Intro: Welcome to Pediatric Voices, Duke Children's podcast about kids' healthcare. Now, here's our host, Dr. Angelo Milazzo.

Dr Angelo Milazzo (Host): Hello and welcome to Pediatric Voices, a podcast that dives deeply into conversation with the people who make up the Duke Children's Healthcare team. I'm Dr. Angelo Milazzo, a pediatric cardiologist and Professor of Pediatrics at Duke Children's, and a co-host of this podcast. My friend and the other co-host of the show is Dr. Richard Chung. Richard is a Pediatric and Adolescent Medicine specialist and a Professor of Pediatrics at Duke Children's. We are both here to bring you expert insights about timely topics in children's health.

On this episode of Pediatric Voices, let's look at health concerns for teens and young adults. In pediatrics, we try to provide care for children from birth all the way through to young adulthood. And for the first few years of life, the routine care of children follows a fairly regular, fairly strict schedule. Things though do tend to fall apart somewhat during adolescence and in young adulthood, and gaps can form in the routine care of teens and young adults. And these teens and young adults have important medical needs which need to be met. So, to help us understand this better, let's talk to Dr. Jane Trinh, a physician and faculty member here at Duke Children's.

Dr. Trinh is a Medicine-Pediatrics physician, that means she has completed a residency program, which includes training both in the care of children and in the care of adults in both the hospital setting and in the office setting. Dr. Trinh is an Associate Professor of Pediatrics and an Associate Professor of Internal Medicine in the Duke University School of Medicine. She's Chief of the Division of Medicine-Pediatrics, and she sees both adults and children in our largest community primary care office here in sunny Durham, North Carolina. Dr. Trinh leads and participates in several key initiatives here at Duke Children's, including the Duke Academy of Health Professions Education and Academic Development Program, the Duke Medical Alumni Council and the Department of Pediatrics Equity, Diversity and Inclusion Committee. She has been nominated three times for the Duke Excellence in Professionalism Award. She's a widely published scholar and researcher. She's recognized as a superb mentor and an excellent teacher, and that's only part of what Dr. Trinh does and what she is known for here at Duke Children's. Welcome, Dr. Trinh. Jane, it is a tremendous pleasure to have you on the show today.

Dr Jane Trinh: Thank you, Angelo. It's great to be here. Thank you for that introduction.

Host: Jane, I was hoping we could start by just giving a quick little overview about what medicine-pediatrics is, because I think our audience is probably familiar with pediatrics and probably familiar with internal medicine. But Medicine-pediatrics may be a new concept, so if you could just give us your perspective on it.

Dr Jane Trinh: Well, thank you for that question. You know, I think that, as an internal medicine and pediatrics physician, I have the opportunity and my colleagues have the opportunities to care for patients throughout the age spectrum. And in our training, we undertake clinical experiences that encompass everything that is involved in a pediatrics residency as well as an internal medicine residency. So, it gives us the expertise to care for patients in the outpatient setting of all ages as well as the inpatient setting of all ages.

Host: Jane, one thing I like to get from our guests is their origin story. So, tell us a little bit about how you became interested and involved in children's health.

Dr Jane Trinh: So, I wanted to do pediatrics since I was a young child. And how I was interested in children's health was really due to my pediatrician, my family immigrated from Vietnam. And in the early part of my life, we lived in a very small town in Oklahoma. And we were one of the very few immigrant families in this very small town in Oklahoma. And I remember distinctly how much we were embraced in our medical home. My sisters, seeing a pediatrician for the first time and how she treated my parents and incorporated us in the conversations in those early stages really influenced my decision to be a pediatrician. So, we are very fortunate to have that exposure. We're also very fortunate, honestly, not to be that's sick. But even in the small number of encounters that we had with them, she had a huge impact in my life and my sisters' lives.

Host: That's really an amazing story. I think medicine is one of the last great apprenticeship systems, and I think many of us were influenced by early experiences and certainly by people whom we saw as exemplars or mentors or great teachers. So, I love that story. So, let's talk about today's topic. Let's dive in here a little bit, and I'd like to start by getting your broad perspective on the challenges in providing care to our teenagers and to our young adults.

Dr Jane Trinh: I think there are a lot of misconceptions about the care of adolescents and young adults. I think that they're often seen as intentional risk takers and not adherent to care, not caring about their health, and that they don't really care what their parents think or what adults think about what their decisions may be. I think those misconceptions lead us, as providers and as parents, to not allow them the space to grow and to learn about themselves and their health and the ways that we can to really foster their sense of responsibility related to their health.

Host: So while we're on the topic of misconceptions, one thing that has occurred to me in my own practice seeing some teens and some young adults, is that they are heavily influenced in terms of their health behavior by what they're seeing in social media. I'm wondering, what is your perspective on the information that these patients are getting, the way they're using that information, the way they're bringing that to the office encounter? And how are you dealing with that in your practice setting?

Dr Jane Trinh: That is a great question and something that we are learning more and more about in terms of how it affects our adolescents and young adults, how it affects their way of thinking, their influences. And I think that's actually something that we as pediatricians and internists are also learning about how to incorporate that in the health encounter. It's also something we didn't train to learn about and how to address. And so, I think having those open conversations in the annual visits to really think about like how much the adolescent may be using social media, what other kind of influences and what other concerns have come to their attention on what they've learned and just start with that open-ended conversation, just to get a sense of what kind of information they're getting. There is some great information, there's some great networking for social media for adolescents and young adults. There's also some that are harmful. So, getting a sense and exploring into that and asking those kind of questions, I think, are great things to start out in that encounter with the pediatrician.

Host: So to dive a little deeper into this part of the conversation, do you have patients who come to you and say, "I'm concerned about a medical problem. It's something I saw on TikTok or something I saw on Instagram or read about on Reddit." And if so, how do you begin to tease apart fact from fiction, reality from fantasy, their perceptions and misperceptions from what you need to convey to them from a purely medical perspective?

Dr Jane Trinh: I think that also gets to some of the important pieces about the routine care that adolescents can have and the relationship they can have with their pediatrician. Because oftentimes this is not one conversation, there's no way to be able to capture all of it in one conversation and in a visit that they may meet the pediatrician for the first time in their adolescence or even maybe have that relationship grow over time. And patients where I've had that relationship with, it's a lot easier to kind of start to have that conversation. And then for patients who are newer to me and are experiencing this, we spend a little bit more time exploring that. So then, to get to your question a little bit, Angela, you know, I start to ask them, "What is it that they're learning? What is it that they're hearing? What things worry them about what they have heard about on these social media outlets?" And then, I start exploring into that a little bit more. And then, I weigh in and let them know, you know, there's some things that may affect them more on a day-to-day basis. And I let them know also that what I know from what we've learned. And then, we kind of talk through where the conflict may come up with these information sources.

Host: That's really fascinating. It's such a tangled web, I think, that we get enmeshed in when we start to have conversations with patients about these non-traditional sources of information because we often have to educate ourselves about those sources. At least, I can say that I've had to do that and I've learned a lot about what my patients are learning. And in some cases, it's been an aid and in other cases, it's been an obstacle and I'm curious if that's been your experience as well.

Dr Jane Trinh: Oh, absolutely. And there are many things that they will bring to the table that I did not know about. And sometimes, I'll use that actually as an opportunity to demonstrate how I'm willing to learn about it. And I'll say, "Where did you see that? Let me look into that." And I think that even if it sounds sort of more off the wall than you'd like, obviously, there are safety concerns that we would address upfront. But if it's something that they're just hearing about and it's something that's an opportunity to be able to build that trust, where I can say, "Well, let me learn about that a little bit more and let's have a conversation about that some more" to allow them to see that I also respect their experience and what they're seeing in their life and kind of their world. And I think that builds that relationship with the pediatrician so that they have an adult that they can go to and they can trust, and some don't have that in other places.

Host: Jane, I wanted to ask you a little bit about the role of mental healthcare and behavioral healthcare in this cohort of patients. Because it has struck me that those kinds of issues, we're seeing those issues in younger and younger children, but still a high concentration of behavioral issues, mood disorders, mental health issues, things like anxiety, depression-related conditions, substance abuse or substance use disorder issues around mental health in general that we see all the time in teens and, obviously, as they transition into young adulthood, and that has to be an incredibly complicated part of your practice, I'm sure. Can you talk a little bit about what that is like and what the challenges and what some of the successes have been?

Dr Jane Trinh: We are seeing, as people have heard about, in the press and things like that, so much mental health. Obviously, there has certainly been mental health concerns over many years. The COVID pandemic really has uncovered so many more challenges that we have, and also outlined so many challenges that we have in our systems to really support patients throughout the age spectrum with anxiety, depression, substance abuse, and the whole gamut of behavioral health concerns. So, I think that there's been a number of changes in the healthcare system that have allowed us to support better our patients. There's different models of connected, integrated primary care and behavioral healthcare models. Certainly, also the acknowledgement and the awareness of the mental health challenges and bringing up to the forefront in a visit also allows us to connect people with other community resources with therapists and allow conversations with patients and families to be more upfront about it, when I think in the past, we've been more hesitant to bring up the concerns, with validated screening tools, additional resources coming down the pipeline, absolutely more resources being thrown into recognizing the behavioral health supports that are necessary for the health and wellbeing of our patients. And again, I hope to see improvement as we move forward. I think we have seen some improvements recently.

Host: Jane, I want to dive a little bit into something you mentioned and that is that integrated care model. Because I think our audience will be interested in hearing that our primary care programs within Duke Children's have had this model for quite some time where we're leveraging resources to be able to provide primary medical care and some primary behavioral and mental health care literally within the scope of the same visit. So, can you give a little bit more detail as to how that works?

Dr Jane Trinh: The integrated primary care and behavioral healthcare is not new to our primary care groups. We've certainly had a connection with our mental health providers for many years. And in the evolution moving forward, we're integrating it even better in our clinic and in a different way of collaborative care. So, our new model of collaborative care allows for a behavioral healthcare manager to be able to connect with a patient sooner and do brief counseling before they are connected with either additional mental health resources or additional medication management. But the behavioral health manager allows for that earlier, more frequent touchpoints. And that person, that behavioral care manager, works very closely with the primary care physician as well as with the extended mental health team.

Host: Jane, as an internal medicine specialist and as a pediatrician, you have the privilege of dealing with diseases that actually can span that gap between. So, I'm thinking of something like high blood pressure, which may start very early in childhood and then may progress during the adolescent years, the teenage years, and then become a problem in the adult years. Are there other examples of diseases that you deal with that do span across that are maybe something special to the purview of an internal medicine/pediatric provider, things that you feel are important for our audience to hear about, and that kind of speak to the special nature of the work that you do.

Dr Jane Trinh: So, yes, because of our training and because of our experience in chronic health conditions that affect adults, we are able to span the ages as we're seeing some of those disease conditions affect our younger populations and the adolescent age and potentially even earlier. So, hypertension you highlighted, diabetes, obesity management, the mental health, that you have already alluded to and all those components, and also reproductive and sexual health, important pieces that our additional training in internal medicine really allows us to be able to extend that knowledge to the care of adolescents and other young adults.

Other areas I think that we have the ability to care for is our children who have pediatric-onset chronic illnesses, that then are growing up to become young adults and then real adults. And I think we have the ability to make those connections, because we have familiarity with adult medical illnesses that then subsequently affect these same patients who have pediatric-onset illnesses all throughout their age spectrum. And so, we have that insight to be able to kind of see them through those transitional stages of learning more about their health, understanding what's affected them and their health when they were potentially even infants, into their school age years, until their teenage years. And these same health conditions will carry through with them through their adult years.

Host: Is there a particular health condition or health problem that comes to the fore during this stage of life that it would be really important for our listeners to be aware of so that maybe families who are hearing this can help their teen or help their young adult get connected to care, if there's been a gap, for example? Is there a certain medical problem or group of problems that you feel there isn't enough talk about or enough visibility around that you deal with all the time that you want to highlight for our listeners?

Dr Jane Trinh: I'm not sure there's a specific disease process for se. I think that what I'd love to be able to emphasize is the importance of maintaining that connection with a primary care physician and the continuity of care, even in the adolescence and young adult ages. I think that, oftentimes, healthy children may need a sports physical, and they come in for their sports physical, maybe get their couple vaccinations in, and those are definitely important things. I think beyond that, what I would emphasize that the connection with the pediatrician and the primary care physician and then certainly, in my space, are internal medicine and pediatric physicians, not only the screening in terms of cardiovascular risk and other things that are going on in their health, but also thinking about the ability to counsel on risk reduction and preventable disorders, giving the immunizations, giving general health advice, and then building that continuity of care so that encourages the adolescent who then becomes the young adult who then becomes the adult to really think about their health and how their health affects them and every part of their life. And I think seeing that and maintaining that relationship is a really an important part of supporting your adolescents and allowing them to see that responsibility of taking care of their health. Again, we see so many people fall outta healthcare in this late adolescence to young adults, and there's a lot more ED visits, there's a lot more acute care visits. And I do think there's a lot of diseases that are preventable if patients still continue to check in with their primary care doctor.

Host: I think that's an incredibly important point to highlight and just sort of a really beautiful encapsulation of your perspective on the care of these somewhat vulnerable people at a vulnerable stage in life. So, I love that answer. So, it's very clear to me that you're inspired by all this. So, in your words, what inspires you the most in your day-to-day working life?

Dr Jane Trinh: I think it's the patients and their families. I think it's hearing their stories. It's being able to see kids that do become adolescents and are successful in their own myriad of ways, whether it's further education, whether it's employment, whether it's their relationships. I mean, obviously, there are so many competing demands in people's lives that sometimes if they're healthy or they're perceived as healthy, then the healthcare is dropped off. But again, that connection and the stories that go along with the patients and their families, and just what they go through in their resilience, really keeps me going in terms of trying to keep them healthy.

Host: I love that answer. So, last question, a little bit of a fun question for you. If you weren't an internist, if you weren't a pediatrician, who would you be, what would you do?

Dr Jane Trinh: I struggle with this question over time. I feel like at different stages I might be somebody or something different. So, I think in my imagining if in this current state of life where if I weren't an internist or weren't a pediatrician, I would be part of a community organization that is committed in terms of bringing up all aspects of health in the community. So, I do think it's still very much be health-related, and really looking to serve the the needs of a community. Somewhat vague, but I think that's still related to what is important to me.

Host: Well, I think that's wonderful. And Jane, I want to thank you for being a guest on our show. I hope you'll come back and talk with me again about other issues in internal medicine and pediatrics. And, you know, it's just been a great pleasure talking with you today.

Dr Jane Trinh: Thank you. It was fun.

Host: Pediatric Voices is brought to you by Duke Children's Hospital in the Department of Pediatrics at the Duke University Medical Center in Sunny Durham, North Carolina. Pediatric Voices was created by Dr. Richard Chung and by me, Dr. Angelo Milazzo. Debbie Taylor provides a huge assist and keeps us organized. Our podcast is produced by the amazing people at DoctorPodcasting. Special thanks to Dr. Ann Reed and the team at Duke Children's for their continued support.

You can find our show and please hit the subscribe button wherever you find your favorite podcasts, Apple Podcasts, Google Podcasts, Stitcher, TuneIn, iHeartRadio and Spotify among others. Connect with us online at dukechildrens.org, at Facebook/DukeChildrens and at Twitter/Duke_Childrens. We'd love to hear from you, so leave us a review. Thank you for being part of the show, and we will see you next time.