Current levels of comfort and barriers to the provision of adolescent medicine among Pediatricians in Southwestern Ontario, Canada.

The provision of care for adolescents and young adults has received growing attention due to the complex nature of their specific health-care needs1 . These needs range from communicable disease prevention to that of mental health disorders2. In this population, mental health disorders such as eating disorders and ADHD have a significant effect on the quality of life for these individuals1,3. The care of adolescents is unique due to complex factors including pubertal changes, psychological/social changes as a result of maturity, and developmentally appropriate identity exploration and risk taking3. However, despite the attention that has begun to be given to this population and current training guidelines that are in place for physicians, there is still a relative lack of resources that are specifically aimed for both adolescents and their physicians4. The result of these gaps in the care for adolescent patients can result in a lack of physician comfort managing the complex needs of their adolescent patients1,2. Conversely, when physicians identify being comfortable with adolescent topics, care provision such as HIV screening have been shown to be tenfold higher than that delivered by providers who were uncomfortable with this care5. This study aims both to identify the current level of comfort that pediatricians have with a variety of adolescent medicine topics, and also to elucidate the potential barriers that physicians are facing to feel comfortable appropriately treating this population. A literature review was conducted to identify the current knowledge level of physician comfort with adolescent medicine topics. With our search terms we identified 1722 papers, 275 of which were duplicates. We narrowed our search to adolescent medicine, primary research studies and studies that specifically analyzed physician comfort (removing papers that solely looked at practice or knowledge characteristics without addressing comfort). This resulted 53 studies that examined physician comfort with adolescent medicine topics. Of these, 6 studies addressed eating disorders, 4 mental health, 21 for reproductive health, 3 analyzing LGBTQ topics, 6 discussing sexually transmitted infections, 7 for substance use and 5 looking at the transition to the adult health care system (Figure 1). There were no studies that identified all adolescent medicine topics together to access physician comfort. Based on the results of this review, a lack of comfort by physicians for treating their respective adolescent medicine topics was identified. Most research identifying physician comfort with adolescent medicine topics addressed contraceptive care. This can be compared to other topics such as LGBTQ+ and mental health topics in which there were fewer results in our review. There were a variety of barriers to physician comfort expressed in the reviewed studies. The most common barrier was a lack of knowledge and training to treat adolescents without referral or assitance6–8. When examining the effects that additional training has on physician comfort, one study compared residents who had additional eating disorder training to residents without either of these factors within their training9. This study found that the residents who had specific training or support reported higher comfort levels with diagnosing patients with eating disorders, signifying that additional training and exposure to adolescent medicine can improve comfort levels9. Additionally, some papers added a training component to their study to examine if there is an increase in physician comfort following the provision of additional resources. Overall, it was found that no matter the specialty or topic examined, physician comfort and respective knowledge levels improved following additional training2,10–12. Several papers examined a range of specialities to determine if the level of comfort with adolescent medicine topics varied depending on the physician’s specialty. The study by Sawyer, et al., found that pediatricians tended to have a higher level of comfort with adolescent medicine topics compared to that of adult medicine physicians2. Further, the study by Davis et al., found that when comparing OB/GYN residents to family medicine and pediatrics residents, nearly all the OB/GYN were comfortable counselling about reproductive health and providing IUD insertions compared to family medicine and pediatric residents13. When additional training was provided, residents and physicians reported more comfort with managing contraception2,13. Lack of training leading to discomfort with adolescent care was found to be further exacerbated when physicians did not feel as they had available referral options for their patients. This was found to be especially relevant for adolescent medicine topics including eating disorders, LGBTQ+ and mental health6,14. One study looking at the care of LGBTQ+ adolescents found that physicians expressed discomfort in managing their needs due to a lack of outreach programs and resources aimed specifically for this population14. In addition to lacking referrals options, physicians also expressed that when it comes to screening and management practices for a variety of adolescent concerns, there is not only a lack of evidence based medicine practices targeted specifically for this population, but some of the knowledge that is currently being used is outdated (such as IUD complications) 15–17. Further, there was an identified lack of adolescent specific protocols to direct appropriate care16. Another barrier to comfort was a lack of previous experience treating and managing adolescent patients either in residency or in practice9,18–20. This was found to especially be the case when treating transgender adolescents, as the study by Vance, et al., found that more than half of their respondents had not had any exposure to transgender patients, which combined with the lack of training and referral options transgender care cumulated to a lack of comfort treating this population18,21. This was additionally found to be the case when delivering positive results for sexually transmitted infection tests, where physicians that reported a lack of experience delivering such news were more uncomfortable providing this care to adolescents22. Physicians felt additionally uncomfortable due to a lack of time in clinic to provide patients with sensitive information8,22. This lack of time barrier to comfort was further identified by emergency physicians when discussing substance use with adolescents, explaining that they do not feel comfortable due to time constraints to discuss all social and mental health aspects to substance abuse in the emergency room23. As there has been no previous study examining the comfort of pediatricians for a wide range of adolescent medicine topics, this study aims to fill this gap and identify which topics pediatricians feel the most/least comfortable with. Further, we aim to explore specific barriers identified by paediatricians to develop strategies to ensure equitable care for this vulnerable population.

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