Rob Steele, MD (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy Kansas City. Before we introduce our guest, I want to you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast and click the Claim CME button.

Today, we are joined by Dr. Ryan Pasternak to discuss confidentiality in the care of adolescents. Dr. Pasternak is a board-certified Adolescent Medicine specialist, Division Director for Adolescent and Young Adult Medicine at Children's Mercy Kansas City, and Professor of Pediatrics at University of Missouri Kansas City.

Dr. Pasternak completed undergraduate training in chemistry at the College of William & Mary in Virginia, and then graduated from Eastern Virginia Medical School in Norfolk, Virginia. He attended Pediatric residency training at LSU Health New Orleans, and completed a Fellowship in Adolescent Medicine and Master's of Public Health Degree at Johns Hopkins School of Medicine and School of Public Health, respectively. Holy bananas, the man's been in school for quite some time! He's a very brilliant man.

Dr. Pasternak discovered his love for adolescent patients in medical school. During fellowship, his research focused on adolescent confidentiality as well as adolescent sexual health and care of minority and marginalized populations. His public health work focused on health policy. He used his training at LSU School of Medicine to develop the Southern Center for Adolescent and Young Adult Health Equity. And now, in Kansas City at Children's Mercy, Dr. Pasternak is a member and fellow of the American Academy of Pediatrics, past board member of the Society of Adolescent Health and Medicine, member of the World Professional Association for Transgender Health and Physicians for Reproductive Health, and faculty of the of the Adolescent Reproductive and Sexual Health Education Program and Fellow of the PRH's Reproductive Health Leadership Training Academy. Holy bananas, that is a mouthful! He's also a member of the Surfers Medical Association. We may have to pull on that string for a little bit. Dr. Pasternak, thank you for joining us today.

Dr. Ryan Pasternak: Thank you, Dr. Steele. And I'm sorry that you were provided all that information.

Host: No, that was fantastic. I'll tell you what, our listeners will know how much of, one, how invested you are in care of the adolescent, but also an expert in what we're going to talk about. You know, before we jump in, you did your training mostly in the South, you're at LSU, EVMS, you are in Virginia, undergraduate. It explains why I've heard you're going to be doing some traveling in the South and Mississippi, maybe checking out the history of the Blues and history of Civil Rights. Is that the case? Is that how you're spending your summer?

Dr. Ryan Pasternak: Well, no, I just got back from that trip. It was my son and I on a road trip. And, yeah, Civil Rights and the Blues. We thought those things were intimately tied both in place and purpose of it, and just came back on Sunday.

Host: Well, that's fantastic. Well, having grown up in the South myself, I'm jealous. I'll bet that. We'll have to talk offline about that trip. That's great. Why don't we jump right on into it? And why don't we just start at a high level and just what does the primary care pediatrician need to know to effectively address confidentiality with youth?

Dr. Ryan Pasternak: Good question. The most basic that it's developmentally expected and clinically appropriate to provide confidential care to youth. That's it. Bigger picture, the essential premise in providing confidential care and caring for adolescent and young adult patients is that they have a developmental need for emerging and increasing autonomy. None of us learns terribly well if we're not able to make choices, including making mistakes. on our own. So, part of becoming a functional adult is making decisions independently. So, the ability to effectively do that with respect to healthcare decisions has been widely recognized to exist for most adolescents around age 14. And it's up to us as providers to give that space and time that allows them to use those emerging skills. And it's to our benefit and their benefit to do that while we oftentimes still have parents, guardians, other supportive adults to rely on to bring into the conversation if and when needed. So, we're not trying to exclude parents. We're trying to use the whole family to be able to support patients. And because of that difference though, in terms of like opinions about confidentiality and confidential care, sometimes you get a dissonance there. Ensuring access to confidential care can be a really serious safety issue for some adolescent patients, just depending on how their parents feel about some of the behaviors that they might be engaging in.

Host: Yeah. So, a really great overview. As a practicing general pediatrician, one of the challenges I had, you mentioned sort of 14 as that age where you 're really making that transition. But that really is an evolution, I found it, that you got to prep the family and you got to prep the patients. Do you have any pearls of wisdom of when does that really occur? How do you sort of prepare for that time when you really are transitioning into that more confidential conversations with the adolescent?

Dr. Ryan Pasternak: Yeah. Well, the AAP really recommends that we start that early, age 10-ish, that we start preparing patients, and as you said, parents, for those conversations, for that one-on-one time, giving patients time at their 10th or 11th well-child visit to really spend a little bit of time one-on-one with the provider.

I very vividly remember my son's 10-year-old well-child visit, my wife and I in the room with the pediatrician, and the pediatrician telling my son that, "Hey, next year when you come, we're going to spend a chunk of time one-on-one, just you and me talking about some things. Your parents will be in the waiting room." And while she was directing her voice to my son, I also recognized that she was actually talking to my wife and I, trying to get us mentally prepared for that time. And so, it happens in baby steps, just like everything else in Pediatrics. We're trying to meet patients where they're at in a developmentally appropriate way.

Host: Well said. Well said. And I think your experience with regard to how it is that you're talking with the patient and yet you're not really talking with the patient, you're indirectly talking with the parents. That's a great pearl of wisdom with that one for sure.

With respect to confidentiality and your interest as well as personal interest in social injustice, can you give a sense of how adolescents experience social injustice? Is it different? And how is it different? And then, how does confidentiality, how does that play a role with social injustice and how adolescents perceive that?

Dr. Ryan Pasternak: There's a lot of ways in which adolescents experience social injustice broadly and within healthcare systems. Some of it overlaps with things that adults can experience, but adolescents definitely experience it with respect to confidential care. I think the first way that many of us recognize that this could be an issue for teens or adolescent patients is just the idea that sometimes they're being told that they cannot, may not, or not permitted to have opinions for any decision-making regarding their reproductive capacity or family planning choices, which is kind of funny because when you ask parents in the exam room, if they want or expect to become grandparents one day, almost overwhelmingly you get a yes. But then, there's this idea that adolescents shouldn't have opinions about those things themselves. But if you ask them, they do. They're thinking about it. They have thoughts on that. They do think about what their goals are with respect to parenthood or not parenting, and ensuring confidential time to spend with patients. And just asking a few key questions in that area can be really helpful for helping that young person outline their goals, and their current plans and actions and whether or not their current plans and their current actions are really lining up or aligning with those long-term future goals of family planning, parenting in the future, maybe not right now, et cetera.

And I think the other way in Pediatrics that we see this play out in really stark terms is with our youth that are experiencing significant chronic medical conditions, so persons with things like trisomy 21, cerebral palsy, solid organ transplant. Oftentimes, they end up in a system that they're so medicalized, that the idea of them having sexuality or having thoughts about their future family planning is sort of put aside. That can be really risky in some cases because they are, again, having those thoughts, thinking about those things. And many persons with chronic medical conditions as young people desperately want to be doing and experiencing the same things that their peers are experiencing. It's super important for us to continue to address those things in a developmentally appropriate way with young people with chronic medical conditions or conditions that affect their developmental capacity.

Host: Yeah, great. So, really great nuances with regard, particularly for those children that do have chronic medical needs. As the clinicians are engaging with adolescents and families, you know, it's important not just what you say, but how you say it and just the use of language, if you will. I'd like to think that I'm still able to do it because I still have teenagers in the house. So, that's helpful. But, for those of us who maybe don't have teenagers either yet, or they're long gone out, what advice do you have for the pediatricians on the use of language in order to support adolescents? Things that we should do, things that maybe we shouldn't do.

Dr. Ryan Pasternak: So, first and foremost, just like we want to do with all of our patients, come at things from a non-judgmental perspective. We're not their parents. We don't want to come at them from sort of a parental perspective either. Be straightforward about medical information. And then, ask them. We want to meet patients where they're at. We want to ask them what their goals are, reflecting information back to them without judgment. I think it is important to acknowledge and respect their personal identity. So, asking about gender identity and pronouns and other choices in that regard are certainly super important in terms of their goals with relationships, and not guiding patients toward a specific decision.

So, two recent cases that I can think about where I was very cognizant of having to work really hard at meeting the patient where they're at and using my language, it's by no means perfect. I'm constantly revising this and talking to peers about it. But we had a patient coming in. She was interested in a method of contraception. She had outlined that she really doesn't see herself having children, or if she does, she sees it in the distant future. So, medically speaking, I could very easily say, "Well, the best method for you is going to be a long-acting method of contraception, like an IUD or an implant or something." But those were things that she pretty clearly stated she was not interested in, right? So, I needed to use my medical information and my language to give her options that she felt comfortable with.

In another case, and we were just talking about this with colleagues last evening, the case of an adolescent that came in wanting pre-exposure prophylaxis for HIV, which is more and more a common part of our practice, something that we want to have be a common part of primary care practice and not labeling that patient with regard to their sexual behaviors versus their identity was super important to them, right? They were coming in asking for a preventive care measure. But they didn't want us to label them based on their behaviors, rather providing us a description of their own identity. And I think that's super important too.

Now, the other things that I think are sort of funny, but real medically, and I'm going to share a colleague's story. So, one of my colleagues that I used to work with in Louisiana lived a few blocks away. And so, we would bump into each other on dog walks and things, and we always would have some new pearl, something that adolescence taught us about how we engage and talk to them. And she excitedly ran up to me one day, Dr. Steele, and said, "Oh my gosh, Ryan, we've been doing it all wrong for so long." I'm like, "What are you talking about?" And she goes, "I had a patient, significant iron-deficiency anemia. I was talking to her about options for treatment as well as dietary changes." And I said, the thing we always say, you know, "Red meat has lots of iron in it. And it's a good option if you're able to afford it." And the patient looked at me and said, "Is it okay if it's gray?" And I said, "What do you mean?" She was like, "Well, do I have to eat it raw and red?" We say eat red meat all the time, right?

Host: Right,. Sure. You know, as you're telling the story, I'm like, "Okay, I'm waiting for the punchline." Then, you're like, "Oh. Oh, yeah, okay."

Dr. Ryan Pasternak: This young person thought we were telling her to eat raw, right? And so, I think our words are just way more powerful than we recognize.

Host: Yeah. Okay. Great story. Great story. I can tell you, even with my own kids, I sometimes recognize that my language may not land, depending on how I use it. So, speaking of language, as we're eliciting that history from patients, how do we do that in a trauma-informed manner, that is affirming to the patient? Do you have advice for the clinician with respect to that?

Dr. Ryan Pasternak: Yeah. And that's an excellent question, because the first thing is we need information to provide options for treatment, and to give good medical information back. So, eliciting information is such an important part of our job. But we only need information that's medically necessary. Particularly in situations where a patient might have experienced trauma, we want to practice trauma-informed care by only eliciting that minimal amount of information that's medically necessary, not re-traumatizing patients and not making them repeat, you know, descriptions of episodes of trauma unnecessarily. Sometimes, we have to ask the question. And depending on our role within the health system, it can be important to ask more, but we always want to ask just what's necessary.

We also want to just avoid, and this is one of those things, again, where we have to kind of catch ourselves and sometimes, be aware of where the patient might be leading us, avoid asking questions from a position of curiosity. Again, we need medically pertinent information, not information because a story is entertaining. And sometimes patients are going to tell us things that are surprising, you sometimes horrific, and we sort of want to hear more about the story. And we need to really check ourselves a little bit there. Sometimes patients will do it on purpose and try and sort of get us off track, maybe not have us provide all the counseling and information we need by entertaining us with their story. And we have to check ourselves and our patients in that regard too. So, I think we just need the information that helps us make those effective, acute medical decisions if we have to report something, et cetera, and then refer on if a traumatized patient in particular needs more specialized services.

Host: Yeah, great. Excellent points, and I really appreciate your time, Dr. Pasternak. This has been very informative. And I certainly have learned a lot about how it is that we can better take care of our adolescent patients. You know, before I let you go, I have to, as someone who enjoys the South as much as I do, we're going to play a quick game of Would You Rather. Would you rather never get to eat shrimp and grits again, or never get to eat chicken and waffles again? That's my Southern dinner right there. My southern choice.

Dr. Ryan Pasternak: I could not live without shrimp and grits.

Host: Oh, I'm right there with you.

Dr. Ryan Pasternak: Chicken and waffles is the hard one to give up, but I can't live without shrimp and grits. And we have hosted an annual Jazz Fest party with a few exceptions during COVID for quite a long time, and that is my job to make shrimp and grits.

Host: Oh, fantastic. Well, I'll invite you over to our next crawfish boil next time we have one. We'll do that. Very good. All right. Again, thank you, Dr. Pasternak, for joining us today. As a reminder, claim your CME credit by listening to our show today and then visit cmkc.link/cmepodcast and click the Claim CME button. This has been another episode of Pediatrics in Practice, a CME podcast. I'm Dr. Rob Steele. See you next time.