BRIDGET FARRANT: In terms of what would be on a wish list to change, that would be really breaking down these artificial silos that we have between paediatric and adult services. And these silos are really based around ease of the system operating, rather than what's needed for young people and families.
CAMILLE MERCEP: Welcome to Pomegranate, a CPD podcast from the Royal Australasian College of Physicians.
The World Health Organization defines “adolescents” as anyone between the ages of 10 and 19, and “youth” as those between 15 and 24. The RACP uses the terms “young people” and “adolescent and young adult” to cover the whole range of 10 to 24 years.
Regardless of how it’s defined, the transition from childhood to adulthood involves a range of physical, mental, and psychosocial issues. If you’re a teenager with a chronic health condition, the situation can be even harder. But for physicians in Australia and New Zealand, there has been no specific training to meet the needs of adolescents—until now.
Over the past few years, the RACP has been working to create an adolescent and young adult medicine curriculum, which will become a dual training program in 2017. Professor Kate Steinbeck is Medical Foundation Chair in Adolescent Medicine at the University of Sydney. She is joined on the podcast by Doctor Michelle Telfer, Acting Head of Department of Adolescent Medicine at the Royal Children’s Hospital, Melbourne, and Doctor Bridget Farrant, an adolescent physician working at the Kidz First Centre for Youth Health in South Auckland.
On today’s episode, they talk about why adolescents and young adults need targeted care and the issues they face in the current system. They also discuss the new curriculum, and how interested Fellows and Trainees can get involved.
KATE STEINBECK: I’m Kate Steinbeck, Medical Foundation Chair in Adolescent Medicine at the University of Sydney, and I'm based at the Children's Hospital at Westmead in Sydney and also work at Royal Prince Alfred Hospital.
Neurocognitive development really does distinguish the adolescent and young adult age group, and we know that there's tremendous plasticity for both good and bad in the adolescent brain. I think that we've looked at it very simplistically up till now and that simplistic view has been helpful in our understanding in that the prefrontal cortex is the last part of the brain to develop fully. So we've thought how very important the prefrontal cortex is to executive control, management of emotion, management of planning and day to day living. And we've sort of seen the prefrontal cortex as fighting the adolescent emotional brain.
I think that's a good starting place but it shouldn't be the simplistic finishing place, because we know that adolescent brain development can be influenced by drugs, alcohol, emotional deprivation, chronic illness, and also simply by feeling and being different. A lot of the adolescent brain has a lot of altruism, optimism, fantastic ideas and innovation. We also need to work with that. And if you think about it, most great composers didn’t write their best symphony when they were 65 and about to retire.
And so it makes sense to look at interventions that are relevant to the developing brain. And really that's in a nutshell what we're talking about often in adolescent and young adult medicine. It's not that we're practicing anything differently, but we do need to think about how puberty may impact on our treatment. And we're also interested in how their psychosocial development is progressing, because really there's an explosion of psychosocial and neurocognitive development that goes on at the same time as their medical condition.
MICHELLE TELFER: My name is Doctor Michelle Telfer and I'm a paediatrician and adolescent physician. I currently hold the position of Acting Head of Department of Adolescent Medicine at the Royal Children's Hospital in Melbourne.
Very recently I had a patient who has chronic liver disease, who also has some significant mental health problems and self-harming behaviour, that I've known for many years. And she has been transitioned to the adult hospital system and she was in tears at the thought of saying good bye to the Children's Hospital. And she told me a story of having a relapse of her liver disease only last month where now as an 18 ½-year-old she was not able to be admitted here at Children's, she was admitted in the adult system. And she was in a room with three other people who were all over the age of 70. She found it a very different experience to that that she'd had here over the past 18 years, really. To go from this beautiful new building, to an older hospital in a room of four people with just curtains separating each patient—it was really a negative experience for this young person.
And I can imagine that if she was to get sick again her reluctance to be admitted would influence her presentation to hospital with symptoms, and clearly contribute to receiving treatment at a later stage than would be optimal for her.
BRIDGET FARRANT: Kia ora, my name is Bridget Farrant; I'm an adolescent physician. I work at Kidz First Centre for Youth Health, which is part of Kidz First Community Paediatrics. I also lecture in population youth health at Auckland University.
So in New Zealand, a new patient presenting will go to adult services at 16, if you’re under an existing paediatric specialist you may be able to stay under that specialist until you’ve left school. But I think one of the major problems we have with transition in New Zealand is around paediatricians being frightened to let go, and assuming that adult services won't be able to care for young people. And also adult services working in quite different ways than paediatric services.
But actually if you get the two services together to talk about their different models of care and how people can work together, the services have the interest of the young person at heart usually. And so it's really improving the communication and discussion between to sort of develop a respectful relationship can go an awfully long way.
I remember a young man that we worked with some time ago with another service and they were having trouble moving him on from the paediatric service. And he came back to do a teaching session with us, and it was incredibly powerful when he stood up and said that, you know, going to adult services had been the best thing that had ever happened to him, and that he felt quite upset that he felt that he'd been kept in paediatric services for so long. Because actually what he found when he got to adult services was that the care was delivered in a very developmentally appropriate way for him, and that he was given more autonomy in terms of his decision-making and actually he felt quite well supported.
Obviously that's one case and there are other cases where things don’t go so well. But I think one of our challenges coming from paediatrics is really to have good respect for our adult colleagues, so that we can enable them to accept young people and work well with them.
KATE STEINBECK: The survival rates in chronic childhood illness have really dramatically increased, and so there's been a tsunami of young people who are now seeking adult care. I think the world is very different. We see children at a very early age being exposed to very grown-up thoughts and concepts, and so perhaps children are growing up, and we are having to interact with them differently as paediatricians. And also their requirements are quite different—there is, as I mentioned, all those psychosocial aspects, getting an education is very important. We now consider that in young people with a chronic illness, it's something to take into account but it shouldn't define them. And they shouldn't be excluded from everything that makes a young person—which is independence from family, seeking a family of their own, and seeking gainful employment and a positive life.
MICHELLE TELFER: We have an eating disorder program here that's multidisciplinary and fairly intensive. And we also have an adult system at the Royal Melbourne Hospital that's multidisciplinary, and also intensive. But to attend in the adult system you really need to be motivated to go, and when young people are here in our service supported by their parents, parents can certainly enable better attendance for appointments and so forth. But when the young people transition over to the adult services and there's a lot of change and a lot of anxiety about the hospital that they're going to go to, they're often reluctant to engage or to attend. And a lot of young people with anorexia nervosa aren't seen in the adult system as they should be.
If we were able to have a bridge connecting the two, there'd be a better transition and less people dropping out of care. And with anorexia nervosa, what's really important is that the earlier that one recovers from the illness the better the rates of relapse and so forth into the future. So for those that are presenting in late adolescence, we really need an intensive program that goes into the first 6-12 months of treatment, and with the difficulties of going from one system to another that opportunity is often lost.
KATE STEINBECK: Young people want a confidential service, an easy access service, a friendly service. They don't like asking where they have to go—I once had a patient who I commented that they hadn't been to see me the first time, and he said, “I walked round Prince Alfred for two hours but couldn’t find where you were.” And I said, “Did you ask someone?” And he said, “I didn’t really want to.”
They want a service that is, actually it needs to be, multidisciplinary—very important. And again, most chronic illnesses we're now acknowledging that it's not just about doctor and patient, it's about many other allied services because medicine has become very complex.
The ideal would be to have, almost, adolescent and young adult services that are placed bridging paediatric and adult services. I can't see that happening completely any time soon. What we need to do within services is to say, “Look, yes this is the way they’ve grown up, but we can look at how we can better serve young people in paediatric or adult hospitals.” And we don't for a minute think that every adolescent, or young adult, needs to see an adolescent and young adult physician—there are many who manage very well in the system who are supported well.
But we do need to have young physicians coming up who have been trained to particularly deal with this age group, so that they can act as specialist consultants looking at how we might manage mental health, substance use, risk-taking behaviours—and probably the biggest of them all in this age group is therapy adherence. And actually doing what is in their best interest for optimal wellbeing. And I think that's where many physicians get frustrated in both the paediatric and adult services, that young people just don't do what they “should” do. And often it's for very complex and complicated reasons, and it often does need hard work.
I see adolescent and young adult physicians probably having a specialty of their own, which is the way it will need to be within dual training. But also being there—working in both institutions that are adult and institutions that are paediatrics, and really advocating for the needs of young people within what are very complicated, overworked and expensive systems.
BRIDGET FARRANT: When I completed my paediatric training we still had an option for undifferentiated training, so our advanced training was a lot less structured than it is now. So I was able to design a three-year Advanced Training Program that met the needs that I had in terms of training and a way of medicine.
But the undifferentiated option has gone, and what this has meant for people working in adolescent and young adult medicine is that there's currently no way to train in that area. So the Trainees that we've had, or the people that we've had interested, have mostly been enrolled in General Paediatric or Community Paediatric Advance Training Committees, and have tried to take perhaps an adolescent young adult medicine focus to that. The challenge is that the training is so structured that it's very difficult for them to fit the training in within the timeframe, and so we've lost a number of, you know, good and interested Trainees because, you know, they’ve needed to complete their training in another area and have got lost doing that.
So I think the new structure is absolutely critical and essential to us being able to get people now training back in adolescent and young adult medicine.
KATE STEINBECK: From 2017, the Royal Australasian College of Physicians is offering a training program in adolescent and young adult medicine which is dual training. So that an Advanced Trainee could select from many numbers of specialties, or where large numbers of adolescents or young adults are seen, or they could do paediatrics, general medicine. They would achieve their FRACP in that particular specialty, and then by following the curriculum they would receive at the end of that dual training a College certification that they have completed their training in this specialty.
BRIDGET FARRANT: Historically we've sort of said enthusiasm for young people means that clinicians are trained to work in the area, almost. So it really draws a line in the sand that enthusiasm is not enough, that you actually need to be well trained to work in this area. And I think that's kind of a significant shift, because one of the challenges that we've seen is that, for example, someone could train in general paediatrics but perhaps because they quite like young people suddenly they're the youth specialist within their service. But actually they may or may not have had much training to do that work.
I think the spin-offs will be both in terms of quality of clinical work but then also in terms of the leadership and the advocacy and working more broadly to advance young people's health.
KATE STEINBECK: Like most things in medicine, five to ten years are probably needed to see changes in practice. I think a fantastic example of having an adolescent and young adult service is the Westmead Adolescent and Young Adult Service run by Doctor Jane Holmes-Walker. And she has probably published one of the few economic analyses of doing this, showing that by having this clinic they kept more than enough young people out of hospital with diabetic ketoacidosis—which is a very costly and always almost an ICU stay—to actually fund a dedicated clinic nurse to assist bringing these young people in to the clinic and really continuing to follow their care.
And so I think that like anything new, physicians will want to test it and see what's on offer. I hope in the long run, and suppose it's partly by bias as being adult-trained, that a large number of Trainees will end up working in the adult system, because there's more than enough patients for them there.
I think the differences to outcomes will be judged over time, and it's very important for us who've been in adolescent medicine for some time to support a program of research that starts to look at how we are changing performance indicators. And I think that's the challenge for all of us who've been practicing in adolescent medicine for a long while, is how we setup those health outcomes. Because often what you do in terms of providing a better health experience for adolescents and young adults might not become visible until ten or twenty years down the track.
BRIDGET FARRANT: So we did some research here that was done through Auckland University looking at the impact of training on outcomes for young people in school settings. This was looking at training of doctors and nurses who work in schools with young people. And what that found was that people who had a higher level of training—and in this scenario that was postgraduate certificate, or papers in youth health—the students in those schools had better reporting and lower rates of poor mental health.
So I think that's where we're starting to see some actual evidence around the value in training and the impact that that can have on the health outcomes for young people.
KATE STEINBECK: Prof Susan Sawyer and her group some years ago put together a Working with Young People resource for basic physician trainees, which is an excellent resource, and that's certainly available through the College website. The curriculum is available also on the College website. And we have an Adolescent and Young Adult Medicine Committee which is chaired now by Doctor Rod McClymont, and that is a varied team of people from both adult and paediatric training. Individual members would be very happy to talk to Advanced Trainees who are interested, and certainly the Advanced Training Committee, which I chair, is also extremely happy to have a conversation with interested Trainees.
BRIDGET FARRANT: In both New Zealand and Australia there are also associations for adolescent health. So in New Zealand we have SYHPANZ, which is the Society for Youth Health Professionals Aotearoa New Zealand, which is a professional group really, where we've got doctors and nurses, and other health professionals working with young people. And we run an annual conference and provide the opportunity for people who are working with young people, and interested in this area, to get together.
There is also the Australian equivalent—the Australian Association of Adolescent Health, who have a conference biannually.
KATE STEINBECK: Working with adolescents and young adults has been a fantastic experience. I go to work feeling interested and invigorated working with this group. And while it's challenging, I think if you believe as an Advanced Trainee that you really work well with this age group, I think if you have a particular interest and skill set, you should think about whether AYAM training is for you.
But I do think that no matter where physicians are in their professional life, most of them will have had adolescent children if nothing else, or know adolescents. And I think if you can take what you understand from family members that you’ve dealt with, and see how that could impact on some person who is struggling with a difficult family, a chronic illness and an adolescent brain, you can see that this age group needs—and developmental stage needs—to be treated in a different manner.
CAMILLE MERCEP: Advanced trainees will be able to undertake training in adolescent and young adult medicine as part of a dual training program starting in 2017. To find out more about the program, and to access any of the resources mentioned on the show, visit the Pomegranate website at racp.edu.au/pomcast.
Many thanks to Kate Steinbeck, Michelle Telfer, and Bridget Farrant for speaking with us on today’s episode. The views expressed are their own, and may not represent those of the Royal Australasian College of Physicians. If you’d like to continue the conversation, share your thoughts using the hashtag #RACPpod, or write to us at firstname.lastname@example.org.
Pomegranate comes to you from the College’s Learning Support Unit. The program is presented by Camille Mercep, and this episode was produced by Alastair Wilson and Anne Fredrickson. Next month, in anticipation of NAIDOC Week, we’ll be focusing on Indigenous concepts of health in Australia.
We hope you can join us.