Abstract
Objectives:
Organizations recommend providing confidential adolescent health care to reduce the consequences of high-risk health behaviors such as substance use, unhealthy eating patterns, and high-risk sexual behaviors. Family physicians are uniquely positioned to provide confidential counseling and care to this vulnerable population but must be trained to provide such care. This study describes the impact of formal and informal training on the knowledge of and comfort level in providing confidential adolescent healthcare among a sample of US Family Medicine residents.
Methods:
Electronic surveys were distributed to all Family Medicine residents throughout the United States. We used descriptive statistics and χ2 analysis where appropriate to determine the association between resident-reported receipt of training, confidence, and frequency in providing confidential adolescent health care.
Results:
A total of 714 family medicine residents completed the survey. The majority reported no formal training in residency (50.3%). The receipt of formal and informal training in both medical school and residency was associated with a greater degree of comfort in providing confidential adolescent care and a higher likelihood of providing confidential time alone. Those reporting formal training were more likely to always provide confidential care (P = 0.001).
Conclusions:
Training focused on confidential adolescent health care in medical school or residency was associated with a greater degree of comfort and a higher likelihood of providing confidential adolescent health care.
Keywords: adolescents, confidentiality, privacy, self-consenting
Adolescents, defined by the American Academy of Pediatrics as those 11 to 21 years old, made up 12.8% of the US population as of 2019.1,2 Although adolescents are generally healthy, they also are in unique stages of psychosocial, cognitive, and physical development that impact their decision-making ability and influences overall health.3–5 During this phase, adolescents may experiment with risky health behaviors, including high-risk sexual behaviors that can result in teen pregnancy and/or sexually transmitted infections.3–5 Adolescents also may engage in illicit drug, alcohol, and tobacco use, as well as unhealthy eating habits, predisposing them to significant morbidity and mortality later in life.3–5 Despite these potential risks, adolescents are less likely to seek prompt medical attention, often due to concerns about parental awareness of their health problems.5 Adolescents are more likely to seek prompt healthcare services if offered the ability to self-consent to health care and receive private and confidential care without parental involvement.5
The Society for Adolescent Health and Medicine, the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists urge healthcare providers to offer confidential healthcare services to adolescents to improve access to care and encourage adolescents to discuss sensitive topics related to sexual and reproductive health, substance use, and mental health.6–8
Although the autonomy to self-consent and the receipt of confidential care are considered human rights and evidence-based elements of high-quality care, individual US state laws on adolescent confidential care and self-consent vary greatly among states and can create major barriers to ensuring adolescents’ privacy.6,9,10
Family physicians are uniquely positioned to provide confidential counseling and care to this vulnerable population because they serve the largest number of adolescents in the United States.11 Having well-trained family physicians experienced in the care of adolescents who understand the impact of providing confidential care for this population is critical for improving their overall health. However, prior research has found significant variability in the knowledge and comfort of primary care clinicians about confidentiality in adolescent healthcare.12 Klein and Mehta found out that only 38.5% of 78 family physician residents received training on adolescent health, and few felt comfortable with their knowledge of providing adolescent health care.13 Other studies suggest that healthcare providers avoid discussing confidential care with adolescents due to inadequate training.5,14–16
The objective of the present study was to assess Family Medicine residents’ training, knowledge, and comfort with providing confidential care to adolescents, including self-consenting for healthcare services. The study aimed to capture resident experiences during training to reflect on opportunities to enhance preparedness to provide adolescent care once they were independent clinicians.
Methods
Data Collection, Participants, and Setting
Using Qualtrics survey software (Qualtrics, Provo, UT), an electronic cross-sectional survey was sent to Family Medicine residents (N = 14,010) in postgraduate years (PGYs) 1 to 3 (expected graduation between 2023 and 2025). Residents unreachable by e-mail and those in their PGY-4 and higher were excluded from the study. Using available data from the American Academy of Family Physicians database access system, surveys were sent to residents from 725 Accreditation Council for Graduate Medical Education (ACGME)–accredited Family Medicine residency programs across the United States, including Puerto Rico. Data were collected from July 2022 through January 2023. This study was granted exemption by the Cone Health institutional review board.
Survey Instrument and Outcome Variables
An anonymous, 14-item electronic survey assessing knowledge, awareness, and comfort with providing confidential healthcare services to adolescents was distributed to all of the participants. To validate the survey, we used the face and content validity method.17 The survey was developed using existing literature and was subsequently reviewed and evaluated by three content experts, who assessed its structure, clarity, and comprehensiveness. Survey items consisted of categorical demographic variables, including current PGY, sex, race, ethnicity, region, practice setting (urban vs rural vs suburban), and percentage of adolescents in respondents’ patient panel. A five-point Likert scale was used to rate confidential adolescent healthcare training in medical school or residency, frequency of care provision, comfort, and knowledge. An open-ended question about barriers to providing confidential adolescent health care was made available to participants at the end of the survey.
Statistical Analysis
Frequencies and percentages were calculated to summarize the survey responses. Two-way tables were constructed to summarize associations between pairs of variables, and P values based on χ2 tests of independence were calculated to determine statistical evidence of an association between variables. It is important to note that the goal of the study was exploratory; hence, there were no a priori hypotheses. Consequently, no meaningful power analysis was possible to determine a minimum sample size.
Results
A total of 714 out of 14,010 completed the survey, resulting in a response rate of 5%. Most respondents were PGY-1 (40.5%), and most identified as female (62.5%) (Table 1).
Table 1.
Demographics
| Characteristic | Residency training year | ||
|---|---|---|---|
| First N = 289 (%) |
Second N = 208 (%) |
Third N = 217 (%) |
|
| Sex | |||
| Female | 173.0 (38.8) | 131.0 (29.4) | 142.0 (31.8) |
| Male | 111.0 (43.5) | 75.0 (29.4) | 69.0 (27.1) |
| Nonbinary/third gender | 2.0 (25.0) | 2.0 (25.0) | 4.0 (50.0) |
| Prefer not to say | 3.0 (60.0) | 0.0 (0.0) | 2.0 (40.0) |
| Race | |||
| White | 137.0 (41.6) | 96.0 (29.2) | 96.0 (29.2) |
| Black/African American | 40.0 (40.0.0) | 30.0 (30.0) | 30.0 (30.0) |
| Hispanic/Latinx/Spanish | 24.0 (36.9) | 19.0 (29.2) | 22.0 (33.8) |
| Asian | 55.0 (40.1) | 36.0 (26.3) | 46.0 (33.6) |
| Other | 32.0 (39.5) | 27.0 (33.3) | 22.0 (27.2) |
| Region | |||
| Midwest | 80.0 (40.6) | 57.0 (28.9) | 60.0 (30.5) |
| Northeast | 74.0 (45.4) | 55.0 (33.7) | 34.0 (20.9) |
| Southeast | 69.0 (41.6) | 46.0 (27.7) | 51.0 (30.7) |
| Southwest | 24.0 (42.1) | 15.0 (26.3) | 18.0 (31.6) |
| West | 35.0 (31.8) | 27.0 (24.5) | 48.0 (43.6) |
| Other | 7.0 (33.3) | 8.0 (38.1) | 6.0 (28.6) |
| Training settings | |||
| Rural | 73 (42.2) | 44 (25.4) | 56 (32.4) |
| Suburban | 107 (41.2) | 77 (29.6) | 76 (29.2) |
| Urban | 109 (38.8) | 87 (31.0) | 85 (30.2) |
| Panel demographics, % adolescents | 0–20 | 21–40 | ≥41 |
| Respondents | 528 (74) | 168 (23.5) | 18 (2.5) |
Formal training in the care of adolescents, defined as devoted conference presentations or educational curricula on confidentiality in adolescent health care during residency education, was reported by 32.4%, 17.4% were uncertain of their training status, and 50.3% reported no formal training during residency training. A majority of respondents, 63.7%, reported informal training, such as during precepting, chart audits, or other modalities, 25.8% reported never receiving informal training regarding this topic, and 10.5% were uncertain. Ultimately, 68.6% reported receiving either formal or informal training in medical school.
With respect to comfort providing confidential care to adolescents, 14.8% were extremely comfortable, 44.4% were somewhat comfortable, 14.3% were neutral, 21.9% were somewhat uncomfortable, and 4.6% were extremely uncomfortable with providing confidential care. When stratified by PGY, the majority of residents who were extremely comfortable with providing confidential care were PGY-3s (41%). Receiving formal or informal training during residency or any training in medical school was each associated with a higher comfort level of providing confidential care to adolescents (P < 0.001, P < 0.001, and P < 0.001, respectively) (Table 2).
Table 2.
Comfort level in providing confidential adolescent care (all years)
| Received formal residency training | <0.001 | |||||
| No | 10.0 (2.8) | 98.0 (27.3) | 57.0 (15.9) | 151.0 (42.1) | 43.0 (12.0) | |
| Uncertain | 4.0 (3.2) | 24.0 (19.4) | 23.0 (18.5) | 61.0 (49.2) | 12.0 (9.7) | |
| Yes | 19.0 (8.2) | 35.0 (15.2) | 22.0 (9.5) | 105.0 (45.5) | 50.0 (21.6) | |
| Received informal residency training | <0.001 | |||||
| No | 8.0 (4.3) | 56.0 (30.4) | 35.0 (19.0) | 66.0 (35.9) | 19.0 (10.3) | |
| Uncertain | 3.0 (4.0) | 20.0 (26.7) | 18.0 (24.0) | 28.0 (37.3) | 6.0 (8.0) | |
| Yes | 22.0 (4.8) | 81.0 (17.8) | 49.0 (10.8) | 223.0 (49.0) | 80.0 (17.6) | |
| Received any training in medical school | <0.001 | |||||
| No | 7.0 (4.6) | 48.0 (31.8) | 27.0 (17.9) | 51.0 (33.8) | 18.0 (11.9) | |
| Uncertain | 3.0 (4.1) | 19.0 (26.0) | 19.0 (26.0) | 29.0 (39.7) | 3.0 (4.1) | |
| Yes | 23.0 (4.7) | 90.0 (18.4) | 56.0 (11.4) | 237.0 (48.4) | 84.0 (17.1) |
Eighteen percent of respondents reported that they always provide confidential care. A similar percentage reported providing confidential care most of the time, whereas 8% provided confidential care half of the time, 49% sometimes provided confidential care, and only 7% never provided confidential care. Most of the residents who received formal training and always provided confidential care were PGY-3 residents (38%), compared with 32% of PGY-1 residents and 30% of PGY-2 residents. Most of the residents who received formal training and never provided confidential care were PGY-1 residents (55%), compared with 15% of PGY-2 residents and 30% of PGY-3 residents. Receiving formal or informal training during residency or any training in medical school was each associated with a higher frequency of providing confidential care to adolescents (P = 0.001, P < 0.001, and P < 0.001, respectively) (Table 3).
Table 3.
Frequency of providing confidential adolescent care (all years)
| Received formal residency training | 0.001 | |||||
| No | 33.0 (9.2) | 195.0 (54.3) | 28.0 (7.8) | 59.0 (16.4) | 44.0 (12.3) | |
| Uncertain | 10.0 (8.1) | 54.0 (43.5) | 10.0 (8.1) | 21.0 (16.9) | 29.0 (23.4) | |
| Yes | 7.0 (3.0) | 102.0 (44.2) | 19.0 (8.2) | 51.0 (22.1) | 52.0 (22.5) | |
| Received informal residency training | <0.001 | |||||
| No | 23.0 (12.5) | 102.0 (55.4) | 17.0 (9.2) | 26.0 (14.1) | 16.0 (8.7) | |
| Uncertain | 11.0 (14.7) | 44.0 (58.7) | 2.0 (2.7) | 5.0 (6.7) | 13.0 (17.3) | |
| Yes | 16.0 (3.5) | 205.0 (45.1) | 38.0 (8.4) | 100.0 (22.0) | 96.0 (21.1) | |
| Received any training in medical school | <0.001 | |||||
| No | 21.0 (13.9) | 83.0 (55.0) | 15.0 (9.9) | 17.0 (11.3) | 15.0 (9.9) | |
| Uncertain | 10.0 (13.7) | 45.0 (61.6) | 2.0 (2.7) | 7.0 (9.6) | 9.0 (12.3) | |
| Yes | 19.0 (3.9) | 223.0 (45.5) | 40.0 (8.2) | 107.0 (21.8) | 101.0 (20.6) |
In terms of knowledge of state laws about adolescent confidential care, most of the respondents reported moderate or slight knowledge (34.5% and 35.3%, respectively) (Table 4).
Table 4.
Frequency of care and knowledge of state laws (all years)
| Knowledge of confidentiality laws | |||||||
|---|---|---|---|---|---|---|---|
| Characteristic | Not at all N = 106 (%) |
Slightly N = 252 (%) |
Moderately N = 246 (%) |
Very N = 90 (%) |
Extremely N = 20 (%) |
P | |
| Frequency of confidential adolescent care | <0.001 | ||||||
| Never | 18.0 (36.0) | 25.0 (50.0) | 6.0 (12.0) | 1.0 (2.0) | 0.0 (0.0) | ||
| Sometimes | 61.0 (17.4) | 135.0 (38.5) | 106.0 (30.2) | 41.0 (11.7) | 8.0 (2.3) | ||
| About half the time | 6.0 (10.5) | 23.0 (40.4) | 22.0 (38.6) | 5.0 (8.8) | 1.0 (1.8) | ||
| Most of the time | 8.0 (6.1) | 33.0 (25.2) | 69.0 (52.7) | 19.0 (14.5) | 2.0 (1.5) | ||
| Always | 13.0 (10.4) | 36.0 (28.8) | 43.0 (34.4) | 24.0 (19.2) | 9.0 (7.2) | ||
| Knowledge of consent laws | |||||||
| Characteristic | Not at all N = 123 (%) |
Slightly N = 257 (%) |
Moderately N = 228 (%) |
Very N = 86 (%) |
Extremely N = 20 (%) |
P | |
| Frequency of confidential adolescent care | <0.001 | ||||||
| Never | 17.0 (34.0) | 26.0 (52.0) | 6.0 (12.0) | 1.0 (2.0) | 0.0 (0.0) | ||
| Sometimes | 66.0 (18.8) | 144.0 (41.0) | 95.0 (27.1) | 38.0 (10.8) | 8.0 (2.3) | ||
| About half the time | 6.0 (10.5) | 22.0 (38.6) | 20.0 (35.1) | 6.0 (10.5) | 3.0 (5.3) | ||
| Most of the time | 14.0 (10.7) | 32.0 (24.4) | 63.0 (48.1) | 19.0 (14.5) | 3.0 (2.3) | ||
| Always | 20.0 (16.0) | 33.0 (26.4) | 44.0 (35.2) | 22.0 (17.6) | 6.0 (4.8) | ||
With respect to knowledge of state laws governing an adolescent’s right to consent to care, most of the respondents reported moderate or slight knowledge (32% and 36%, respectively) (Table 4). PGY-1 residents were more likely to report no knowledge of confidentiality or consent laws, as compared with PGY-2 and PGY-3 residents (Table 5).
Table 5.
Self-reported knowledge of state laws
| Not at all (%) | Slightly (%) | Moderately (%) | Very (%) | Extremely (%) | |
|---|---|---|---|---|---|
| Self-reported knowledge of confidentiality laws | |||||
| PGY-1 | 53(18.3) | 113 (39.1) | 98 (33.9) | 21(7.3) | 4 (1.4) |
| PGY-2 | 27 (13.0) | 77 (37.0) | 70 (33.7) | 26 (12.5) | 8 (3.8) |
| PGY-3 | 26 (12.0) | 62 (28.6) | 78 (35.9) | 43 (19.8) | 8 (3.7) |
| Self-reported knowledge of consent laws | |||||
| PGY-1 | 61(21.1) | 119 (41.2) | 84 (29.1) | 20 (6.9) | 5 (1.7) |
| PGY-2 | 30 (14.4) | 80 (38.5) | 64 (30.8) | 28 (13.5) | 6 (2.9) |
| PGY-3 | 32 (14.7) | 58 (26.7) | 80 (36.9) | 38 (17.5) | 9 (4.1) |
PGY, postgraduate year.
Some of the reported barriers to providing confidential healthcare services to adolescents include lack of access, insufficient time, lack of physician, patient, and parent education/awareness, cultural limitations, billing and cost issues, and inconsistent state laws (Appendix 1, [COMP: INSERT SDC1 URL HERE]).A
Discussion
We found that resident comfort with confidential adolescent health care was greater for those who receive formal or informal training. In addition, as residents move through their training, comfort levels rise. Despite this, nearly one-fourth of PGY-3 respondents who reported receiving formal (24.8%) and informal (21.1%) training during their residency still felt “somewhat or extremely uncomfortable” with confidential adolescent care. Future work characterizing the experiences of those with high levels of comfort would be helpful to enhance training in this area. Longitudinal studies exploring the impact of training and comfort on future practice also may be worthwhile. In addition, a small but significant percentage of respondents reported that they were uncertain whether they received training during residency. To clarify training status and methods, surveys of residency program faculty about curricula would need to be conducted.
Variations in training and laws governing the provision of care to adolescents may explain the differences in resident comfort with confidential adolescent health care noted in this study. Informal resident training in adolescent care varies widely because ultimately it may be determined by the population served by individual residency programs.18 Although guidance exists for pediatric training experiences,11 the minimum time (at least 200 h) dedicated to the care of children in the ambulatory setting does not delineate what portion of these experiences should be for adolescents.
Similarly, the ACGME does not provide specific recommendations to guide or hold Family Medicine residency programs accountable for their adolescent care curricula.19 Programs might consider the introduction of standardized patients, targeted objective structured clinical examinations, or other clinical exposures to supplement training in this domain. Educational efforts to enhance all stages of training in providing well adolescent care (medical school and residency), revising minimum standards by the ACGME, and establishing standardized competency-based assessments during training may help address low comfort levels among residents and improve future care provision.20
Existing studies suggest that healthcare providers refrain from discussing confidential care with adolescents due to inadequate training, which may influence their frequency of providing such care.5,14–16 Our study supports these findings, because we discovered that participants were more likely to offer confidential care to adolescents more frequently if they reported receiving formal or informal training during residency. A similar pattern was noted regarding whether responders received any (formal or informal) training about confidential adolescent care in medical school and the frequency of confidential adolescent care. The higher percentage of residents in each group that “always” offer care or offer care “most of the time” suggests that formal and informal training corresponds positively with a higher frequency of providing confidential adolescent health care in residency and medical school settings.
Current study findings indicate that a low number of residents were knowledgeable about the laws governing confidential adolescent care and self-consenting in their states. This result is reflective of the study by Riley et al, who reported that 76.6% of primary care providers believed that they lacked adequate training regarding adolescent healthcare confidentiality policy and law, which correlates inversely with the frequency of providing confidential care and comfort level.21 A notable barrier to the standardization of adolescent health care includes the immense variation in state laws with respect to confidentiality and consenting to care.22–24 State laws also vary depending on the kind of health care being sought by an adolescent. For instance, there are not only variations among states with respect to confidentiality in sexual and reproductive health but also within states for confidentiality and consent related to mental health care.25 According to Sharko et al, among the adolescent healthcare services studied, no two states had identical laws or policies governing the care of adolescents.10 Unfortunately, when it comes to adolescent consent and confidentiality, clinicians receive little training about the laws and policies of their states.9,14–16 The result may be an avoidance of discussions about confidentiality or even an avoidance of seeing adolescents without the presence of parents/guardians.9,10
Although providing confidential care to adolescents has been championed and supported by several national medical societies,22 compliance with such evidence-based guidelines can be extremely hampered by the necessity to follow state laws or, worse, by a lack of clinician knowledge of their own state laws. As such, it is incumbent upon clinicians to learn, maintain, and teach accurate and up-to-date knowledge of the laws governing adolescent confidentiality and consent in their state. By the same token, clinicians also should be aware of and knowledgeable about federal laws that allow for confidential adolescent care, including the Health Insurance Portability and Accountability Act, Title X, the Substance Abuse and Mental Health Services Administration, and Medicaid.22 This is especially important for clinician teachers, given the current political environment, in which laws are often fluctuating and being altered.10,24 Moreover, academic departments and their institutions should work to establish training and policies that facilitate clinician awareness and clear knowledge of state laws. In fact, clinicians and their institutions already may be among those best positioned to protect adolescents by effecting best practices in training and education programs as well as in clinical workflows.9
Among the limitations of this study is the relatively low response rate of 5%. This low response rate likely reflects the single recruitment method and electronic strategy. Higher response rates may have been achieved by using monetary incentives, multiple recruitment methods, and additional data collection methods, such as paper mailings.26 Furthermore, the volunteer sampling method used for participant selection may have introduced selection bias, and thus the generalizability of our findings is limited. In addition, although results showed that residents who receive formal or informal training were more comfortable providing adolescent health care and were more likely to conduct time alone with adolescents than those who did not receive training, the specific type of training received was not explored. Lastly, our findings are limited by the cross-sectional design, the inability to assess the adolescent educational content of residency programs, and the potential for recall bias.
Conclusions
There is significant variability in the knowledge and comfort of family physicians with respect to confidential adolescent healthcare.12 Unfortunately, our study data also suggest that training focused on confidential adolescent health care is sparse, because more than half of respondents reported no such training during residency. Expanding capacity for confidential care through enhanced medical school and residency education has the potential to improve health outcomes for adolescents, and establishing effective training modalities for medical trainees may achieve this goal. Although study participants reported being more confident in providing adolescent care as they advance throughout their training, formal education in residency may further promote confidential adolescent healthcare and, in addition, knowledge of state laws governing such care. Family Medicine residency represents an ideal opportunity to train the physicians of the future to provide better care for adolescents. This study highlights the need to provide more enhanced training for Family Medicine residents about confidential adolescent health care. The ultimate goal is to provide better, more equitable health care for our adolescent patients.
Supplementary Material
Key Points.
Confidentiality and the ability of adolescents to self-consent to health care without parental involvement may encourage them to seek healthcare services promptly.
Healthcare providers should offer confidential services to adolescents to encourage the discussion of sensitive topics related to sexual and reproductive health, substance use, and mental health.
Significant variability exists in primary care clinicians’ knowledge and comfort regarding confidentiality in adolescent health care.
Acknowledgments
D.N.C. is required to make it known that 70% of her work effort is funded by a grant from the National Institutes of Health (NIH). The work to participate in this study conception, data analysis, data interpretation, and manuscript writing was completed during that 70% of time that is supported by the NIH. The NIH directly pays her institution for her time. She is required by the NIH to disclose this information for any publications per their open access publication policy. She also has received compensation from the University of California, San Francisco and the Contraceptive Access Initiative. Under “Public Access Policy” Funding Disclosure, lists National Institutes of Health (NIH). The remaining authors did not report any financial relationships or conflicts of interest.
Footnotes
Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (http://sma.org/smj).
References
- 1.Alderman EM, Breuner CC; Committee on Adolescence. Unique needs of the adolescent. Pediatrics 2019;144:e20193150. [DOI] [PubMed] [Google Scholar]
- 2.US Department of Health & Human Services Office of Population Affairs. America’s diverse adolescents. https://opa.hhs.gov/adolescent-health/adolescent-health-facts/americas-diverse-adolescents#:~:text=Number%20of%20Adolescents,12.8%20percent%20of%20the%20population.&text=As%20the%20U.S.%20population%20ages,proportion%20of%20the%20total%20population. Accessed May 20, 2022.
- 3.World Health Organization. Adolescent health. https://www.who.int/health-topics/adolescent-health#tab=tab_1. Accessed May 20, 2022.
- 4.US Department of Health and Human Services. Adolescent health. Healthy People 2020. https://wayback.archive-it.org/5774/20220413181755/https://www.healthypeople.gov/2020/topics-objectives/topic/Adolescent-Health. Accessed May 20, 2022.
- 5.Kaiser Family Foundation. Adolescent health: coverage and access to care. https://www.kff.org/womens-health-policy/issue-brief/adolescent-health-coverage-and-access-to-care. Published September 30, 2011. Accessed May 20, 2022.
- 6.Society for Adolescent Health and Medicine; American Academy of Pediatrics. Confidentiality protections for adolescents and young adults in the health care billing and insurance claims process. J Adolesc Health 2016;58:374–377. [DOI] [PubMed] [Google Scholar]
- 7.American Academy of Family Physicians. Adolescent health care, confidentiality. https://www.aafp.org/about/policies/all/adolescent-confidentiality.html. Accessed December 24, 2023.
- 8.Confidentiality in adolescent health care. ACOG Committee Opinion, number 803. Obstet Gynecol 2020;135:e171–e177. [DOI] [PubMed] [Google Scholar]
- 9.Pathak PR, Chou A. Confidential care for adolescents in the U.S. health care system. J Patient Cent Res Rev 2019;6:46–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Sharko M, Jameson R, Ancker JS, et al. State-by-state variability in adolescent privacy laws. Pediatrics 2022;149:e2021053458. [DOI] [PubMed] [Google Scholar]
- 11.American Academy of Family Physicians. Adolescent health: recommended curriculum guidelines for family medicine residents in adolescent health. https://www.aafp.org/content/dam/AAFP/documents/medical_education_residency/program_directors/reprint278-adolescent-health-2023.pdf. Accessed April 25, 2022.
- 12.Kershnar R, Hooper C, Gold M, et al. Adolescent medicine: attitudes, training, and experience of pediatric, family medicine, and obstetrics-gynecology residents. Yale J Biol Med 2009;82:129–141. [PMC free article] [PubMed] [Google Scholar]
- 13.Klein D, Mehta K. Training in adolescent health: how much have second-year residents had? Can Fam Physician 2006;52:980–981. [PMC free article] [PubMed] [Google Scholar]
- 14.Ford CA, Thomsen SL, Compton B. Adolescents’ interpretations of conditional confidentiality assurances. J Adolesc Health 2001;29:156–159. [DOI] [PubMed] [Google Scholar]
- 15.Ford CA, Millstein SG, Halpern-Felsher BL, et al. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. A randomized controlled trial. JAMA 1997;278:1029–1034. [PubMed] [Google Scholar]
- 16.Ford CA, Millstein SG. Delivery of confidentiality assurances to adolescents by primary care physicians. Arch Pediatr Adolesc Med 1997;151:505–509. [DOI] [PubMed] [Google Scholar]
- 17.Setia MS. Methodology series module 9: designing questionnaires and clinical record forms. Part II. Indian J Dermatol 2017;62:258–261. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Krugman S, Hodo LN, Morgan ZJ, et al. Challenges meeting training requirements in the care of children in family medicine residency programs: a CERA study. Fam Med 2023;55:238–244. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in family medicine. https://www.acgme.org/globalassets/pfassets/programrequirements/120_familymedicine_2023.pdf. Accessed September 2, 2023
- 20.Barr WB, Stutzman K. Changing gears: family medicine residencies transitioning to competency-based medical education (CBME) framework with the new ACGME FM program requirements. Ann Fam Med 2023;21:285–286. [Google Scholar]
- 21.Riley M, Ahmed S, Reed BD, et al. Physician knowledge and attitudes around confidential care for minor patients. J Pediatr Adolesc Gynecol 2015;28:234–239. [DOI] [PubMed] [Google Scholar]
- 22.Maslyanskaya S, Alderman EM. Confidentiality and consent in the care of the adolescent patient. Pediatr Rev 2019;40:508–516. [DOI] [PubMed] [Google Scholar]
- 23.Cornell Law School, Legal Information Institute. Emancipation of minors – laws. Laws of the fifty states, District of Columbia and Puerto Rico governing the emancipation of minors. https://www.law.cornell.edu/wex/table_emancipation. Accessed August 25, 2023.
- 24.Guttmacher Institute. An overview of consent to reproductive health services by young people. https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law. Accessed August 25, 2023.
- 25.Kerwin ME, Kirby KC, Speziali D, et al. What can parents do? A review of state laws regarding decision making for adolescent drug abuse and mental health treatment. J Child Adolesc Subst Abuse 2015;24:166–176. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Ericson A, Bonuck K, Green LA, et al. Optimizing survey response rates in graduate medical education research studies. Fam Med 2023;55:304–310. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.