-general-issues-advisory-social-media-and-youth-mental-health

The Lund Report. (2025, January). Majority of state attorneys general seek warnings for youth social media. Retrieved January 12, 2025, from https://www.thelundreport.org/content/majority-state-attorneys-general-seek-warnings-youth-social-media