Originally published in The Medical Post, VOLUME 39, NO. 29, August 12, 2003

By uncovering the motives of adolescent behaviour, you, your patients and the teens themselves all stand to gain

Your 15-year-old patient wants to go on the Pill. Why? What does she stand to gain from a sexual relationship? Does she fear her boyfriend will dump her if she does not take this step? If so, what does this imply about respect and the state of their relationship? What will they do if she does become pregnant?

My previous column discussed the stages of adolescent development and many of the problems children face as they progress toward adulthood. The “adolescent toolkit” is designed to help foster the development of age-appropriate behaviours and decisions, and promote independence based on respect, honour, dignity and integrity.

These staid qualities are not just words. Indeed, today they seem to be branded as quaint human characteristics from an era long ago. The tangible loss of these qualities contributes to the difficulties our children face.

Witness the willingness to sacrifice self-respect and honour for a chance at fame and fortune on the take-your-pick reality TV show.

The loss of the meaning of these words leaves many to act selfishly; we can do what pleases us as long as it does not harm others. This is first-order thinking—the concrete, immediate response to a problem or situation with little consideration of the consequences.

For example, teen sexual activity while living at home does affect the rest of the family. The family deals with the fallout if pregnancy or serious illness occurs. Drug and alcohol abuse acts like a virus, infecting everyone around it. The angst and stress due to illness, infection, surgery or depression is not borne alone by the individual.

The toolkit contains these important pieces: three defining questions, two “life rules,” the concept of true self versus false self and second-order thinking.

The three questions help many teens understand their concept of friendship, relationships and their self image:

• “What do you like and dislike about yourself?” This focuses on personality and physical characteristics and attributes.

• “What is good and bad about you?” What are their moral and ethical values? How does it affect their behaviour?

• “What are your definitions of a friendship and a relationship?” Many teens confuse the two or provide incomplete definitions. A starting point would include independence as a prerequisite in any relationship—two independent people contributing love, trust, compassion and support so their union exceeds the sum of each individual’s qualities with neither losing their sense of self.

One can discern possible contradictions and congruencies in the answers and use them to help the teen discover broader, more reliable and consistent definitions to use in their lives. It can challenge the first-order thinking inherent in their early and middle stages of development.

The life rules focus on two straightforward statements: “It is not what people say but rather how they act that reveals their true intent,” and “People always do things for a reason.”

Many teens choose to ignore these rules for reasons of discomfort, lack of support and feelings of hopelessness. They do not hold others accountable for their behaviour, in effect condoning it through their own inaction or denial. The undercurrent in this response is fear of rejection if they do not project an image of compassion and understanding.

For example, many of us have heard a spouse’s explanation of living with his/her alcoholic wife/husband as “He/she is great when they are sober,” and “She/he promised they would stop but they always return to their drinking.”

The alcoholic’s actions continually supercede their words of promise.

Yet the spouse continues to give one chance after another until the act loses its value. This damages one’s sense of self and independence.

The concept of the true self versus false self defines who we are. The true self usually discerns right from wrong. It is our conscience, sounding an alarm if confronted by something that threatens our commitment to be true to ourselves. People who follow their inner voice tend to respect themselves and their motives.

They become more self-confident and self-reliant. They are not afraid to say no.

The false self ignores the alarm. He/she knows the action is wrong but do it anyway. Frustrated with this contradiction, they direct their anger inward, damaging their self-respect.

Over time, this pattern of behaviour and decision making leads to a loss of independence. These people have difficulty saying no.

They try to solve everyone else’s life problems except their own, and rarely experience similar acts of consideration from others.

Before parents use these tools, it is essential they try to avoid first-order thinking. Visceral reactions (“Are you out of your mind?” or “What were you thinking?”) rarely solve problems. Second-order thinking invites the person to step back and ask a series of questions to uncover the true reasons behind a behaviour, action or thought.

It gives the adolescent a chance to reflect on their motives for their actions and holds them accountable in an adult framework.

Adolescents strive for independence. Appealing to this desire is a pragmatic means of providing a solid foundation of rules, limits and encouragement.

Mature and appropriate actions in response to the rules deserve respect: Parents can loosen the reins in an age-appropriate manner.

Flouting the rules should have predetermined consequences. The adolescent bears the responsibility of his or her decisions if they wish to be treated as an adult.

We can promote and nurture this desire for independence by using the toolkit in the office setting.

It is truly remarkable watching the changes as our patients travel the path toward adulthood.

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1. Keep a well-stocked teen toolkit (part 1)
2. Help teens tune in to their true selves
3. Adapt parenting to your teen’s development

Originally published in The Medical Post, VOLUME 39, NO. 4, January 28, 2003

Before she can improve relations with her divorced and feuding parents, a young woman must get to know her true self

As adolescents progress through their teenage years we bear witness to their emotional and cognitive development. Some sprout early and surprise us with their clarity of thought and insight. Others remain stuck in neutral for long stretches of time. This is one of the challenges of providing adolescent care.

Fifteen-year-old Caitlin falls into the former category. The reason she came to the high school clinic was her concern about the risk of an eating disorder relapse. About a year ago, she cut breakfast and lunch out of her diet. She did not binge or purge her meals. She did not have a distorted sense of body image or depressive illness. Her behaviour continued for several months then abruptly stopped.

She now remains stable and of normal weight. Her goal was to find out how she could prevent future recurrence.

Adolescent behaviours do not come vacuum-packed. When they seek help, an earnest empathetic approach creates an atmosphere of trust. Let them know you may be asking potentially charged or pointed questions. They need to understand that its intention is to help, not harm or anger them but to draw a clear understanding of their problem. For Caitlin, it turned out her eating disorder arose due to her parents’ post-marital strife.

Caitlin’s parents divorced when she was nine years old. Her father suddenly left the family to marry another woman. Her mother did not establish any new relationship and remains bitter and angry with her father. Many unresolved issues remain between them.

Both parents use Caitlin as a sounding board to snipe and criticize one another. They reveal marital details that she does not want to hear. Caught in the middle, she resents both for their actions.

She is angry with her father for breaking up her family yet still tries to maintain a father-daughter relationship. She tries to support her mother but is uncomfortable with being her mom’s confidant. This stress and worry consumes her. She bears the burden of being the intermediary for a situation she cannot resolve; her frustration grows. She has no control over her parents’ behaviour.

Further, her mother perceives that she is in competition for Caitlin’s love and attention. Tearfully, Caitlin recounted how her mother made it clear that she will not attend her graduation (two years hence) if her father brings his wife.

Instead of looking forward to one of the milestone days in her life, she faces two years of its use as a weapon to control her actions. Her mother, unwilling to resolve the issue herself, transfers the responsibility onto her daughter’s shoulders.

This is a fork-in-the-road life moment. How she handles these relationships and their inherent difficulties can affect the rest of her life and future relationships.

Already seeking solace from within her peer group she takes on the role of therapist solving their personal problems. Yet when she needs their support, they beg off with excuses that they have homework or are busy. Her response is to redouble her efforts, further ensnaring her in an unequal relationship situation: a response akin to her family dynamics.

The goal for Caitlin is to develop the tools to counter the guilt and manipulation on the part of both parents. Given her insight, it is necessary to provide a plan and establish short- and long-term goals.

Clearly, she desires a normal adolescence without the aforementioned burdens. She wants her father to treat her with respect and to spend time with her. Her love for her mother, cognizant that she is alone and now increasingly dependent upon her, hinders her ability to act. She needs a method to approach her parents to discuss these issues. She also needs someone in her corner to support her efforts.

Introducing the concept of true and false self, respectively listening to or ignoring one’s inner voice or conscience, adds another dimension to cognitive therapy. The true-self usually can discern right from wrong. It is akin to an inner voice trying to keep us true to our morals and beliefs. People who follow this inner voice tend to respect themselves and their motives. They become more self-confident and self-reliant. They are not afraid to say “no.”

The false-self follows a path or decision contrary to doing the right thing. The person knows their actions or decisions are wrong but they follow through with them anyway.

Sometimes others try to draw a person away from their true-self using guilt and manipulation, as in Caitlin’s situation. Other times it is the person himself or herself listening to an addictive or self-deprecating thought. The result is anger, frustration and loss of self-respect.

One approach is for Caitlin to write down and organize her thoughts. She has to define what friendships and relationships mean to her. She needs to identify and explore her good and bad qualities and her likes and dislikes. Helping her define these concepts gives her the initial foundation to confront present and future issues that will challenge her sense of self. Once this process is under way, she can focus on her parents.

Caitlin has difficulty discussing her concerns with her father. He consistently interrupts her train of thought. He will twist her words to suit his argument: an irritating and frustrating situation. Her goal is to get him to listen to her.

She is afraid of telling her mother it would be best if she talked about her issues with a friend instead of her. Caitlin needs to grow and develop her own sense of self. She cannot accomplish this goal if her mother becomes increasingly dependent on her for her emotional stability. Yet, she does not want her mother to feel rejected or abandoned.

The beginning of dysfunctional patterns between her mother and herself has grave implication for the future. Caitlin is aware that her future relationships and friendships will naturally move her away from her mother. Requiring more attention, her mother has already shown she is insecure with Caitlin’s foray into adulthood. Caitlin does not want to face the choice of moving away in the future to avoid her mother’s intrusions into her life.

The emotional challenge is overwhelming from Caitlin’s standpoint to talk to her parents face-to-face without some preparation. Caitlin can write letters to her mother and father in a non-confrontational manner explaining how their behaviour affects her. Writing it down reduces the argumentation inherent in parental discussions fraught with emotion.

One way is to look at her relationships as a series of contracts. Every relationship has a contract of needs, expectations and consequences. She should define her needs and wants and ask her parents to define theirs. They should meet to clarify and honour them. Enlisting the support of a counsellor as mediator could support Caitlin’s efforts.

Early to mid-adolescence is fraught with healthy and damaging events that define a person’s future interactions. Offering them the basic tools and support to use in these instances, combined with appropriate followup, can serve them well.

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3. The Birthday Present

Originally published in The Medical Post, VOLUME 38, NO. 16, April 23, 2002

School children tend to set the agenda when it comes to what health info they want

Despite numerous health advisory and information campaigns, inroads into curbing or modifying deleterious adolescent behaviours remain wanting. There are many reasons, including competition from television and movies, advertising, peer pressure, academic responsibilities, development of independent attitudes and rebelliousness, and their own social calendar

The messages and ideas we try to impart to them are lost in information overload. It is not that they don’t want access to accurate and practical health information—they certainly do. The problem is fitting it into their day.

If, as physicians, we are to influence adolescent health, it must start from the ground floor. We have to go to their schools and engage them in classroom discussions. In my nine years of classroom visits at Canterbury High School in Ottawa, I am consistently surprised by what the students want to know. Each class has its own focus and interests. This is yet another reason why single-message ad campaigns fail. They miss a great number of their intended audience.

Health information tends to be broadcast with a sense of urgency: “If the kids don’t hear this now we will have lost our chance.” Classroom visits of an hour per week throughout the school year will deliver all these health messages, but it will be the students who set the tempo and discussion topics. Ceding this control to them makes them responsible for their health concerns and respects their interests. They always listen to what is being said. Their questions are relevant. They also force us to evaluate our own biases.

The students’ questions vary by grade. Each class can have a different area of interest that can include health and fitness, diet, STDs, contraception, abortion, depression, eating disorders, musculoskeletal complaints, cancer, smoking and drug abuse among others. Obviously it requires more than one visit to cover these topics in any detail. It also requires a consistent presence in the school. Students talk to each other. They will know who you are and, if they like you, you will have a greater chance of success getting the message out.

In the course of one Grade 10 classroom visit, I was asked the following anonymously written questions (verbatim):

• Every woman in my family has been depressed at one point or another. My mother warns me about it. Is there anything I can do not to get it?
• What is the average penis size? What is the biggest? How long when erect? What is shrinkage?
• Is breathing helium bad for you and why?
• How can I gain weight? I eat at least twice what normal people eat and weight-gain shakes and still never gain an ounce. If I occasionally miss a meal I tend to lose a lot of weight.
• Why do some men go balder faster than others?
• Can you have an abortion when you are 16 without letting your parents know?
• Why do people shy away from people with disabilities or physical disadvantages or limits?
• I’ve heard smoking pot does not harm you because it is a natural drug and all that is harmful is the smoke. Is this true?
• What are the long-term effects of LSD?
• I keep telling my doctor I am depressed a lot but she just tells me it’s a phase. I don’t think it is. What should I do?
• My joints crack and snap (painfully) all the time. Is this something I should have looked at?
• Is there any proof steroids cause cancer?
• Why is it that the Olympic federation includes such things as Aspirin and cold or cough suppressants on their banned substances list?
• I get excessively angry and violent at times. When I feel this way I feel like hurting or destroying someone or something. Is there something wrong with me?
• What is the best diet to be on?
• What is worse, smoking cigarettes or grass? If cigarettes are so bad for you why are they legal?

If anything, these questions keep us on our toes. They are all answered in class. A common followup from the students is asking about the rationale for our drug laws given alcohol and cigarettes cause most of the morbidity and mortality compared to recreational drugs.

I think the millions spent on ad campaigns could be put to better use establishing permanent teams of physicians and nurses in all our high schools. School-based clinics complement classroom visits and provide a good followup for students who have expressed concerns through questions. A contract for trust grows and the students will seek us out for medical services. It is also one of the more enjoyable aspects of family medicine.

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3. Trust, teens and the family doc

Originally published in The Medical Post, VOLUME 37, NO. 29, September 4, 2001

A 13-year-old girl erroneously believes her suicide will improve life for her eight-year-old brother

There are times when I encounter a patient who leaves a permanent, haunting impression on me. The situations that lead to such heart-wrenching memories can make it difficult to remain objective.
Melinda, not her real name, was 13 years old. Her guidance counsellor advised her to see me at our school clinic. There were concerns she was severely depressed and needed help. Earlier in the week, she had eaten about 30 Tylenol tablets. Her parents, aware of her actions, did nothing. According to the guidance counsellor, their assumption was that Melinda was acting out for attention.

Suicide is the number one cause of death in teens.

She was an unassuming, polite girl, but looked sad. She seemed adrift. Her school performance was good. She had friends and participated in school activities. I could not shake my impression that she was resigned to some predetermined fate.

Both her parents worked long hours. She had an eight-year-old brother. After school their nanny cared for them until her parents returned home. She said her parents had little time to spend with them. She missed that time and was concerned about how this affected her little brother. She did not want him to suffer the same rejection she felt from her parents. This was her reason for the pill overdose. She said if she killed herself her parents would spend more time with her brother. By removing herself from the family there would be only one child to focus upon. Perhaps then they would make time for him, she thought.

She did not want to tell her parents her reasons for taking pills. She did not want them to feel guilty. She loved them and felt they were working hard to help the family.

It was imperative she let her parents know how she felt. I suggested she write a letter to them if she was uncomfortable talking about it. The guidance counsellor and I both offered our support to help her communicate with her parents. She wished to do neither. I saw her only the one time. She did not return to me for followup.

But her guidance counsellor was able to follow up with her. She said Melinda did not resolve the issue that led to her overdose. She continued to consider herself an obstacle to her brother’s happiness. There were no further suicide attempts that school year. This occurred three years ago. She was lost to followup thereafter.

Everyday we face problems that seem unsolvable. I am struck by the degree of pain and suffering endured by some children. Melinda was willing to sacrifice herself to better the life of her brother. It is a sacrifice she should never even have had the opportunity to consider.

An interesting dichotomy exists at this age. Entering early adolescence, Melinda was beginning to mature and consider the problem from a different perspective. Yet her thinking demonstrated a childlike simplicity. She saw the problem as one requiring an immediate solution—although it had existed for some time. Little consideration was given to the consequences of her actions. Her behaviour was based in the present.

Future considerations or long-term solutions were not acceptable because they were incongruous with her world view. She loved her family yet did not consider the effect her suicide would have upon them. She did not feel valued, ergo her death would be of little consequence. In her pursuit to make her brother happy, her death would result in the opposite.

I wish she had come back. I want to reach out and protect teens like this from their altruistic yet misguided solutions to their problems. The parent in me wanted to make her happy. She needed someone to help her develop a sense of self-worth and perspective, a time-consuming process she rejected.

Professional demands insidiously consume our time. The time we spend with our family can be compromised. Parents try to be there for their kids. Children are remarkably resilient and recover from the occasional disappointment.

But I now have this image in my head of a child so utterly abandoned that I will never allow my sons to experience such despair. Work be damned.

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Originally published in The Medical Post, VOLUME 37, NO. 19, May 15, 2001

At just 16, Mary was faced with her second pregnancy and a decision that would affect more than just herself

Life is about options, the choices we make and the paths we follow. For some it can be a bittersweet experience. Yet, these decisions can alter the lives of many. Some are aware of these changes and some, regretfully, are not.

We tell this story to the students during our classroom visits:

Mary (not her real name) was 16. Her mother, an alcoholic, paid little attention to her. Her father disappeared from her life when she was five years old. Her boyfriend abused drugs.

She came to the high school clinic 20 weeks pregnant, complaining of bleeding and cramping. She expressed hope the baby was dead. A fetal Doppler exam did not pick up a heart beat. An ultrasound performed the next day showed overlapping cranial bones and a deformed thoracic cavity. She was induced and the fetus delivered. She grieved after the abortion.

Three months later, in March, she was five weeks pregnant. She said she could not afford the cost of the Pill. She requested an abortion. She said she felt guilty and foolish about the pregnancy. She returned to the clinic in late April, stating she had slashed her wrists because she was overwhelmed by her problems and “lost it.” There was little support from her mother regarding her despondency. Her mother was unaware of the pregnancy. Mary admitted she was burying her feelings and was depressed since the abortion. Her depression was treated. Within a month, she felt better and had no further urge to hurt herself.

In early June, she returned to say she did not go for the abortion because she thought the baby had died. She said a Doppler done two months earlier did not pick up the heart beat. She admitted she had not come back to the office sooner because she felt ashamed. She feared if she did go for the abortion the staff at the hospital would judge her. An ultrasound showed a healthy 20-week fetus. She returned to her family doctor for prenatal care.

Come September, she returned because her family doctor threatened to tell her mother about the pregnancy. She did not follow up with her family doctor because of this threat. She was at 31 weeks of gestation for her first prenatal visit. Mary was initially not compliant with the required prenatal visits and tests. Our office had to call her often to remind her of her appointments. Her ambivalent behaviour stemmed from several areas. She bore the guilt over the loss of her first baby and faced difficult truths. Her boyfriend was unaware of her pregnancy. She feared telling him because he was not the father. She did not want her mother to know she was pregnant. She had plans for her life. These included continuing her education and attending university. She did not have the financial or emotional capacity to raise the child in the manner she wished.

At this later stage of adolescence, the future comes more into focus. One’s career, education, life goals and relationships assume greater importance. It is a remarkable transformation from the gregarious peer group behaviours seen in middle adolescence (14 to 16 years old) to the individualism of late adolescence.

After much thought, she decided to give the child up for adoption. There was no pressure on Mary to choose one course of action over another. Once her decision was made I informed her a couple in my practice wanted to adopt a child and that they should direct their attention to the appropriate child services to pursue this option. Mary spent time with the couple and accepted them. They were a great support to her. In many ways, they fulfilled Mary’s need for a stable family. They arranged to bring her to the hospital once labour started. They attended the birth and participated in the delivery. When she was in labour, she called her mother from the birthing room to tell her she was staying at a friend’s house for two days.

Her pregnancy was uneventful, except in one respect. No one acknowledged it! She began her pregnancy weighing about 72 kg. She gained about 11 kg. What was astonishing was that her friends did not comment or ask one question about the pregnancy. She hid her pregnancy well by wearing loose clothes, and no one seemed to suspect a thing. Her mother remarked she thought Mary was losing weight and looked good.

Two days after her delivery she was back in school with no one the wiser. In fact, people continued to comment about how good she looked.

This story increases student awareness that many people in school have problems; some minor, some more serious. The fact no one approached her about her pregnancy demonstrates fear or discomfort of not knowing what to say or do. It is a common denominator in many of the students’ “What do I do?” questions. Many of the students acknowledge there are people they know who are in trouble. We point out to them there is a distinction between thinking they must solve their friend’s problem and expressing concern. This matters most when a friend is depressed and potentially suicidal. They learn there are people who can help but they must become involved and ask questions.

During her pregnancy, Mary was depressed and ambivalent about her pregnancy. She lacked family support and was mistrustful of those who tried to help her. She needed continuous reinforcement to attend her prenatal visits. In short, she wanted someone to care for her. She wanted a family. With all these obstacles, it is a reminder how different the outcome could have been.

Now, almost seven years later, I continue to see Mary, her son Devon and his adoptive parents. They occasionally meet to maintain contact. Mary is attending university and pursuing her career. She does not regret her decision. Her son lives in a warm and caring environment. To this day, Mary’s mother does not know she has a grandson.

It is remarkable to witness how one person’s decision can change the lives of so many people.

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Originally published in The Medical Post, VOLUME 37, NO. 6, Feb 13, 2001

A teen seeks her doctor’s advice when her boyfriend asks for sex as his birthday gift

One of the great joys of adolescent practice is when one is able to have a positive influence upon one’s patient. Once your patient trusts your judgment and counsel, the ability to affect positive change in their lives improves dramatically.

Erica (not her real name), 16 years old, dropped in to the high school clinic. Her complaint was dry skin in the usual atopic areas and flaky eyelids. I gave her some cortisone ointment and asked her to return in about a week. She came back pleased to report the condition had improved. Without missing a beat, she announced she was having bouts of depression for about a year since beginning high school. Her parents were arguing daily and she feared they were heading for a divorce. She felt powerless to stop them. She said her father was critical about her work and that her best efforts were never good enough. She felt she could not approach her parents about her depression because she feared they would be disappointed with her.

I usually give the patient some “homework” after the preliminary evaluation to better understand their concepts of friendships, relationships and their self-image. Questions asked include:

* “What do you like and dislike about yourself?” (focuses on personality and physical characteristics);
* “What is good and bad about you?” (focuses on the moral and ethical implications of their behaviours and actions);
* “What are your definitions of a friendship and relationship?”

The answers to these questions provide a wealth of information. The physician is able to see possible contradictions and congruencies in their reasoning. It also indicates a willingness on the part of the patient to participate in their treatment. I asked her to return to the clinic for followup.

She could not give any examples of what she liked about herself. She disliked her nose and hair and thought her bad qualities were her attitude and that she let stress build up within her.

After further history was elucidated, it was clear she was depressed. Her school performance was declining. I recommend using the Child and Youth Depression Screening and Rating Scale to help with the diagnoses (Patient Care, April 1996). Her score was 75 (over 50 suggests major depressive disorder).

She raised an additional problem she was having with her boyfriend of two months. She said he cared for her and “is in tune with my moods and feelings.” The problem was that he asked her to have sex with him for his birthday. She initially agreed but was now having reservations. I asked her to consider the positive and negatives of agreeing to his request. She admitted there were more negatives but that she was afraid of saying “no” to people.

There is a useful set of concepts to introduce to your patients that can provide them with the tools necessary to deal with interpersonal problems.

The first deals with the concept of the “true” versus “false” self. The true self usually can discern right from wrong. We sometimes refer to this as the alarm bell that goes off in our head. When we ignore this alarm, we do so at out own peril. People who follow this inner voice tend to respect themselves and their motives. They become more self-confident and self-reliant. They are not afraid to say “no.”

The false self is best described as following a path or decision contrary to doing the right thing. The person directs anger inward. They know what they are doing is wrong but they follow through with it anyway. They lose respect for themselves. They have a difficult time saying “no.”

The second focuses upon two straightforward statements, the Two Rules as I call them: “It is not what people say but rather how they act that reveals their true intent,” and “People always do things for a reason.”

I would like to emphasize that before any solutions are offered to the patient, there are some issues to keep in mind. A good trusting relationship must exist for us to be effective in treating adolescents. This may take weeks or months to develop. It is an investment in time that pays huge dividends. We have a natural tendency to offer suggestions to help our patients. However, teens will listen when they ask for your opinion. Before offering your opinion, let them know they may not get the answer they are expecting. Let them again decide whether they want to hear what you want to say to them. You have given them an “out.”

Usually at this point of the process, they are curious to know what it is you might say to upset them. However, they rarely become upset because of how the lead-up was presented.

In this particular situation, although the solution is obvious (“tell him no way”), some adolescent patients may chafe at someone telling them what to do. I like to engage them with their own words and statements from their written answers to their homework questions and use them to better evaluate their situation. In Erica’s case, she was terrified her boyfriend would dump her. She had little in the way of support from her parents. Her father was distant and not providing the emotional support and stability that she needed.

Erica went through this exercise in detail. Why would her boyfriend dump her because she refused to have sex with him for his birthday? He claimed to love her. He was in tune with her feelings. But then why did his actions betray his claims? Was he not objectifying her? What was his real intent? She also knew the right thing to do was not to have sex with him. But she loved him! Needless to say, she admitted to being very confused.

In the end, after several sessions and much deliberation, she decided against being a birthday present. He promptly dumped her. Initially upset she saw her decision was the correct one. In fact, her boyfriend made many overtures to resuming the relationship. She felt better because she did not compromise herself and had some measure of control of her life. She was able to apply the Two Rules and determine motive. She could then listen to her true self and be comfortable with her decision.

I am in no way suggesting this method is a panacea for all adolescent ills. But it has served well in helping many of our adolescent patients. Erica continues to see me at my office. She is now 21 years old and in university. She is happy and in a stable relationship. She admits she cringes when she thinks about what she actually contemplated doing six years ago.

So why did she open up and discuss her depression in the first place? When I asked her, she replied, “Because you cured my eyelid problem. My other doctor didn’t take this problem seriously. I wasn’t about to bring up anything else because he didn’t seem to care about my skin problem.”

Related articles:

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Originally published in The Medical Post, VOLUME 36, NO. 35, October 17, 2000

Eight years ago, two Ottawa doctors went back to high school to start the first in-school medical centre of its kind in Canada

Adolescents are an under-serviced population — and there are several factors that contribute to this phenomenon.

The most trusted source of information among teens is their friends; next, the Internet; finally, an adult such as a guidance counsellor, teacher or parent. Most adolescents have a family doctor but few feel comfortable speaking with that doctor about their most important health concerns (more on this later). While adolescent health care is one of the areas identified by the College of Family Physicians of Canada where residents require more training, the realities of budget cuts have led to a low level of prioritization for this discipline. Adolescents will continue to obtain care in a haphazard manner through different walk-in clinics, the ER, their friends, or not at all if we do not give them better options.

As physicians there is a tendency to be less comfortable when dealing with the sensitive issues of our adolescent patients. How does one approach the adolescent patient? How do we prepare ourselves to talk to a 13-year-old versus a 16-year-old? How do we sit in our chair? Do we take notes while they are speaking? Do we glance at our watches? Although these questions may seem superfluous, they embody an approach that can contribute to either a strong or weak doctor-patient relationship.

The information I will present is based upon eight years of experience running the only full-service high school medical clinic in Canada. Eight years ago, Dr. Peter Cote and I established a high school-based medical centre that was incorporated into the family medicine program at the University of Ottawa, Elisabeth Bruyere campus. It provides residents with the opportunity to deal with adolescent issues on the students’ own turf.

Canterbury High School is an arts and science school with 1,200 students from around Ottawa. The male/female ratio is 30/70. The program there includes the medical centre and classroom visits. The hours of operation are Monday afternoons and Thursday mornings for 2.5 hours and three hours respectively.

Classroom visits are scheduled on Monday afternoons. Students are given the opportunity to ask questions written on slips of paper. Anonymity is preserved. Most questions are answered, but we usually run out of time. The visits give us more exposure to the students and increase their level of comfort with us. In fact, one of the first questions we ask the class is how many have their own family doctor. Most will raise their hands. The followup question is: “How many of you feel completely comfortable talking to your doctor about any subject?” Few if any hands remain raised. This response is universal for the hundreds of classes we have attended. This lack of trust is one of the greatest obstacles to providing effective preventive care.

The classroom visits invariably attract the students to the medical centre. We have become a recognizable fixture at the school. Students can come to the clinic with their friends for support. They have brought friends who have been in crisis. Even though we are not employed by the school board, we interact with teachers and guidance counsellors who bring their concerns about particular students. Clearly, teachers are already strained for time and classroom sizes are increasing. This year, there will be 2.5 guidance counsellors for 1,200 students at Canterbury. Underfunding of the education system is similar to underfunding of the health-care system. Health or social problems cannot easily be noticed and dealt with as early as possible. The overall cost to society is greatly increased as a result of our ignorance.

Trust and confidentiality are of paramount importance. This is the challenge of adolescent medicine. Adolescents are concerned their family doctor will speak with their parents about their problems. Right or wrong, that is their consistent impression. We need to develop a means to reverse this trend.

In future articles I will focus on the formula we have used to make our centre a success, our experiences with the clinic, case histories, the issues brought forth by the family medicine residents, and the moral and ethical dilemmas encountered at the centre. We have compiled and collected all the questions asked over the eight years. I will present them to you with our responses. Stay tuned.

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Originally published in The Medical Post, VOLUME 35, NO. 24, June 22, 1999

Original Title: Slaughter of the Innocents

This article was awarded the Kenneth R, Wilson Silver Medal for “Best One of a Kind Article” by the Canadian Business Press in June, 2000.

An Ottawa doctor reflects on the beauty of his brother’s life, the horror of his death and the need to examine just who should be allowed to drive

One Halloween several years ago, my brother Steven shaved his head, coloured himself green, put two devil horns on his head and taught his class clad in only a pair of green shorts. I’m sure they still talk about it at the University of Chicago. I keep a picture of that Halloween stunt. And I look at it often.

I’m so happy that my brother lived. But I can barely contain my fury with the way he died.

My brother loved to cycle. On a bright sunny April afternoon two years ago, Steven was cycling along one of his familiar routes in Galveston,Tex. It was a straight road with a bicycle lane on either side.

A 73-year-old woman driving her car at 60 miles per hour drifted into his lane for no apparent reason. Witnesses at the scene said her car just lined itself up behind him and struck him down. He hit the windshield full force. As he lay on the hood of the car, the driver did not stop. There were no skid marks suggesting an attempt to brake.

As my brother tumbled from the hood, he was dragged and thrown by the car. At the accident scene we could see his blood on the pavement at the point of impact and splatters of blood every 20 feet or so for the next 400 feet.

He lay on the ground, struggling to breathe. Even though he had been wearing a helmet, his head, as witnesses would later testify, was no longer shaped like a human head.

At the hospital, he was rushed into surgery, where he suffered cardiac arrest. The doctors were able to resuscitate him, but his injuries were extensive. He had a crushed jaw, fractures to the right side of his face, severe lacerations to his head and body, a torn right lobe of his liver, contusions to his lungs, a crushed right lower leg, a fractured 12th thoracic vertebrae, and brain damage. He was comatose.

His young wife, Noel, identified him only by the small mole over his left eyebrow. His massive blood loss resulted in disseminated intravascular coagulation, which made it impossible for his body to stop bleeding. He was transfused with more than 60 units of blood and coagulants with little success. Every time another unit of blood was given to him, it just poured from his wounds.

When Noel put her hand upon his chest, blood would come out of his intubation tube. She had to continually wipe the blood from his face and watch helplessly as the blood dripped onto the floor. He was given so much fluid to keep his blood pressure from falling that he became grotesquely swollen.

Even with medications to keep his blood pressure elevated, his brain was not receiving enough oxygen. Soon, there was no brain activity. Steven was gone. He would not want blood products wasted on a dying man. He was a regular blood donor and knew the value of this life-saving substance. The hospital staff were asked to stop giving him blood. They complied.

It took his heart a little over an hour to stop beating. He died beneath Noel’s fingertips. He died listening to her voice repeating his name and speaking her love for him. He was 31 years old.

It was April 7, 1997 at 2 a.m., nine hours after the accident. My life and the lives of my family members were completely shattered.

Steven had earned his PhD in Mathematics in 1996. He found a job teaching at Rice University in Houston, Tex. He was admired by faculty and popular with his students. A memorial service was held at the university in his honour on April 14, 1997. The university newspaper devoted an issue to him.

He has an identical twin brother, Joel. They were as close as two people can be. Steven had long blocked off early May in his calendar. He had plans to travel to Vanderbilt University in Memphis to watch proudly as his twin graduated from his MD, PhD program.
Muscular and handsome, Steven and Joel were the focus of a number of photographic studies. Their poses have been documented in the New Yorker magazine, the Chicago Institute of Art and in a television special titled “Twin Stories” which aired six months after Steven’s death.

Two years later, his wife Noel, remains devastated. They had known each other for six years. She is in her third year of medical school now. She showed Steven a side to life that science was not able to teach. They were to have celebrated their first wedding anniversary on April 27, 1997.

He had a busy and vibrant life. He cared for more than 200 rare and endangered cacti and succulents that were his passion. He loved to cook and enjoyed classical music. He was in the process of mastering car repair. And he was helping his wife’s grandparents build an enclosed porch on their old ranch house.

And as for the woman who brought an end to that life? Well, she continues to drive. The police department did not press criminal charges against her. A Grand Jury review in October 1997 felt that she was too old to stand trial.

She did not call to express her remorse about what she had done. She did not attend the funeral. She has wrought incalculable pain upon our family.

As a practising family physician, I witness the effects of age every day. I do not subscribe to the notion that one has a right to drive. It is ludicrous that mandatory driver’s assessments occur only after 80 years of age.

After the age of 60, one’s reflexes and sensory capacities wane. Peripheral vision and hearing falters. Given our knowledge of the aging body, I think we, as physicians, have a responsibility to take the lead in this issue. We need to bring it to our elected officials’ attention that yearly exams after the age of 60 just make good, safe sense. It is a minor inconvenience that would help reduce the number of senseless deaths.

I propose further that all persons under the age of 60 be tested every five years since there are diseases that can incapacitate younger individuals.

Physicians must report any suspicion, based on medical evidence, that their patient is not capable of operating a motor vehicle. That is the law.

Let’s exercise it in our personal lives too. Look at your parents. Were you surprised the last time you visited your father? Did he seem to have a hard time following the conversation? Speak to him, address the issue. The woman who killed my brother may well have had adult children who could have prevented my family’s tragedy.

One of the greatest difficulties we face when tragic events occur is to find meaning for it. Steven was a brilliant and pragmatic man. If he were asked for a meaning behind this tragedy, he would have said, in his matter-of-fact way, that the driver had no business driving a car. She was too old and incompetent to drive. He would be angry that she hadn’t voluntarily revoked her licence. She simply failed to do right. There would be no other explanation in his mind.

That is the meaning he would want you to take away from this. Be strong, live your life to the fullest and accept reality for what it is or can be.

That is his final and everlasting lesson.

I love you, my brother.

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