Vicki Hayes, MD, Department of Family Medicine, Maine Medical Center

Helping a medical student or resident feel comfortable working with the adolescent patient population can be challenging. Students must become adept at rapidly developing rapport and gaining the teen's confidence to a degree that allows them to delve into sensitive topics such as safety, substance abuse, sexual practices, sexual orientation, and intimate partner violence. Tools have been developed to help with this process, such as the well-known HEADSS mnemonic,¹ which allows the interview to progress in a manner such that generally non-threatening topics (home, education, school, diet) are addressed initially prior to proceeding to more sensitive topics such as drugs, sex, and psychological issues/suicide. However, perhaps the most essential component in the adolescent interview process is delivering a confidentiality statement. Confidentiality is a prime factor in adolescents' decision to seek care and discuss their engagement in risk behaviors.²

Here are some tips regarding confidentiality to share with medical students/residents:

• Know the laws addressing minors' rights in your state regarding consent for medical care. To ensure confidentiality, the student needs to know the areas in which the patient does not need parental consent, such as contraception, STI screening, substance abuse treatment, mental health counseling, etc.
• Teach the student that one of the "rules" of adolescent medicine is to get some time to interview the teen alone. It helps to begin setting the stage when the child is younger. Starting at age 8, 9, and 10 prepares the family that in the future the patient will be spoken to alone so that they aren't resistant when the time comes.
• For that occasional parent who is reluctant to vacate the room, the student can tell the parent, "To be the best doctor for your child that I can be, I need some time alone with him or her to develop a relationship. I need them to trust me, and I need you to trust me."
• They can also tell the parent that their child may share some things during the interview that they won't be able to discuss with the parent, but that should be viewed as a good thing. It's important for that teen to be able to have someone to talk to with whom they can feel safe and who could provide help if needed.
• Help the student script a statement that they can use to discuss confidentiality that also includes when they would have to break that confidentiality: "Everything you tell me will remain confidential, unless it involves an issue of seriously harming yourself, harming someone else, or someone is harming you." Assure the patient that if you did have to break confidentiality, it would be best to let them know first and discuss together how to share that information.
• Deliver your confidentiality statement at the beginning of the visit and assess for understanding. It is awkward and challenging to have to backtrack and introduce the confidentiality statement once a sensitive topic has already been broached. I instruct students that though it doesn't have the same ring to it, I would rename the mnemonic CHEADSS so that they would always remember to address confidentiality first.

Helping students to set the stage with a confidentiality discussion is so important. Assure them that even if nothing concerning is revealed at that visit, doing this work up front will allow the patient to view them as a safe resource to utilize in the future.

References
1. Cohen E, MacKenzie RG, Yates GL. HEADSS, a psychosocial risk assessment instrument: implications for designing effective intervention programs for runaway youth. J Adol Health 1991;7:539-44.

2. Berlan ED, Bravender T. Confidentiality, consent and caring for the adolescent patient. Curr Opin Pediatr 2009;2d1:450-6

Additional Resources
1. Physicians for Reproductive Health. Minors' access cards available for thirteen states. http://prh.org/resources/minors-access-cards/

2. Guttmacher Institute. State policies in brief. Overview of minors' consent law as of March 1, 2013. http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf.

3. Center for Adolescent Health and the Law. Volume of state minor consent laws for purchase. www.cahl.org.

4. Your hospital legal department can also serve as a valuable resource.