Pediatric Emergency Physicians’ Knowledge, Attitudes, and Behaviors Regarding Confidential Adolescent Care

Abstract

Objectives

Over 19 million adolescents seek care in the emergency department (ED) annually. We aimed to describe the knowledge, attitudes, and behaviors related to confidential adolescent care among pediatric ED physicians.

Methods

We conducted a cross-sectional questionnaire of U.S. physician members of the Pediatric Emergency Medicine Collaborative Research Committee survey listserv. The 24-item questionnaire assessed familiarity with adolescent confidentiality laws, attitudes towards providing confidential care, frequency of discussing behavioral health topics confidentially, and factors influencing the decision to provide confidential care. We dichotomized Likert responses and used chi-square to compare subgroups.

Results

Of 476 eligible physicians, 151 (32%) participated. Most had completed pediatric emergency medicine fellowship (91.4%). More participants reported familiarity with all sexual health related laws compared to all mental health related laws (64% vs. 49%, p < 0.001). The median age at which participants thought it was important to begin routinely providing confidential care was 12 years; 9% thought confidential interviews should not be routinely conducted until older adolescence or at all. Their decision to provide confidential care was influenced by: chief complaint (97%), time (43%), language (24%), presence of family (23%) or friends (14%), and space (22%).

Conclusions

Respondents reported moderate familiarity with adolescent confidentiality laws. While they viewed confidential care as something they were comfortable providing, the likelihood of doing so varied. Barriers to confidential care were influenced by their assessment of adolescents’ behavioral health risk, which may contribute to health inequity. Future efforts are needed to develop strategies that augment confidential ED care for adolescents.

Introduction

Confidentiality is a central tenet of adolescent health care. Under the Health Insurance Portability and Privacy Act of 1996, adolescents have the right to confidentiality in their medical care and decision making concerning sexual and reproductive health, mental health, and substance use.¹ This right to consent and privacy is supported by the Society for Adolescent Health and Medicine, the American Academy of Pediatrics, and the American College of Emergency Physicians.^2–4

Efforts to improve confidential adolescent health care have focused primarily on outpatient clinical settings, such as primary care and school-based health clinics.⁵ However, there is growing recognition of the important role that emergency departments (EDs) can play in adolescent health care.^6,7 Over 19 million adolescents seek care in the emergency department (ED) annually. Although the traditional role of the ED is to respond to immediate, emergency conditions, a substantial proportion of the population has inadequate access to high-quality primary care, and the role of the ED in addressing important public health concerns is increasingly recognized.^8–10 Adolescents access the ED frequently for a variety of health care complaints, and each interaction represents an opportunity to address behavioral health risks and concerns.⁶ Adolescents who utilize the ED for non-urgent health care issues often do not have the resources and support to navigate behaviors that have the potential to negatively impact their health.¹¹ Further, they may otherwise encounter few other opportunities to engage with health care professionals. These adolescents are less likely to identify a primary care provider, less likely to have been seen for preventive health visits, and have higher risk of unintended pregnancy, sexually transmitted infection, substance use, and mental health crises.^11–14 Importantly, adolescents are interested in and willing to receive care regarding these medical issues in the ED.^15–20 For adolescents who use the ED as their usual or only source of care, this is an important avenue in which the ED can promote health equity.²¹

Defining best practices regarding confidential care for adolescents in emergency settings is an important pediatric research priority.⁶ We conducted a cross-sectional questionnaire study to assess physician 1) attitudes towards confidential adolescent health care in the ED, 2) behaviors in providing confidential adolescent health care in the ED, and 3) familiarity with and knowledge of respective state laws regarding adolescent consent and confidentiality.

Materials and Methods

Study Design and Population

This was a descriptive cross-sectional electronic questionnaire study of members of the Pediatric Emergency Medicine Collaborative Research Committee (PEM CRC) survey listserv. The PEM CRC is a subcommittee of the American Academy of Pediatrics Section on Emergency Medicine. Members who volunteer to participate in the PEM CRC survey listserv receive 3–4 electronic questionnaires annually, each of which is evaluated and selected for distribution by the PEM CRC Survey Subcommittee. Listserv members were eligible to participate if they were physicians (MD or DO) who practiced in an emergency or urgent care setting in the United States (n = 476). This can include PEM, general emergency medicine, or general pediatric medical providers.

Our questionnaire was administered via REDCap (Research Electronic Data Capture, Nashville, TN)²² and took less than 10 minutes to complete. Listserv members received an email with a unique link to complete the questionnaire. Questionnaire responses were collected anonymously and contained no individual identifiers. One reminder email per month was sent to those who had not yet participated during the study period from March 1, 2022 – May 31, 2022. The study was approved by the Institutional Review Board at the University of Florida.

Questionnaire Development

The questionnaire was designed by a panel of five pediatric emergency medicine physicians with expertise in adolescent health (CKG, AK, MP, SH, LC). Items were adapted from published studies assessing physician knowledge, attitudes, and behaviors regarding adolescent health care.^23–26 The questionnaire was reviewed and pilot tested by nine additional members of the Pediatric Emergency Care Applied Research Network Adolescent Sexual Health Working Group and critically revised based on open-ended feedback regarding clarity, readability, content, and completeness. The questionnaire was additionally reviewed by the 10 member PEM CRC Survey Subcommittee, with final approval after two rounds of critical revisions.

The final questionnaire consisted of 24 closed-ended items and one allowing a free text ‘other’ response (Appendix A). Items on the questionnaire evaluated participant knowledge, attitudes, and behaviors related to confidential care of adolescents in the ED. Knowledge items assessed the participants’ familiarity with their state’s minor consent laws regarding the provision of sexual and mental health care. Sexual health topics included those related to contraception, sexually transmitted infections, and pregnancy. Mental health topics included those related to mental health and substance use. To assess physician attitudes and behaviors, participants were asked to identify the age at which it is important to begin routinely conducting confidential interviews with adolescents, the frequency which with they discussed sexual and mental health topics confidentially with adolescents, and the factors that influence their decision to conduct a confidential interview with an adolescent.

Participants were presented with two parallel clinical scenarios: Scenario 1 involved an ED visit for a 16-year-old female presenting with abdominal pain, and Scenario 2 involved an ED visit for a 16-year-old male presenting with an ankle sprain. For each scenario, participants were provided with Likert responses to provide their perception of the importance of interviewing the adolescent confidentially, their comfort asking the parent to step out of the room for and conducting a confidential interview with the adolescent, and the likelihood that they or a member of their medical team would conduct a confidential interview with the adolescent.

Analysis

Data were analyzed with descriptive statistics, including frequencies and proportions for categorial variables, median and interquartile range for non-normally distributed continuous variables, and chi-square for comparisons between dichotomous variables. Likert responses were dichotomized, and, in the case of five-point scales, the “neither” response was grouped with the negative responses (“Disagree”/”Unlikely” and “Strongly Disagree”/”Very Unlikely”). A p-value <0.05 was considered statistically significant. All data analyses were performed using R Statistical Software (v4.2.1; R Core Team 2022).

Results

One hundred and fifty-one eligible physicians completed the questionnaire (32% response rate). The demographic characteristics of the respondents are shown in Table 1. Respondents practiced in 32 states and the District of Columbia. Half were female, and half were older than 50 years old. Most respondents worked in a pediatric ED (97%), in an urban setting (89%), and/or in university-affiliated hospital (95%). The majority had completed a pediatrics residency followed by a pediatric emergency medicine fellowship (91%) and provided emergency care for adolescent patients at least once a week (89%).

Table 1.

Characteristics of Physician Respondents

	Physician Characteristics n = 151 (%)
Demographics
Age
30–40 years old	33 (21.9)
41–50 years old	47 (31.1)
51 years or older	71 (47.0)
Gender1
Female	80 (53.0)
Male	71 (47.0)
U.S. Census Region
South	37 (24.5)
Midwest	38 (25.2)
Northeast	47 (31.1)
West	29 (19.2)
Clinical Experience & Practice
Residency Specialty
Pediatrics	144 (95.4)
Emergency Medicine	2 (1.3)
Combined Pediatrics and Emergency Medicine	5 (3.3)
Fellowship Training
None	7 (4.6)
Current pediatric emergency medicine fellow	3 (2.0)
Completed pediatric emergency medicine fellowship	128 (91.4)
Completed other fellowship	3 (2.0)
Years of Experience After Residency
Five or fewer	8 (5.3)
Six to ten	30 (19.9)
More than ten years	113 (74.8)
Practice Setting2,
Urban	135 (89.4)
Suburban	23 (15.2)
Rural	1 (0.7)
University Affiliated ED
Yes	141 (93.4)
No	10 (7.6)
Type of ED2
General ED	6 (4.0)
Pediatric ED	146 (96.7)
Annual Pediatric Patient Volume
Less than 20,000	12 (8.0)
20,000 – 39,999	34 (22.5)
40,000 – 59,999	28 (18.5)
More than 60,000	71 (47.0)
Don’t Know	6 (4.0)
Average hours spent working clinically,
Fewer than 15 hours per week	49 (32.5)
15 – 30 hours per week	82 (54.3)
More than 30 hours per week	20 (13.3)
Frequency providing care for adolescent patient in ED
Less than once per month	1 (0.7)
Two or three times per month	3 (2.0)
Once per week	13 (8.6)
More than once per week	134 (88.7)

¹Available options which were not selected by any participants included non-binary, genderqueer, transgender female, transgender male, prefer to self-describe

²Participants had the opportunity to select more than one response

Knowledge

Respondents reported overall high familiarity with state laws related to adolescent confidentiality (Figure 1). Familiarity varied by topic, with a higher proportion of participants reporting familiarity with all sexual health related laws compared to all mental health related laws (64% vs. 49%, p < 0.001).

Figure 1.

Self-reported familiarity with state laws regarding confidential adolescent care.

Attitudes

The median age at which respondents thought it was important to routinely conduct confidential interviews was 12 years old (interquartile range 12–13 years, Table 2). A minority of respondents thought that confidential interviews should not be routinely conducted until older adolescence (age 15 or 16, 4%) or at any age in the PED (5%).

Table 2.

Participant Attitudes and Behaviors Regarding Confidential Interviews with Adolescents During Visits to the Emergency Department

	Responses n = 151 (%)
Age at which it is important to routinely conduct confidential interviews
11	0
12	65 (43.1)
13	52 (34.4)
14	8 (5.3)
15	2 (1.3)
16	4 (2.7)
17	0
I do not think that speaking confidentially to minor patients during an ED visit is routinely needed	8 (5.3)
Scenario 1: A 16 year old female presents for evaluation of abdominal pain. She is here with her parent.
It is important that this adolescent be interviewed confidentially.
Strongly Disagree	2 (1.3)
Disagree	0
Neither	2 (1.3)
Agree	25 (16.6)
Strongly Agree	122 (80.8)
I am comfortable asking the parent to step out of the room.
Strongly Disagree	0
Disagree	2 (1.3)
Neither	1 (0.7)
Agree	29 (19.2)
Strongly Agree	119 (78.8)
I am comfortable interviewing this adolescent confidentially.
Strongly Disagree	1 (0.7)
Disagree	0
Neither	0
Agree	25 (16.6)
Strongly Agree	125 (82.8)
In general, how likely would it be that you (or a member of your medical team) would interview this adolescent confidentially?
Very Unlikely	0
Unlikely	0
Neither	3 (2.0)
Likely	38 (25.2)
Very Likely	110 (72.9)
Scenario 2: A 16 year old male presents for evaluation of an ankle injury he sustained while participating in after-school sports. He is here with his parent.
It is important that this adolescent be interviewed confidentially.
Strongly Disagree	9 (6.0)
Disagree	47 (31.1)
Neither	61 (40.4)
Agree	24 (15.9)
Strongly Agree	10 (6.6)
I am comfortable asking the parent to step out of the room.
Strongly Disagree	2 (1.3)
Disagree	9 (6.0)
Neither	16 (10.6)
Agree	50 (33.1)
Strongly Agree	74 (49.0)
I am comfortable interviewing this adolescent confidentially.
Strongly Disagree	1 (0.7)
Disagree	2 (1.3)
Neither	4 (2.7)
Agree	51 (33.8)
Strongly Agree	93 (61.6)
In general, how likely would it be that you (or a member of your medical team) would interview this adolescent confidentially?
Very Unlikely	33 (21.9)
Unlikely	60 (39.7)
Neither	30 (19.9)
Likely	17 (11.3)
Very Likely	11 (7.3)

Attitudes regarding the importance of conducting a confidential interview differed for each clinical scenario (Table 2; Scenario 1: female adolescent with abdominal pain; Scenario 2: male adolescent with ankle injury;). Eighty-one percent of respondents strongly agreed that the adolescent in Scenario 1 should be interviewed confidentially. Respondents were more likely to agree that it was important to interview the adolescent alone for Scenario 1 compared to Scenario 2 (97% vs. 23%, p < 0.001).

Behaviors

In the hypothetical clinical scenarios, respondents reported higher likelihood of conducting a confidential interview with the female adolescent with abdominal pain in Scenario 1 compared to the male adolescent with an ankle injury in Scenario 2 (97% vs 19%, p < 0.001). Table 3 shows the frequency with which respondents reported that they confidentially discuss sexual and mental health topics with adolescents. When asked to select factors that influence their decision of whether to conduct a confidential interview with an adolescent, the majority selected the presenting chief complaint (97%), followed by time (43%), the presence of a language barrier (24%), the presence of family members (23%) or friends (14%), and space (22%). Discomfort with conducting a confidential interview with the adolescent was selected by a minority (2%). Participants who elected to include a free text response reported being influenced by elements of the interaction (n=2: non-verbal cues, appearance of holding back information; n=2: other information during the history or exam), by the adolescent’s willingness or preference to be interviewed confidentially (n=2), and by universal adolescent screening tools integrated into ED care (n=2).

Table 3.

Participant reported frequency of confidentially discussing adolescent health topics during an emergency department visit

	Frequency1, No. (%)
	Never	Rarely	Sometimes	Often	Always
Sexual Health	0	0	26 (17.2)	100 (66.2)	25 (16.6)
Mental Health	0	1 (0.7)	33 (21.9)	79 (52.3)	38 (25.2)
Alcohol Use	1 (0.7)	6 (4.0)	49 (32.5)	76 (50.3)	19 (12.6)
Substance Use	0	5 (3.3)	43 (28.5)	84 (55.6)	19 (12.6)

¹Frequency in which the topic is discussed confidentially with adolescent patients by the participant or a member of their team (any combination of medical student, resident, fellow, attending, advanced practice provider [nurse practitioner, physician’s assistant] and/or nurse with whom the participant works to care for the patient).

Discussion

In this cross-sectional questionnaire study of pediatric emergency medicine physicians, participants reported moderate familiarity with adolescent confidentiality laws and high levels of comfort with providing adolescent confidential care, yet self-reported attitudes and behaviors towards providing confidential care to adolescents in the ED were suboptimal. Our findings have important implications for efforts to improve adolescent health during ED visits.

In order to support physicians in providing equitable confidential care during adolescent ED visits, there is a clear need to improve pediatric ED physician familiarity with, and likely knowledge of, state laws regarding confidentiality. Confidentiality laws vary by state, are subject to change, may be difficult to find, and can contain complex nuances that are challenging to interpret.²⁷ This presents a meaningful challenge to physicians who aim to remain up to date in their practice. That a substantial proportion of participants had little to no familiarity with their state’s laws regarding confidential mental health care is of particular importance in the context of the rising number of adolescent ED visits for mental health crises.^28,29 For those working in institutions with adolescent medicine specialists or with access to adolescent medicine, this may be an area of interdisciplinary collaboration. While our study did not explore physician knowledge, attitudes, and behaviors regarding confidentiality around topics such as abortion, and gender identity, this becomes increasing important given rapidly changing legislation. There is a critical need to further explore these issues as states introduce and pass legislation that has the potential to not only physically harm patients but also criminalize patients, families, and the physicians who care for them.^30–32

Among sexual health topics, familiarity with confidentiality laws for contraceptive services was lowest. While not a traditional “emergency” intervention, same-day contraception initiation in the ED is acceptable to both adolescents and providers.^7,20,33 Additionally, emergency contraception is time sensitive and should be considered an urgent intervention to prevent unplanned pregnancy. Utilizing the ED visit as an opportunity to prevent unintended adolescent pregnancy is of paramount importance in the context of increasing barriers to sexual and reproductive health care in many parts of the United States. However, advancing such essential health care for adolescents in the ED is only possible if providers are aware of the local laws regarding adolescents’ rights to confidential care.

It is notable that a quarter of respondents reported that it was “likely”, rather than “very likely”, that they (or a member of their team) would conduct a confidential interview with an adolescent female presenting with abdominal pain. The high rate of agreement with this statement is expected, given the possibility of a sexual health related diagnosis, yet the degree of agreement suggests that, even with a chief complaint that indicates possible gynecologic concerns, confidential care is not always provided. This inaction risks missing important potential diagnoses. Although tests to assess for pregnancy, sexually transmitted infections, and drug use are often ordered without the adolescent’s knowledge, adolescent autonomy, consent, and right to decline testing should be considered when ordering such tests.^34,35 To ensure the adolescent understands the rationale for recommending such tests and to respect the adolescent’s autonomy, confidential interviews are critical when the ED provider deems such tests are indicated.

Our findings have important implications for health equity. First, similar to prior studies, we found that language barriers impact whether ED physicians provide confidential care to adolescents.³⁶ Denying confidential care for adolescents who use languages other than English propagates health inequities. This demonstrates the clear need to understand and develop best-practices for providing confidential adolescent care with professional interpreting. Second, prior studies have also found that barriers to confidential conversations in the ED include individual provider skill in conducting confidential interviews, as well as systems level barriers, including access to resources such as social work and time and space to confidentially interview adolescents.³⁶ In our sample, however, time and space were selected as barriers by a minority of respondents, and comfort with performing confidential interviews was high. Instead, the factors that respondents indicated influenced their decision to conduct a confidential interview were primarily informed by their interaction with the adolescent. This included the adolescent’s chief complaint, language for medical care, the presence of other individuals with the patient, and an assessment of nonverbal cues. There is a risk for bias, and the potential to propagate health disparities, when the decision to perform a confidential interview depends on the physician’s subjective degree of concern for a behavioral health risk factor.^37–40 Implicit racial and gender bias is evident in adolescent sexual health care in the ED: adolescent females, and in particular, Black adolescent females, are more likely to have a sexual history documented in their ED chart and more likely to be tested for sexually transmitted infections, even when presenting with similar chief complaints.^21,41–43 Our study identifies elements of the physician assessment that may be influenced by biases and lead to differential care provision and health inequity.

Routine screening for behavioral health needs may reduce individual bias while simultaneously increasing the delivery of effective sexual and mental health services during adolescent ED visits.^41,44–46 There is a need to better understand when, how, and with whom ED-based adolescent health interventions are most effective. Further, it is essential that such screening tools be developed and implemented with an intentional focus on equity, so as to not instead worsen inequities and health outcomes.⁴⁷ Finally, for adolescents with sexual and mental health needs identified through such screening tools, there must be well-established processes that then facilitate confidential conversations and documentation in the medical record, as well as shared decision-making between the adolescent and provider regarding the next steps of evaluation, management, and transition to an outpatient medical home.

Limitations

Our study is subject to several limitations. First, our response rate is 32%, and we are unable to characterize non-respondents. Given that our participants represent those who were motivated to answer such a survey from within a sample of primarily academic subspecialty trained pediatricians, our findings may overestimate familiarity with and behaviors regarding adolescent confidentiality in most emergency settings. Additionally, our study did not include myriad other providers, including general community-based emergency medicine physicians and advanced practice providers, who may not have dedicated training in adolescent health but who provide care for most adolescents seeking emergency care in the United States. Second, our results rely on self-report, not actual knowledge and behaviors; such results can be affected by social desirability and recall bias. Third, we analyzed our data on dichotomized Likert variables, which may have lost some of the granularity of the discrete Likert responses and may limit future validation. Finally, in order to keep the questionnaire short and feasible to complete, we did not include hypothetical scenarios in which the gender and chief complaint were reversed; such data might have allowed for a more nuanced understanding of how each of these distinct factors influences physician behaviors.

Conclusion

Pediatric ED physicians reported moderate familiarity with adolescent confidentiality laws. Physicians viewed confidential care as something they were comfortable providing yet the likelihood of doing so was suboptimal. Physicians acknowledged barriers to confidential care that were influenced by their assessment of adolescents’ behavioral health risk, which may contribute to health inequity. Future efforts are needed to enhance physician knowledge of adolescent legal rights to confidentiality and to develop strategies that augment the equitable provision of confidential care for adolescents in the pediatric ED.