The race of patients and physicians can affect the quality of health care provision

Ellen and colleagues' study indicates a low screening rate for a high-risk population. These findings are alarming because the need for consistent screening of adolescents has been repeatedly established.

One study of inner-city adolescent females concluded that they should be screened for chlamydia every 6 months, based on the incidence of this infection in the study population.¹ Another study also suggests an optimal screening interval of 6 months, based on highSTD prevalence and incidence despite moderate risk behavior, such as only 1lifetime sexual partner.²

Ellen and associates found a low rate of STD screening even among adolescents attending for primary care visits. This is consistent with other reports of poor rates of screening and delivery of preventive services to adolescents in a variety of clinical settings, including primary care visits.^3,4

As health care physicians for a substantial African American population in the Adolescent Medicine clinic of Children's Hospital, Oakland, California, we believe that a major barrier to adequate STD education and screening in adolescents is physicians' failure to discuss sexuality. This failure occursdespite well-documented guidelines, such as the American Medical Association'sGuidelines for Adolescent Preventive Services (GAPS), and screening and assessment tools, such as the “HEADS” psychosocialassessment—home environment, education, activities and employment, peer activities, drugs, sexuality, and suicide.⁵ A recent study of California primary care providers showed that less than 40% of physicians asked all of their adolescent patients about sexual activity.³Appropriate STD screening cannot be performed without taking an adequate sexual history. The preventive primary care visit is just 1 of many opportunities to obtain sexual histories and perform appropriate screening.The philosophy at our clinic is to use every visit as an opportunity to discuss issues related to sexuality and to screen for STDs, if indicated. This requires flexibility in the physician's schedule because a visit for a minor respiratory tract infection might turn into a lengthier STD screening.

In the African American population studied by Ellen and colleagues, there may have been inherent barriers to the delivery of primary health care services. As a group composed primarily of African American health care providers, we find it interesting that the authors did not comment on the role that race itself may have had in determining health care access and delivery, despite the fact that the study focused exclusively on African American adolescents. Race may have been a major barrier to the delivery of primary care services to the study population. The race of patients and providers affects quality of care, access to care, health care service provision, and screening.^6,7,8Provider attributes, including race, can undoubtedly influence patients' use of health care. Black patients are more likely to report having received preventive and other medical care, and to rate their physician as excellent, if their physician is also black.⁸ There is increasing evidence of the importance of such racial concordance in ensuring access to and continuation of healthcare.⁹ It is reasonable to assume that screening rates for African American adolescents might have been higher if they had been given access to African American providers. At the very least, the issue of racial concordance and discordance should have been explored and discussed.

In another article in the same study population, it was reported thatAfrican American teens placed the greatest importance on provider attributes when deciding to seek STD care. Provider attributes did not include race but focused on those characterized primarily as behavior.^10,11It is critical to explore the effect of provider race as one of the provider attributes. We encourage health care professionals to consider these issues when caring for adolescent patients.