BELLEVUE, WASH. – Start preparing parents during well-child visits at ages 8, 9, and 10 that eventually you’ll want to see the preteen or teenager alone, so they don’t resist when the time comes. Dr. Cora C. Breuner said.
She tells parents, "I really need to be your child’s physician, and it’s really important that I have a rapport with him or her. I need the child to trust me, and I need you to trust me," she said at a conference sponsored by the North Pacific Pediatric Society.
"I need you to trust that I’m going to tell you if there’s a serious medical problem that is uncovered when your child talks with me. I will bring you in on that. Sometimes kids tell me stuff as a provider that they might not necessarily share with you," said Dr. Breuner, professor of pediatrics and adolescent medicine at the University of Washington, Seattle.
Dr. Cora C. Breuner
The script seems to work, because parents always leave the room without a fuss when the time comes, even though some mothers try to assure her that there are no secrets between them and their daughters.
Dr. Breuner uses a different script to build trust and confidentiality between her and the patients: "Everything you say is between you and me unless you say you hurt yourself or someone else, or someone is hurting you physically or sexually."
She said it every time she sees them, even if it’s for something like strep throat. Some patients tease her for saying it repeatedly, but every once in a while it prompts a patient to reveal that this time they do feel sad, or someone is hurting them, or they’re cutting themselves, for example.
If you tell patients that everything they say is confidential, be explicit about what "confidential" means, because adolescents are concrete thinkers, she added. Dr. Breuner explains that what they say will be part of a dictated note in the chart, but behind a special tab so that only certain providers see it.
She uses yet another helpful script when a female patient reveals she’s sexually active and wants birth control, but doesn’t want her parents to know. One 14-year-old girl, for example, was brought in by her parents to discuss behavioral problems. The mother pulled Dr. Breuner aside to tell her that her daughter was hanging out with a "fast crowd" and that the parents wanted in the room at the end of the confidential part so all could talk about the situation.
The patient revealed that she is sexually active, asked for birth control, and begged her not to tell her parents. Her parents didn’t want her to be sexually active because "we’re not supposed to do this in our family," the girl said, adding, "but I love him."
"These kinds of situations are tough," Dr. Breuner said. She can’t provide contraception and bill for it without the parents finding out, but she wants to avoid a pregnancy, and she wants the parents to remain her allies and keep bringing the child back.
First she helps the patient calm down emotionally and step back from the flood of feelings, then she gives her three options: She can go down the street to Planned Parenthood for contraception and screenings without being billed. "Or, I can bring your mom and dad in, one at a time or together, and have a conversation as your advocate, because I’m your provider. Or, you can stop having sex. It’s your call, but you need one of those three things to happen," Dr. Breuner said.
Patients typically worry that their parents will get mad or upset.
"You have to trust me on that," Dr. Breuner said. "I’m pretty good at doing this, I think, and can advocate for you to keep you safe. Or, you can have a really terrible car ride home" if the parents aren’t let in. "Maybe I can help you."
Sometimes she does have to refer the patient somewhere else for confidential services, but in most cases, "It’s pretty easy to push families through to come up with something that’s more for her protection and their protection," she said.
Dr. Breuner reported having no relevant financial disclosures.