Who is Invited to a Diabetes Follow-up Visit?

Treating infants, children, teens, and young adults requires multiple medical and educational strategies. Appropriate therapy for a 6-year-old in first grade does not necessarily translate to success for 16-year-old in 10^th grade. Indeed, each visit becomes an opportunity to try different techniques to establish both a rapport with the patient and family and provide medical treatment. As always, I learn new things daily from my patients and their families. Several days ago, I ran into a medical colleague whose teenager was a former patient of mine. Things did not go particularly well with our (teen and doc) therapeutic relationship and a mutual decision was made for the young woman to receive care elsewhere. Naturally, I wondered how I could have been more productive and successful in this medical relationship. Indeed, "doctor-teen" relationship was the key here. Her mother and I had a very useful chat retrospectively. What did I learn from this relationship?

Most pediatricians will tell you that they see their teenage patients separately from their parents (probably after age 14) to find out what is really happening. After the visit, they summarize what is medically necessary to the parent. This takes time. My policy with teens is inconsistent. If a teen wants to see me alone, I am okay with that. Interestingly enough, these visits tend to go very well and I learn a lot, some of which I wish I did not hear. However, this information was extremely important and I was able to do anticipatory guidance from the viewpoint of both the pediatrician and diabetelogist.

Getting back to my previously unsuccessful relationship, I had always evaluated this young teen with her mother present. Her mom felt that things would have worked much better if I had seen the young lady alone to avoid the sensation of us "ganging up on her." I took this advice to heart and tried to think just why I was not seeing teens separately all the time.

After a period of brainstorming, I came up with three reasons:

1. Time (I am always running behind in clinic. Visiting with both parent and teen separately will make me even later.)
2. The parent seems to just walk in with the teen and the visit becomes a team discussion: kid gives me the pump/meter, mom gives me the download information, discusses concerns: hypos, hypers, school, travel, sports, etc. Of course, the teen can't launch into worries about sex, drugs, alcohol, relationships, etc. unless he/she specifically asks to see me alone. Although I always ask the kid (and mom) if there are any further questions, I do not always ask the patient if he wants to ask me anything without the parent in attendance. Not a really good practice.
3. If the teen is under 18, the parent needs to sign an instruction sheet to say he/she understands everything we talked about.

The reality is that I am just accustomed to seeing patients with their parents in attendance and unless specifically asked by the teen to be seen alone, it is a group visit. I am now more cognizant of the need to see these young adults by themselves to find out what is really going on. A major benefit of the private doctor/teen visit is that the "drama" of the parent/child dyad is eliminated. There is no naming, blaming, and pointing at the teen's lapses of diabetes care. The teen generally knows what is required in the care of  his/her diabetes and will readily admit that help is needed to do all the required tasks. My job is to be supportive and present two to three realistic goals for the teen so he may achieve success, at least in the short term. I am always surprised that when the teen is left alone, he often willingly confesses his concerns. Sometimes the truth will not be told and I will have to go talk to the parent for a reality check. I have to trust my instincts regarding the veracity of the information from the teen and make appropriate therapeutic suggestions.