Original Study Physician Knowledge and Attitudes around Confidential Care for Minor Patients Margaret Riley MD 1,*, Sana Ahmed MD 2, Barbara D. Reed MD, MSPH 1, Elisabeth H. Quint MD 3 1
Department of Family Medicine, University of Michigan, Ann Arbor, MI Department of Pediatrics, University of Michigan, Ann Arbor, MI 3 Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 2
a b s t r a c t Study Objective: Minor adolescent patients have a legal right to access certain medical services confidentially without parental consent or notification. We sought to assess physicians' knowledge of these laws, attitudes around the provision of confidential care to minors, and barriers to providing confidential care. Design: An anonymous online survey was sent to physicians in the Departments of Family Medicine, Internal Medicine-Pediatrics, Obstetrics/Gynecology, and Pediatrics at the University of Michigan. Results: Response rate was 40% (259/650). The majority of physicians felt comfortable addressing sexual health, mental health, and substance use with adolescent patients. On average, physicians answered just over half of the legal knowledge questions correctly (mean 56.6% 16.7%). The majority of physicians approved of laws allowing minors to consent for confidential care (90.8% 1.7% approval), while substantially fewer (45.1% 4.5%) approved of laws allowing parental notification of this care at the physician's discretion. Most physicians agreed that assured access to confidential care should be a right for adolescents. After taking the survey most physicians (76.6%) felt they needed additional training on confidentiality laws. The provision of confidential care to minors was perceived to be most inhibited by insurance issues, parental concerns/relationships with the family, and issues with the electronic medical record. Conclusions: Physicians are comfortable discussing sensitive issues with adolescents and generally approve of minor consent laws, but lack knowledge about what services a minor can access confidentially. Further research is needed to assess best methods to educate physicians about minors' legal rights to confidential healthcare services. Key Words: Confidentiality, Adolescent health services, Privacy, Informed consent by minors, Parental notification
Introduction
High risk behaviors including substance use, sexual activity, interpersonal violence, and suicide are the primary causes of morbidity and mortality in adolescents.1 However, less than 20% of adolescents receive recommended screening and counseling on these risky behaviors from their healthcare provider.2,3 Adolescent patients are unlikely to bring up sensitive issues on their own, but want to discuss these subjects with their physician and cite confidentiality as one of the key determinants of their use of healthcare.2,4,5 One study showed that 58% of high school students have health concerns they want to keep private from their parents.6 The most common reason adolescent girls identify for missing a necessary health service is that they do not want their parents to know.7 Studies have shown that a lack of confidential care does not delay or dissuade adolescents from engaging in high risk behavior and may lead to unintended health and social
The authors would like to thank the University of Michigan Adolescent Health Initiative (AHI) for their assistance in study design and review. The authors indicate no conflicts of interest. * Address correspondence to: Margaret Riley, MD, Department of Family Medicine, University of Michigan, 1150 West Medical Center Drive, M7300 Medical Science I, SPC 5625, Ann Arbor, Michigan 48109-5625; Phone: (734) 232-6222; fax: (734) 615.2687 E-mail address: [email protected] (M. Riley).
consequences.8,9 In fact, adolescents who forego healthcare due to confidentiality concerns are more likely to engage in risky behaviors and report psychological stress.10 Federal and state laws have been in place for decades to allow minor patients to receive confidential care for specific healthcare issues related to sexual health, mental health, and substance use. However, physicians have been found to have low knowledge about the laws that exist in their state regarding a minor patient's ability to consent for healthcare services.11 Patients and their parents are frequently unaware of minor consent laws as well.12,13 The majority of primary care physicians support offering confidential care to adolescent patients.14,15 However, addressing sensitive issues with adolescents can be a challenge. Physicians have cited difficulty having these discussions due to lack of expertise, low patient demand for confidential services, and inadequate staffing.16 Physicians may have more comfort offering confidential services to older adolescents, but can be less likely to provide this care to younger adolescents,15 and while some physicians are routinely offering confidential care to their adolescent patients, they may be incorrectly stating the limits of confidentiality.17 This study was designed to assess University of Michigan Family Medicine, Internal Medicine-Pediatrics, Obstetrics and Gynecology, and Pediatrics physician knowledge of and attitudes towards Michigan's minor consent and parental
1083-3188/$ - see front matter Ó 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2014.08.008
M. Riley et al. / J Pediatr Adolesc Gynecol 28 (2015) 234e239
notification laws. Physician comfort with managing sensitive issues in adolescents was also measured. Finally, we assessed perceived barriers to the provision of confidential care for minor patients. This study serves as a needs assessment to better understand knowledge gaps and barriers (both in attitudes and logistics) to providing confidential care in our ambulatory care clinics. Findings will be used to develop and engage physicians in educational activities with the ultimate goal of improving adolescent healthcare at our institution. Materials and Methods
All faculty, fellows, and resident physicians in the Departments of Family Medicine (Fam Med), MedicinePediatrics (Med-Peds), Obstetrics and Gynecology (Ob/ Gyn), and Pediatrics (Peds) at the University of Michigan received an anonymous online survey link via e-mail inviting them to participate in a survey exploring clinicians' knowledge and attitudes related to providing confidential healthcare to adolescent patients. Two reminder e-mails were sent 10 and 20 days after the original invitation. This survey received Medical IRB exemption in June 2013. The survey was divided in several main sections; starting with physician demographics and practice characteristics including questions on gender, specialty, level of training, length of time as an attending physician, if they are a primary care provider (PCP), the percent of their patient population that is aged 12 to 18, if they have children, and if their children are aged 12 or older. Physicians were then questioned on their level of comfort in addressing sexual health, mental health, and substance use with adolescent patients. Knowledge of Michigan's confidentiality laws was explored by asking if statements related to a minor's ability to consent for certain aspects of healthcare, physicians' ability to notify parents about this care, and parental health record access were true or false. Physicians were also able to choose if they were uncertain if the statement was true or false, and uncertain answers were coded as incorrect in the analysis. To explore clinician attitudes, Michigan minor consent and parental notification laws were then provided, and participants were asked if they approved, disapproved, or felt neutral about each law. Attitudes were further examined by asking physicians to rate their agreement with statements regarding an adolescent's right to confidential care, adolescent maturity in making care decisions, and parental rights to notification of healthcare provided to their minor child. Finally, physicians were questioned on their ability to provide confidential care to minors seen in the outpatient clinic setting, and what barriers they felt inhibited their provision of confidential care. Associations between demographic information, knowledge, and attitudes were explored using t-tests, ANOVA, and Pearson's correlation as appropriate. Results Survey Demographics
The survey link was sent to 650 potential participants. Three hundred and nineteen physicians began the
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demographic questions, and 259 answered the knowledge questions about minor confidentiality laws and were included in the analysis for an overall response rate of 40%. Characteristics of survey responders compared to all potential participants are shown in Table 1. Comfort with Discussing Sensitive Subjects with Adolescents
On a scale of 1 (very uncomfortable) to 5 (very comfortable), the majority of physicians felt comfortable addressing sexual health (mean 4.07 1.12), mental health (3.97 1.02), and substance use (3.89 1.09) with patients aged 12 to 18. There was a trend towards difference by physician specialty in comfort addressing sexual health in this age group, with Ob/Gyns being most comfortable and pediatricians least comfortable (Ob/Gyn mean 4.38 1.21, Med-Peds 4.31 0.75, Fam Med 4.09 1.07, Peds 3.94 1.10, P 5 .08). Female physicians felt significantly more comfortable discussing sexual health than male physicians (females mean 4.18 1.07, males 3.81 1.8, P 5 .02). Physicians with children aged 12 or older were more comfortable addressing mental health and substance use in this age group than those without adolescent children (with children aged 12 or older mean 4.28 1.07 vs without 3.86 0.99, P 5 .01 for mental health and 4.07 1.05 vs 3.75 1.13, P 5 .07 for substance use), but were not more comfortable discussing sexual health (4.07 1.25 vs 4.10 1.07, P 5 .90). There were no other differences in comfort addressing sensitive subjects with adolescents by specialty, gender, level of training, length of time as an attending physician, if the physician was a PCP, or percent of patient population that is adolescent. Knowledge of Michigan Laws
On average, physicians answered just over half of the legal knowledge questions correctly (mean 56.6% 16.7%), see Table 2. When grouped by topic, physicians varied on the percent of questions they answered correctly (percent correct on questions about health records 63.1% 33.8%, sexual health 57.9% 19.3%, mental health 53.5% 30%, substance abuse 47.7% 31.7%, P 5 .03). Physicians answered more questions correctly about minors' ability to consent for care (65.8% 19.9%) compared to questions around parental notification of care (24.5% 35.4%), P ! .01. When questions provided the same scenario with an older minor (age 17) compared to a younger minor (age 13), physicians were more likely to answer correctly for the older minor (P ! .001). There was a trend towards difference in number of knowledge questions answered correctly by specialty (Fam Med 61.9% 16.3%, Ob/Gyn 56.3% 13.4%, Peds 55.2% 17.4%, Med-Peds 52.2% 13.8%, P 5 .06), and a statistically significant difference by gender (females 58.4% 15.2%, males 52.3% 19.3%, P 5 .01), and whether or not the physician was a PCP (PCPs 60.6% 14.6%, non-PCPs 52.1% 17.8%, P ! .01). There was no statistically significant difference in number correct based on level of training,
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Table 1 Characters of Survey Responders Compared to all Potential Participants Demographic Information of Respondents vs Non-Respondents
Respondents (259) N (% of Total)*
Non-Respondents (391) N (%)
P-Value .001y
Specialty Family medicine Medicine-pediatrics Obstetrics and gynecology Pediatrics Gender Female Male Level of training Resident physician or fellow Attending
54 12 52 139
(50.9) (16.4) (46.8) (38.6)
52 61 59 221
(49.1) (83.6) (53.2) (61.4) .001
182 (44.7) 77 (31.7)
225 (55.3) 166 (68.3)
102 (40.5) 156 (39.2)
150 (59.5) 242 (60.8)
.745
Other Demographics of Respondents
N (% of Respondents)
PCP Yes Length of Time as an Attending (y) #5 6-10 11-15 16-20 $21 % of Patient Population Ages 12e18 0e25 26e50 51e75 76e100 Have children Yes Children are age 12 or older Yes
137 (52.9) 41 36 22 22 36
(26.1) (22.9) (14.0) (14.0) (22.9)
167 71 17 3
(64.7) (27.5) (6.6) (1.2)
167 (65.5) 67 (39.6)
* Some respondents did not answer all demographic questions. y Significance due to discrepancy in Med-Peds respondents, no other significant differences between respondents and non-respondents by specialty.
length of time as an attending physician, percent of patient population that is adolescent, or if the physician has children. Physicians with increased comfort in discussing sexual health had increased knowledge on the sexual health
laws (P 5 .001, r 5 0.21), but comfort with addressing mental health and substance use did not correlate with related legal knowledge (P 5 .33 and P 5 .14 respectively).
Table 2 Knowledge of Michigan Laws Related to a Minor's Ability to Consent for Care, Parental Notification of Care, and Health Records Question (Correct Answer in the State of Michigan) Insurance/health record issues The parents of a 15 y/o have the legal right to access their minor child's complete medical record. (False) An insurance company has the right to send an explanation of benefits (EOB) to the parents for confidential services provided to a minor. (True) Mental health A 14 y/o can consent to counseling for a mental health issue without his or her parents' knowledge or consent. (True) The same 14 y/o can consent to begin an SSRI for depression without his or her parents' consent. (False) Sexual health A 17 y/o can consent to receiving an IUD without her parents' knowledge or consent. (True) A 13 y/o can consent to receiving an IUD without her parents' knowledge or consent. (True) A 15 y/o can receive pregnancy testing and prenatal care without informing her parents. (True) A physician may choose to inform the parents of a 14 y/o requesting birth control. (True) A 17 y/o can consent to testing and treatment for gonorrhea without his or her parents' knowledge or consent. (True) A 13 y/o can consent to testing and treatment for gonorrhea without his or her parents' knowledge or consent. (True) A physician may choose to inform the parents of a 14 y/o requesting sexually transmitted infection treatment. (True) A 17 y/o can consent to receive the HPV vaccine without his or her parents' consent. (False) Substance use A 16 y/o abusing alcohol can consent to substance abuse treatment without his or her parents' knowledge or consent. (True) The physician treating the 16 y/o abusing alcohol may choose to inform the patient's parents without his or her consent. (True)
Correct N (%)
Incorrect N (%)
Uncertain N (%)
174 (67.4) 153 (59.8)
65 (25.2) 48 (18.8)
19 (7.4) 55 (21.5)
149 (57.5)
57 (22.0)
53 (20.5)
128 (49.6)
61 (23.6)
69 (26.7)
200 117 235 49 251
(77.2) (45.3) (91.1) (19.0) (96.9)
10 78 11 175 1
(3.9) (30.2) (4.2) (67.8) (0.4)
49 63 12 34 7
(18.9) (24.4) (4.7) (13.2) (2.7)
191 (73.7)
37 (14.3)
31 (12.0)
58 (22.5)
170 (65.9)
30 (11.6)
99 (38.7)
113 (44.1)
44 (17.2)
164 (63.6)
45 (17.4)
49 (19.0)
83 (32.3)
117 (45.3)
58 (22.5)
Some respondents did not answer every question. When grouped by topic, physicians had more correct answers on questions about insurance/health records vs. sexual health vs mental health vs. substance abuse (P 5 .03). Physicians answered more questions correctly about minors' ability to consent for care compared to questions regarding parental notification of care (P ! .01). When given the same scenario about an older vs. a younger minor, physicians were more likely to answer correctly for the older minor (P ! .001). An overview of minor consent laws in each state is available from the Guttmacher Institute at: http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf.
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Table 3 Attitudes Regarding Michigan's Minor Consent and Parental Notification Laws (N 5 237) Minor Consent Laws A mature minor aged 12-18 can consent to the following without their parents' knowledge or consent:
A mature minor aged 14-18 can consent to the following without their parents' knowledge or consent:
Parental Notification Laws A physician may choose, but is not obligated, to inform the parent or guardian of a mature minor aged 12 to 18 seeking:
Parental Consent for Abortion Law Written consent from a parent or guardian is necessary for a minor to receive an abortion.
Attitudes Regarding Minor Consent and Parental Notification Laws
The majority of physicians approved of laws allowing minors to consent for confidential care (90.8% 1.7% approval), while under half (45.1% 4.5%) approved of laws allowing parental notification of this care at the physician's discretion. Only one-quarter approved of the Michigan law mandating written parental consent for a minor to have an abortion, Table 3. A few differences in approval of the laws arose by specialty. Ob/Gyns were most likely to approve of a minor's ability to access confidential care (approval rate for Ob/Gyn was 97.9% 8.5%, Fam Med 92.2% 20.3%, Peds 88.9% 22.7%, Med-Peds 80.0% 31.6%, P 5 .02), and least likely to approve of the law requiring written parental consent for an abortion (approval rate for Ob/Gyns 4.2% 20.2%, Fam Med 28.6% 45.6%, Peds 30.2% 46.1%, Med-Peds 53.9% 51.9%, P ! .01). Parents of an adolescent child were more likely to approve of parental notification laws (approval rate
54.9% 48.9% vs 35.5% 45.2% for those without adolescent children, P 5 .01). There were no other differences in approval of the laws based on demographics or practice. After completing the section in which Michigan's minor confidentiality laws were listed, over three-quarters of physicians (76.6%) felt they needed additional training on these laws. Lower correct numbers of knowledge questions correlated with feeling more strongly that additional training is needed (r 5 -0.211, P 5 .001). Attitudes Regarding Confidential Care for Adolescents
On a scale of 1 (strongly disagree) to 5 (strongly agree), the majority of physicians agreed that assured access to confidential care should be a right for adolescents (mean 4.55 0.88). Physicians were less confident that most adolescents are mature enough to consent for confidential care (mean 3.71 1.06), and male physicians were significantly less likely than female physicians to agree that most minors have the maturity to provide consent (males
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Table 4 Factors that Inhibit the Ability to Provide Confidential Care to Adolescents Ranked From Most to Least Inhibiting
3.46 1.06 vs females 3.82 1.05, P 5 .02). The majority of physicians disagreed or felt neutral about whether parents should have a right to know about all care provided to their adolescent child (mean 2.30 1.04). Barriers to Providing Confidential Care to Adolescents
On a scale of 1 (strongly disagree) to 5 (strongly agree), physicians voiced uncertainty about their ability to guarantee legally allowed confidentiality for adolescent patients seen in clinic (mean 3.60 1.12), and this differed by specialty (Ob/Gyn 4.00 1.11, Med-Peds 3.62 0.96, Fam Med 3.50 1.14, Peds 3.47 1.10, P 5 .05). When asked about factors that inhibit confidential care, insurance issues, parental attitudes about confidential care/relationships with the parents or guardians, and issues with the electronic medical record (EMR) ranked highest. Discomfort discussing sensitive issues with adolescents and the time it takes to discuss confidentiality were deemed the least inhibiting (see Table 4). Discussion
The Institute of Medicine published a report entitled “Adolescent Health Services: Missing Opportunities” which commented that the U.S. healthcare system today is not designed to help young people develop healthy routines, behaviors, and relationships to prepare them for adulthood, and that increased attention to confidential care is an essential component in the improvement of healthcare for adolescents.18 Adolescents may choose to forego medical care if they are concerned about confidentiality, hence physicians are missing opportunities to provide age appropriate and legally protected care to minor patients for sensitive medical and psychosocial issues.2e9 A clear understanding by medical providers regarding which services can be provided with strict confidentiality, and which allow and/or require parental notification is imperative if
adolescents are to feel secure about seeking comprehensive care. Similar to what was reported in Minnesota,11 our physicians had incomplete knowledge of state laws related to a minor patient's ability to consent for confidential care, answering just over half of the legal knowledge questions correctly. Physicians knew more about laws related to confidential testing for pregnancy and sexually transmitted infections, and less about laws related to mental healthcare and substance abuse treatment. Physicians were less certain about confidential care for younger minors than older teens. Finally, physicians were largely unaware that in Michigan a physician may choose to notify parents about all care received by a minor patient if they believe it is in the patient's best interest. Physicians generally felt comfortable discussing sexual health, mental health, and substance use with adolescent patients. Ob/Gyns and female physicians felt most comfortable discussing sexual health and pediatricians and male physicians felt less comfortable with this issue. Increased comfort with discussing sexual health was associated with increased knowledge of the laws around confidential care for sexual health issues. However, increased comfort with discussing mental health issues and substance abuse was not associated with knowledge of related laws. This raises concerns that physicians may be offering confidentiality assurances that are incongruent with legal protections, similar to what was found by Ford and Millstein.17 Comparable to previously published reports, the majority of our physicians felt favorable about laws protecting minor consented care and agreed that minors have a right to confidential care.14,15 Less than half of physicians approved of laws allowing parental notification of legally allowed confidential care at the physician's discretion, and only one-quarter approved of the law requiring written parental permission for a minor to have an abortion. Negative physician attitudes are therefore less likely to be a
M. Riley et al. / J Pediatr Adolesc Gynecol 28 (2015) 234e239
limiting factor in the provision of confidential care for our adolescent patients. Systems issues with insurance companies and the EMR were cited as significant barriers to providing confidential care to minors. Concern of an “explanation of benefits” with an itemized list of services received being sent to the patient's parents was named as the most limiting factor. An additional concern was raised that the EMRs printed “after visit summary” listing diagnoses, tests, etc, may inadvertently disclose confidential material to parents. The American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetrics and Gynecology, the Society for Adolescent Medicine, and the American Medical Association support the provision of confidential care for adolescents.19 These physician groups should advocate for legally protected adolescent rights to be supported by insurance companies' policies and procedures. Large institutions and small medical practices alike should also work to ensure confidentiality of medical records for minors. School-based health centers have been shown to be effective in providing confidential care for teens and should be considered nationally as well.20 Parental attitudes about confidential care and familial relationships were cited as an additional barrier. Studies have shown that parents often have conflicting feelings about their child receiving confidential care.21,22 However, the majority of parents support the idea that their adolescent child has the opportunity to spend time alone with the physician.23 Parents with a high level of trust in their child's physician have been found to be more comfortable with their children having confidential consultations.21 Additionally, parents who initially did not support confidential care for teens frequently changed their opinion after receiving education about adolescent risk-taking behaviors.23 Clinics can work towards standardizing confidentiality policies to improve communication between providers, parents, and adolescent patients. There are a number of limitations to this study. The survey was limited to physicians in a single academic institution and may not be generalizable to physicians in other settings. The response rate was 40%, and was likely lessened by timing as the survey was sent in late June with reminders in early July when faculty, residents, and fellows are entering and exiting the health system. In addition, survey respondents did not match the potential participants in specialty and gender. Interestingly, there was no relationship between most of the demographical data collected and responses to the survey, therefore the mismatch between survey respondents and nonrespondents may have had little impact on the results. There were some differences in knowledge and attitudes based on gender, specialty, and if the provider was a primary care physician, but there were no differences based on level of training (resident vs attending physician), length of time as an attending physician, or percent of adolescent patients comprising the physician's patient population.
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In summary, this study found that physicians have inadequate knowledge about minor consented healthcare services, but in general approve of confidential care for adolescent patients. Further research is needed to determine best practices for improving physician knowledge on minor consent laws and to address systems-based issues inhibiting confidential care for this vulnerable group of patients. Next steps include developing educational and clinical interventions to improve physician knowledge about confidential services and reduce systematic barriers to the provision of confidential care.
References 1. US Congress, Office of Technology Assessment: Adolescent Health: Summary and Policy Options. Washington, DC, US Government Printing Office, 1991. OTA-H-468. 2. Bethell C, Klein J, Peck C: Assessing health system provision of adolescent preventive services: the Young Adult Health Care Survey. Med Care 2001; 39: 478 3. Blum RW, Beuhring T, Wunderlich M, et al: Don't ask, they won't tell: the quality of adolescent health screening in five practice settings. Am J Public Health 1996; 86:1767 4. Klein JD, Wilson KM: Delivering quality care: adolescents' discussion of health risks with their providers. J Adolesc Health 2002; 30:190 5. Ford CA, Bearman PS, Moody J: Foregone health care among adolescents. JAMA 1999; 282(23):2227 6. Cheng TL, Savageau JA, Sattler AL, et al: Confidentiality in healthcare. A survey of knowledge, perceptions, and attitudes among highschool students. JAMA 1993; 269:1404 7. Klein JD, Wilson KM, McNulty M, et al: Access to medical care for adolescents: results from the 1997 Commonwealth Fund Survey of the Health of Adolescent Girls. J Adolesc Health 1999; 25:120 8. Jones RK, Purcell A, Singh S, et al: Adolescents' report of parental knowledge of adolescents' use of sexual health services and their reactions to mandated parental notification for prescription contraception. JAMA 2005; 293:340 9. Reddy DM, Fleming R, Swain C: Effect of mandatory parental notification on adolescent girls' use of sexual health care services. JAMA 2002; 288:710 10. Lehrer JA, Pantell R, Tebb K, et al: Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern. J Adolesc Health 2007; 40:218 11. Rock EM, Simmons PS: Physician knowledge and attitudes of Minnesota laws concerning adolescent health care. J Pediatr Adolesc Gynecol 2003; 16:101 12. Loertscher L, Simmons PS: Adolescents' knowledge of and attitudes toward Minnesota laws concerning adolescent medical care. J Pediatr Adolesc Gynecol 2006; 19:205 13. Cutler EM, Bateman MD, Wollan PC, et al: Parental knowledge and attitudes of Minnesota laws concerning adolescent medical care. Pediatrics 1999; 103: 582 14. Resnick MD, Litman TJ, Blum RW: Phyisican attitudes toward confidentiality of treatment for adolescents: findings from the Upper Midwest Regional Physicians Survey. J Adolesc Health 1992; 13:616 15. Fleming GV, O'Connor KG, Sanders JM Jr: Pediatricians' views of access to health services for adolescents. J Adolesc Health 1994; 15:473 16. Akinbami LJ, Gandhi H, Cheng TL: Availability of adolescent health services and confidentiality in primary care practices. Pediatrics 2003; 111:394 17. Ford CA, Millstein SG: Delivery of confidentiality assurances to adolescents by primary care physicians. Arch Pediatr Adolesc Med 1997; 151:505 18. Lawrence RS, Gootman JA, Sim LJ: Adolescent health services: missing opportunities. Washington, DC, National Academies Press, 2009 19. Morreale MC, Stinnett AJ, Dowling EC: Policy Compendium on Confidential Health Services for Adolescents, (2nd ed.). Chapel Hill, NC, Center for Adolescent Health and the Law, 2005 20. Gibson EJ, Santelli JS, Minguez M, et al: Measuring school health center impact on access to and quality of primary care. J Adolesc Health 2013; 53:699 21. Sasse RA, Aroni RA, Sawyer SM, et al: Confidential consultations with adolescents: an exploration of Australian parents' perspectives. J Adolesc Health 2013; 52:786 22. Tebb K, Karime Hernandez L, Shafer M, et al: Understanding the attitudes of Latino parents toward confidential health services for teens. J Adolesc Health 2012; 50:572 23. Hutchinson JW, Stafford EM: Changing parental opinions about teen privacy through education. Pediatrics 2005; 116:966
Department of Family Medicine, University of Michigan, Ann Arbor, MI Department of Pediatrics, University of Michigan, Ann Arbor, MI 3 Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 2
a b s t r a c t Study Objective: Minor adolescent patients have a legal right to access certain medical services confidentially without parental consent or notification. We sought to assess physicians' knowledge of these laws, attitudes around the provision of confidential care to minors, and barriers to providing confidential care. Design: An anonymous online survey was sent to physicians in the Departments of Family Medicine, Internal Medicine-Pediatrics, Obstetrics/Gynecology, and Pediatrics at the University of Michigan. Results: Response rate was 40% (259/650). The majority of physicians felt comfortable addressing sexual health, mental health, and substance use with adolescent patients. On average, physicians answered just over half of the legal knowledge questions correctly (mean 56.6% 16.7%). The majority of physicians approved of laws allowing minors to consent for confidential care (90.8% 1.7% approval), while substantially fewer (45.1% 4.5%) approved of laws allowing parental notification of this care at the physician's discretion. Most physicians agreed that assured access to confidential care should be a right for adolescents. After taking the survey most physicians (76.6%) felt they needed additional training on confidentiality laws. The provision of confidential care to minors was perceived to be most inhibited by insurance issues, parental concerns/relationships with the family, and issues with the electronic medical record. Conclusions: Physicians are comfortable discussing sensitive issues with adolescents and generally approve of minor consent laws, but lack knowledge about what services a minor can access confidentially. Further research is needed to assess best methods to educate physicians about minors' legal rights to confidential healthcare services. Key Words: Confidentiality, Adolescent health services, Privacy, Informed consent by minors, Parental notification
Introduction
High risk behaviors including substance use, sexual activity, interpersonal violence, and suicide are the primary causes of morbidity and mortality in adolescents.1 However, less than 20% of adolescents receive recommended screening and counseling on these risky behaviors from their healthcare provider.2,3 Adolescent patients are unlikely to bring up sensitive issues on their own, but want to discuss these subjects with their physician and cite confidentiality as one of the key determinants of their use of healthcare.2,4,5 One study showed that 58% of high school students have health concerns they want to keep private from their parents.6 The most common reason adolescent girls identify for missing a necessary health service is that they do not want their parents to know.7 Studies have shown that a lack of confidential care does not delay or dissuade adolescents from engaging in high risk behavior and may lead to unintended health and social
The authors would like to thank the University of Michigan Adolescent Health Initiative (AHI) for their assistance in study design and review. The authors indicate no conflicts of interest. * Address correspondence to: Margaret Riley, MD, Department of Family Medicine, University of Michigan, 1150 West Medical Center Drive, M7300 Medical Science I, SPC 5625, Ann Arbor, Michigan 48109-5625; Phone: (734) 232-6222; fax: (734) 615.2687 E-mail address: [email protected] (M. Riley).
consequences.8,9 In fact, adolescents who forego healthcare due to confidentiality concerns are more likely to engage in risky behaviors and report psychological stress.10 Federal and state laws have been in place for decades to allow minor patients to receive confidential care for specific healthcare issues related to sexual health, mental health, and substance use. However, physicians have been found to have low knowledge about the laws that exist in their state regarding a minor patient's ability to consent for healthcare services.11 Patients and their parents are frequently unaware of minor consent laws as well.12,13 The majority of primary care physicians support offering confidential care to adolescent patients.14,15 However, addressing sensitive issues with adolescents can be a challenge. Physicians have cited difficulty having these discussions due to lack of expertise, low patient demand for confidential services, and inadequate staffing.16 Physicians may have more comfort offering confidential services to older adolescents, but can be less likely to provide this care to younger adolescents,15 and while some physicians are routinely offering confidential care to their adolescent patients, they may be incorrectly stating the limits of confidentiality.17 This study was designed to assess University of Michigan Family Medicine, Internal Medicine-Pediatrics, Obstetrics and Gynecology, and Pediatrics physician knowledge of and attitudes towards Michigan's minor consent and parental
1083-3188/$ - see front matter Ó 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2014.08.008
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notification laws. Physician comfort with managing sensitive issues in adolescents was also measured. Finally, we assessed perceived barriers to the provision of confidential care for minor patients. This study serves as a needs assessment to better understand knowledge gaps and barriers (both in attitudes and logistics) to providing confidential care in our ambulatory care clinics. Findings will be used to develop and engage physicians in educational activities with the ultimate goal of improving adolescent healthcare at our institution. Materials and Methods
All faculty, fellows, and resident physicians in the Departments of Family Medicine (Fam Med), MedicinePediatrics (Med-Peds), Obstetrics and Gynecology (Ob/ Gyn), and Pediatrics (Peds) at the University of Michigan received an anonymous online survey link via e-mail inviting them to participate in a survey exploring clinicians' knowledge and attitudes related to providing confidential healthcare to adolescent patients. Two reminder e-mails were sent 10 and 20 days after the original invitation. This survey received Medical IRB exemption in June 2013. The survey was divided in several main sections; starting with physician demographics and practice characteristics including questions on gender, specialty, level of training, length of time as an attending physician, if they are a primary care provider (PCP), the percent of their patient population that is aged 12 to 18, if they have children, and if their children are aged 12 or older. Physicians were then questioned on their level of comfort in addressing sexual health, mental health, and substance use with adolescent patients. Knowledge of Michigan's confidentiality laws was explored by asking if statements related to a minor's ability to consent for certain aspects of healthcare, physicians' ability to notify parents about this care, and parental health record access were true or false. Physicians were also able to choose if they were uncertain if the statement was true or false, and uncertain answers were coded as incorrect in the analysis. To explore clinician attitudes, Michigan minor consent and parental notification laws were then provided, and participants were asked if they approved, disapproved, or felt neutral about each law. Attitudes were further examined by asking physicians to rate their agreement with statements regarding an adolescent's right to confidential care, adolescent maturity in making care decisions, and parental rights to notification of healthcare provided to their minor child. Finally, physicians were questioned on their ability to provide confidential care to minors seen in the outpatient clinic setting, and what barriers they felt inhibited their provision of confidential care. Associations between demographic information, knowledge, and attitudes were explored using t-tests, ANOVA, and Pearson's correlation as appropriate. Results Survey Demographics
The survey link was sent to 650 potential participants. Three hundred and nineteen physicians began the
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demographic questions, and 259 answered the knowledge questions about minor confidentiality laws and were included in the analysis for an overall response rate of 40%. Characteristics of survey responders compared to all potential participants are shown in Table 1. Comfort with Discussing Sensitive Subjects with Adolescents
On a scale of 1 (very uncomfortable) to 5 (very comfortable), the majority of physicians felt comfortable addressing sexual health (mean 4.07 1.12), mental health (3.97 1.02), and substance use (3.89 1.09) with patients aged 12 to 18. There was a trend towards difference by physician specialty in comfort addressing sexual health in this age group, with Ob/Gyns being most comfortable and pediatricians least comfortable (Ob/Gyn mean 4.38 1.21, Med-Peds 4.31 0.75, Fam Med 4.09 1.07, Peds 3.94 1.10, P 5 .08). Female physicians felt significantly more comfortable discussing sexual health than male physicians (females mean 4.18 1.07, males 3.81 1.8, P 5 .02). Physicians with children aged 12 or older were more comfortable addressing mental health and substance use in this age group than those without adolescent children (with children aged 12 or older mean 4.28 1.07 vs without 3.86 0.99, P 5 .01 for mental health and 4.07 1.05 vs 3.75 1.13, P 5 .07 for substance use), but were not more comfortable discussing sexual health (4.07 1.25 vs 4.10 1.07, P 5 .90). There were no other differences in comfort addressing sensitive subjects with adolescents by specialty, gender, level of training, length of time as an attending physician, if the physician was a PCP, or percent of patient population that is adolescent. Knowledge of Michigan Laws
On average, physicians answered just over half of the legal knowledge questions correctly (mean 56.6% 16.7%), see Table 2. When grouped by topic, physicians varied on the percent of questions they answered correctly (percent correct on questions about health records 63.1% 33.8%, sexual health 57.9% 19.3%, mental health 53.5% 30%, substance abuse 47.7% 31.7%, P 5 .03). Physicians answered more questions correctly about minors' ability to consent for care (65.8% 19.9%) compared to questions around parental notification of care (24.5% 35.4%), P ! .01. When questions provided the same scenario with an older minor (age 17) compared to a younger minor (age 13), physicians were more likely to answer correctly for the older minor (P ! .001). There was a trend towards difference in number of knowledge questions answered correctly by specialty (Fam Med 61.9% 16.3%, Ob/Gyn 56.3% 13.4%, Peds 55.2% 17.4%, Med-Peds 52.2% 13.8%, P 5 .06), and a statistically significant difference by gender (females 58.4% 15.2%, males 52.3% 19.3%, P 5 .01), and whether or not the physician was a PCP (PCPs 60.6% 14.6%, non-PCPs 52.1% 17.8%, P ! .01). There was no statistically significant difference in number correct based on level of training,
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Table 1 Characters of Survey Responders Compared to all Potential Participants Demographic Information of Respondents vs Non-Respondents
Respondents (259) N (% of Total)*
Non-Respondents (391) N (%)
P-Value .001y
Specialty Family medicine Medicine-pediatrics Obstetrics and gynecology Pediatrics Gender Female Male Level of training Resident physician or fellow Attending
54 12 52 139
(50.9) (16.4) (46.8) (38.6)
52 61 59 221
(49.1) (83.6) (53.2) (61.4) .001
182 (44.7) 77 (31.7)
225 (55.3) 166 (68.3)
102 (40.5) 156 (39.2)
150 (59.5) 242 (60.8)
.745
Other Demographics of Respondents
N (% of Respondents)
PCP Yes Length of Time as an Attending (y) #5 6-10 11-15 16-20 $21 % of Patient Population Ages 12e18 0e25 26e50 51e75 76e100 Have children Yes Children are age 12 or older Yes
137 (52.9) 41 36 22 22 36
(26.1) (22.9) (14.0) (14.0) (22.9)
167 71 17 3
(64.7) (27.5) (6.6) (1.2)
167 (65.5) 67 (39.6)
* Some respondents did not answer all demographic questions. y Significance due to discrepancy in Med-Peds respondents, no other significant differences between respondents and non-respondents by specialty.
length of time as an attending physician, percent of patient population that is adolescent, or if the physician has children. Physicians with increased comfort in discussing sexual health had increased knowledge on the sexual health
laws (P 5 .001, r 5 0.21), but comfort with addressing mental health and substance use did not correlate with related legal knowledge (P 5 .33 and P 5 .14 respectively).
Table 2 Knowledge of Michigan Laws Related to a Minor's Ability to Consent for Care, Parental Notification of Care, and Health Records Question (Correct Answer in the State of Michigan) Insurance/health record issues The parents of a 15 y/o have the legal right to access their minor child's complete medical record. (False) An insurance company has the right to send an explanation of benefits (EOB) to the parents for confidential services provided to a minor. (True) Mental health A 14 y/o can consent to counseling for a mental health issue without his or her parents' knowledge or consent. (True) The same 14 y/o can consent to begin an SSRI for depression without his or her parents' consent. (False) Sexual health A 17 y/o can consent to receiving an IUD without her parents' knowledge or consent. (True) A 13 y/o can consent to receiving an IUD without her parents' knowledge or consent. (True) A 15 y/o can receive pregnancy testing and prenatal care without informing her parents. (True) A physician may choose to inform the parents of a 14 y/o requesting birth control. (True) A 17 y/o can consent to testing and treatment for gonorrhea without his or her parents' knowledge or consent. (True) A 13 y/o can consent to testing and treatment for gonorrhea without his or her parents' knowledge or consent. (True) A physician may choose to inform the parents of a 14 y/o requesting sexually transmitted infection treatment. (True) A 17 y/o can consent to receive the HPV vaccine without his or her parents' consent. (False) Substance use A 16 y/o abusing alcohol can consent to substance abuse treatment without his or her parents' knowledge or consent. (True) The physician treating the 16 y/o abusing alcohol may choose to inform the patient's parents without his or her consent. (True)
Correct N (%)
Incorrect N (%)
Uncertain N (%)
174 (67.4) 153 (59.8)
65 (25.2) 48 (18.8)
19 (7.4) 55 (21.5)
149 (57.5)
57 (22.0)
53 (20.5)
128 (49.6)
61 (23.6)
69 (26.7)
200 117 235 49 251
(77.2) (45.3) (91.1) (19.0) (96.9)
10 78 11 175 1
(3.9) (30.2) (4.2) (67.8) (0.4)
49 63 12 34 7
(18.9) (24.4) (4.7) (13.2) (2.7)
191 (73.7)
37 (14.3)
31 (12.0)
58 (22.5)
170 (65.9)
30 (11.6)
99 (38.7)
113 (44.1)
44 (17.2)
164 (63.6)
45 (17.4)
49 (19.0)
83 (32.3)
117 (45.3)
58 (22.5)
Some respondents did not answer every question. When grouped by topic, physicians had more correct answers on questions about insurance/health records vs. sexual health vs mental health vs. substance abuse (P 5 .03). Physicians answered more questions correctly about minors' ability to consent for care compared to questions regarding parental notification of care (P ! .01). When given the same scenario about an older vs. a younger minor, physicians were more likely to answer correctly for the older minor (P ! .001). An overview of minor consent laws in each state is available from the Guttmacher Institute at: http://www.guttmacher.org/statecenter/spibs/spib_OMCL.pdf.
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Table 3 Attitudes Regarding Michigan's Minor Consent and Parental Notification Laws (N 5 237) Minor Consent Laws A mature minor aged 12-18 can consent to the following without their parents' knowledge or consent:
A mature minor aged 14-18 can consent to the following without their parents' knowledge or consent:
Parental Notification Laws A physician may choose, but is not obligated, to inform the parent or guardian of a mature minor aged 12 to 18 seeking:
Parental Consent for Abortion Law Written consent from a parent or guardian is necessary for a minor to receive an abortion.
Attitudes Regarding Minor Consent and Parental Notification Laws
The majority of physicians approved of laws allowing minors to consent for confidential care (90.8% 1.7% approval), while under half (45.1% 4.5%) approved of laws allowing parental notification of this care at the physician's discretion. Only one-quarter approved of the Michigan law mandating written parental consent for a minor to have an abortion, Table 3. A few differences in approval of the laws arose by specialty. Ob/Gyns were most likely to approve of a minor's ability to access confidential care (approval rate for Ob/Gyn was 97.9% 8.5%, Fam Med 92.2% 20.3%, Peds 88.9% 22.7%, Med-Peds 80.0% 31.6%, P 5 .02), and least likely to approve of the law requiring written parental consent for an abortion (approval rate for Ob/Gyns 4.2% 20.2%, Fam Med 28.6% 45.6%, Peds 30.2% 46.1%, Med-Peds 53.9% 51.9%, P ! .01). Parents of an adolescent child were more likely to approve of parental notification laws (approval rate
54.9% 48.9% vs 35.5% 45.2% for those without adolescent children, P 5 .01). There were no other differences in approval of the laws based on demographics or practice. After completing the section in which Michigan's minor confidentiality laws were listed, over three-quarters of physicians (76.6%) felt they needed additional training on these laws. Lower correct numbers of knowledge questions correlated with feeling more strongly that additional training is needed (r 5 -0.211, P 5 .001). Attitudes Regarding Confidential Care for Adolescents
On a scale of 1 (strongly disagree) to 5 (strongly agree), the majority of physicians agreed that assured access to confidential care should be a right for adolescents (mean 4.55 0.88). Physicians were less confident that most adolescents are mature enough to consent for confidential care (mean 3.71 1.06), and male physicians were significantly less likely than female physicians to agree that most minors have the maturity to provide consent (males
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Table 4 Factors that Inhibit the Ability to Provide Confidential Care to Adolescents Ranked From Most to Least Inhibiting
3.46 1.06 vs females 3.82 1.05, P 5 .02). The majority of physicians disagreed or felt neutral about whether parents should have a right to know about all care provided to their adolescent child (mean 2.30 1.04). Barriers to Providing Confidential Care to Adolescents
On a scale of 1 (strongly disagree) to 5 (strongly agree), physicians voiced uncertainty about their ability to guarantee legally allowed confidentiality for adolescent patients seen in clinic (mean 3.60 1.12), and this differed by specialty (Ob/Gyn 4.00 1.11, Med-Peds 3.62 0.96, Fam Med 3.50 1.14, Peds 3.47 1.10, P 5 .05). When asked about factors that inhibit confidential care, insurance issues, parental attitudes about confidential care/relationships with the parents or guardians, and issues with the electronic medical record (EMR) ranked highest. Discomfort discussing sensitive issues with adolescents and the time it takes to discuss confidentiality were deemed the least inhibiting (see Table 4). Discussion
The Institute of Medicine published a report entitled “Adolescent Health Services: Missing Opportunities” which commented that the U.S. healthcare system today is not designed to help young people develop healthy routines, behaviors, and relationships to prepare them for adulthood, and that increased attention to confidential care is an essential component in the improvement of healthcare for adolescents.18 Adolescents may choose to forego medical care if they are concerned about confidentiality, hence physicians are missing opportunities to provide age appropriate and legally protected care to minor patients for sensitive medical and psychosocial issues.2e9 A clear understanding by medical providers regarding which services can be provided with strict confidentiality, and which allow and/or require parental notification is imperative if
adolescents are to feel secure about seeking comprehensive care. Similar to what was reported in Minnesota,11 our physicians had incomplete knowledge of state laws related to a minor patient's ability to consent for confidential care, answering just over half of the legal knowledge questions correctly. Physicians knew more about laws related to confidential testing for pregnancy and sexually transmitted infections, and less about laws related to mental healthcare and substance abuse treatment. Physicians were less certain about confidential care for younger minors than older teens. Finally, physicians were largely unaware that in Michigan a physician may choose to notify parents about all care received by a minor patient if they believe it is in the patient's best interest. Physicians generally felt comfortable discussing sexual health, mental health, and substance use with adolescent patients. Ob/Gyns and female physicians felt most comfortable discussing sexual health and pediatricians and male physicians felt less comfortable with this issue. Increased comfort with discussing sexual health was associated with increased knowledge of the laws around confidential care for sexual health issues. However, increased comfort with discussing mental health issues and substance abuse was not associated with knowledge of related laws. This raises concerns that physicians may be offering confidentiality assurances that are incongruent with legal protections, similar to what was found by Ford and Millstein.17 Comparable to previously published reports, the majority of our physicians felt favorable about laws protecting minor consented care and agreed that minors have a right to confidential care.14,15 Less than half of physicians approved of laws allowing parental notification of legally allowed confidential care at the physician's discretion, and only one-quarter approved of the law requiring written parental permission for a minor to have an abortion. Negative physician attitudes are therefore less likely to be a
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limiting factor in the provision of confidential care for our adolescent patients. Systems issues with insurance companies and the EMR were cited as significant barriers to providing confidential care to minors. Concern of an “explanation of benefits” with an itemized list of services received being sent to the patient's parents was named as the most limiting factor. An additional concern was raised that the EMRs printed “after visit summary” listing diagnoses, tests, etc, may inadvertently disclose confidential material to parents. The American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetrics and Gynecology, the Society for Adolescent Medicine, and the American Medical Association support the provision of confidential care for adolescents.19 These physician groups should advocate for legally protected adolescent rights to be supported by insurance companies' policies and procedures. Large institutions and small medical practices alike should also work to ensure confidentiality of medical records for minors. School-based health centers have been shown to be effective in providing confidential care for teens and should be considered nationally as well.20 Parental attitudes about confidential care and familial relationships were cited as an additional barrier. Studies have shown that parents often have conflicting feelings about their child receiving confidential care.21,22 However, the majority of parents support the idea that their adolescent child has the opportunity to spend time alone with the physician.23 Parents with a high level of trust in their child's physician have been found to be more comfortable with their children having confidential consultations.21 Additionally, parents who initially did not support confidential care for teens frequently changed their opinion after receiving education about adolescent risk-taking behaviors.23 Clinics can work towards standardizing confidentiality policies to improve communication between providers, parents, and adolescent patients. There are a number of limitations to this study. The survey was limited to physicians in a single academic institution and may not be generalizable to physicians in other settings. The response rate was 40%, and was likely lessened by timing as the survey was sent in late June with reminders in early July when faculty, residents, and fellows are entering and exiting the health system. In addition, survey respondents did not match the potential participants in specialty and gender. Interestingly, there was no relationship between most of the demographical data collected and responses to the survey, therefore the mismatch between survey respondents and nonrespondents may have had little impact on the results. There were some differences in knowledge and attitudes based on gender, specialty, and if the provider was a primary care physician, but there were no differences based on level of training (resident vs attending physician), length of time as an attending physician, or percent of adolescent patients comprising the physician's patient population.
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In summary, this study found that physicians have inadequate knowledge about minor consented healthcare services, but in general approve of confidential care for adolescent patients. Further research is needed to determine best practices for improving physician knowledge on minor consent laws and to address systems-based issues inhibiting confidential care for this vulnerable group of patients. Next steps include developing educational and clinical interventions to improve physician knowledge about confidential services and reduce systematic barriers to the provision of confidential care.
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