Advancing Training in Advancing Training in Adolescent Medicine Adolescent Medicine for upgrading the for upgrading the quality of health care quality of health care for Adolescentsfor Adolescents

Christos Kattamis M.D.Christos Kattamis M.D.Emeritus Professor of PediatricsEmeritus Professor of Pediatrics

Athens University, School of Athens University, School of MedicineMedicine

4th Joint Meeting on Adolescent MedicineCatanzaro 12-14 October 2010

Main Objective of Main Objective of PediatricsPediatrics

The concern of the health of The concern of the health of infants, children and youths, infants, children and youths, their growth and development their growth and development and their opportunity to achieve and their opportunity to achieve full potential as adults. full potential as adults.

Nelson’s Textbook of Pediatrics

Definition of AdolescenceDefinition of Adolescence(Derives from the latin word adolescere meaning grow into (Derives from the latin word adolescere meaning grow into

maturity)maturity)

««Adolescence refers to the stage of Adolescence refers to the stage of human development encompassing human development encompassing the transition from childhood to the transition from childhood to adulthood. Is broader than puberty, adulthood. Is broader than puberty, the period of biological changes and the period of biological changes and sexual maturation, including in sexual maturation, including in addition the period of psychological addition the period of psychological and sociocultural dimensions of and sociocultural dimensions of developmental maturationdevelopmental maturation»»

Factors influencing Factors influencing prolongation of transmission prolongation of transmission

periodperiod Extreme changes in cultural and socioeconomic Extreme changes in cultural and socioeconomic conditions of modern societiesconditions of modern societies

Relevant favoring factorsRelevant favoring factors Increase affluence Increase affluence Prolonged education periodProlonged education period Structure change in family, school, societyStructure change in family, school, society Socioeconomic-environmental conditionsSocioeconomic-environmental conditions

Comment: Prolonged adolescence created new health Comment: Prolonged adolescence created new health problems for adolescents (rise in psychosocial mental problems for adolescents (rise in psychosocial mental disorders, substance misuse, antisocial disorders and disorders, substance misuse, antisocial disorders and others)others)

WHO TerminologyWHO Terminology

Adolescents: People aged 10-19 yearsAdolescents: People aged 10-19 years Youth: People aged 15-24 years Youth: People aged 15-24 years Young people: People aged 10-24 years Young people: People aged 10-24 years

Adolescence subgroupsAdolescence subgroups Early: 8-11 years Early: 8-11 years Middle: 12-16 years Middle: 12-16 years Late: 17-20/24 yearsLate: 17-20/24 years

Adolescence period in literatureAdolescence period in literature: : 10-19; 12-19; 12-24; 15-24 yrs and other10-19; 12-19; 12-24; 15-24 yrs and other

Adolescents Population (10-Adolescents Population (10-24ys) worldwide24ys) worldwide

Total: 1.75 billions Total: 1.75 billions

In developing countries: 1.5 billions In developing countries: 1.5 billions

In least developed nations: more than In least developed nations: more than one third of population one third of population

The poorer the country the younger its The poorer the country the younger its population, and the higher the mortality population, and the higher the mortality and morbidity ratesand morbidity rates

Diseases with increasing Diseases with increasing morbidity rates in America’s morbidity rates in America’s

AdolescentsAdolescents Sexually Transmitted Sexually Transmitted

DiseasesDiseases

Mental Health ConditionsMental Health Conditions

ObesityObesity

Substance abuse or Substance abuse or substance depended substance depended disordersdisorders

26%26%

21%21%

16%16%

8%8%

Fundamental Principles Fundamental Principles incorporated in Lancet’s papers incorporated in Lancet’s papers for adolescent health care for adolescent health care (8)(8)

Rapidly change of social context created Rapidly change of social context created new and unexpected priorities new and unexpected priorities

Health and ill health are better Health and ill health are better understood as a result of complex understood as a result of complex interplay between biological, interplay between biological, psychological and sociological factorspsychological and sociological factors

Sociological factors have global reach in Sociological factors have global reach in their effect on young peopletheir effect on young people

Topics for discussionTopics for discussion

The demography of adolescents health The demography of adolescents health care in Europe and other countriescare in Europe and other countries

The youth friendly health care services; The youth friendly health care services; their contribution to upgrade the quality their contribution to upgrade the quality of adolescents healthof adolescents health

The necessity of advanced training in The necessity of advanced training in adolescent medicine of the workforce of adolescent medicine of the workforce of health care services health care services

Systems of primary Systems of primary pediatric-adolescent health pediatric-adolescent health

care servicescare services The pediatric system: More than 75% of The pediatric system: More than 75% of

children and adolescents are under the care children and adolescents are under the care of pediatricians of pediatricians

The general practitioner (GP) and/or family The general practitioner (GP) and/or family physician (FP) system: GP and FP follows > physician (FP) system: GP and FP follows > 75% of the population 75% of the population

The combined system (Pediatric - GP/FP), The combined system (Pediatric - GP/FP), offers care to almost equal number of offers care to almost equal number of pediatric population (50 ± 25%)pediatric population (50 ± 25%)

Types and distribution of Types and distribution of primary health care primary health care

services in Europe (UNESPA, services in Europe (UNESPA, survey)survey)

SystemSystem Countries Countries Remark Remark

Pediatric Pediatric 6/296/29

GP/FP GP/FP 9/299/29 UK, *Denmark, Norway, UK, *Denmark, Norway, *Netherlands, *Netherlands, *Portugal, Spain, *Portugal, Spain, Switzerland, *Estonia Switzerland, *Estonia

Combined Combined 14/2914/29 Germany, France, Italy, Germany, France, Italy, Sweden and othersSweden and others

* No pediatrician in primary health care for adolescents* No pediatrician in primary health care for adolescents

Additional findings of Additional findings of UNEPSA surveyUNEPSA survey

Variations of the upper age limit of Variations of the upper age limit of adolescents under pediatric care, for in adolescents under pediatric care, for in and out patientsand out patients

Difficulties in hospitalization and lack of Difficulties in hospitalization and lack of special wards for adolescent’s inpatient special wards for adolescent’s inpatient carecare

Lack of proper training and confidence of Lack of proper training and confidence of the majority of physicians in adolescent’s the majority of physicians in adolescent’s health care serviceshealth care services

Important attributes of Important attributes of quality health carequality health care

For all age groups: For all age groups: Access, Access, AffordabilityAffordability Clinical effectivenessClinical effectiveness EmpathyEmpathy

For children requires in addition: For children requires in addition: Relation of pediatrician with families and institutions Relation of pediatrician with families and institutions

(schools, child care providers)(schools, child care providers)

For adolescents:For adolescents: The pediatrician’s support to patients and families to The pediatrician’s support to patients and families to

develop: autonomy, responsibility and adult identitydevelop: autonomy, responsibility and adult identity

Types for the provision of Types for the provision of youth-friendly services youth-friendly services (21)(21)

Centre specializing in adolescent health.Centre specializing in adolescent health. It is set in a hospital It is set in a hospital and provides inpatient and drop in services to young people, serves and provides inpatient and drop in services to young people, serves as referral centre for nearby health facilities and provides training as referral centre for nearby health facilities and provides training and research. and research.

The community based health facility.The community based health facility. The facility caters for The facility caters for young people in the context of health services to all segments of the young people in the context of health services to all segments of the population. It is a model of stand alone unit that is run by the population. It is a model of stand alone unit that is run by the government or non-governmental organizations. government or non-governmental organizations.

School or college based health services and centers linked School or college based health services and centers linked with schools or colleges.with schools or colleges.

Community based centre that provides other services in Community based centre that provides other services in addition to health.addition to health. They provide health information, some health They provide health information, some health services and links with nearby health facilities for adolescents. services and links with nearby health facilities for adolescents.

Pharmacies and shops selling health productsPharmacies and shops selling health products (condoms etc) (condoms etc)

Outreach information and service provision.Outreach information and service provision. Efforts to distribute Efforts to distribute health information, health products and services to marginalized health information, health products and services to marginalized young people (bars, malls, factories, schools etc). young people (bars, malls, factories, schools etc).

WHO guide for WHO guide for development of youth development of youth friendly services friendly services (21)(21)

An equitable point of deliveryAn equitable point of delivery (equitable provision and experience of care. (equitable provision and experience of care. In all patients. regardless of status)In all patients. regardless of status)

An accessible point of deliveryAn accessible point of delivery (health services are free or affordable to all (health services are free or affordable to all young people at convenient location and working time with community young people at convenient location and working time with community support)support)

An acceptable point of deliveryAn acceptable point of delivery Policies and procedures guarantee confidentiality for allPolicies and procedures guarantee confidentiality for all Health care providers are well educated, informed and motivated to work with Health care providers are well educated, informed and motivated to work with

youthsyouths Point of delivery ensures privacy, has clean and safe environment, andPoint of delivery ensures privacy, has clean and safe environment, and Young people are actively involved in the assessment and provision of health Young people are actively involved in the assessment and provision of health

servicesservices

Appropriateness of health services for young peopleAppropriateness of health services for young people Health services are provided for all young people either at delivery or referral Health services are provided for all young people either at delivery or referral

linkageslinkages

Effective health services for young peopleEffective health services for young people Health care providers are competent, have technical facilities and follow proper Health care providers are competent, have technical facilities and follow proper

guidelines and sound protocolsguidelines and sound protocols Points of service delivery are fully equipedPoints of service delivery are fully equiped

Proposed options of training in Proposed options of training in Adolescent Medicine to Adolescent Medicine to

improve quality of health improve quality of health servicesservices

Enriching medical education programs Enriching medical education programs in Adolescent Medicine topicsin Adolescent Medicine topics

Formulation of efficient training Formulation of efficient training programs in Adolescent Medicine programs in Adolescent Medicine (European and other countries)(European and other countries)

Implementation of advanced Implementation of advanced postgraduate programs for Adolescent postgraduate programs for Adolescent Medicine subspecialty in Pediatrics, Medicine subspecialty in Pediatrics, Family and Internal MedicineFamily and Internal Medicine

Enriching medical Enriching medical education programseducation programs Adolescent Medicine topics should Adolescent Medicine topics should

supplement:supplement:

Undergraduate and postgraduate (especially Undergraduate and postgraduate (especially in pediatric residency curriculum)in pediatric residency curriculum)

UK favors delivering adolescent medicine UK favors delivering adolescent medicine training to all health professionals, rather training to all health professionals, rather than creating a separate workforce or than creating a separate workforce or specialty. The same option is shared by specialty. The same option is shared by other countriesother countries

Formulation of efficient teaching Formulation of efficient teaching and training programs in Adolescent and training programs in Adolescent

Medicine in EuropeMedicine in Europe

The European training in Effective Adolescent Health Care The European training in Effective Adolescent Health Care (EUTEACH)(EUTEACH) The program developed by adolescent health professionals from The program developed by adolescent health professionals from 11 European countries and offers an effective and efficient 11 European countries and offers an effective and efficient training curriculum. It is managed by the “Multidisciplinary Unit of training curriculum. It is managed by the “Multidisciplinary Unit of Adolescent health” in LausanneAdolescent health” in Lausanne and is freely available to all and is freely available to all health professionals.The Unit also run an annual one week health professionals.The Unit also run an annual one week summer school summer school

The Israel’s “Alternative Effective Procedure of Training in The Israel’s “Alternative Effective Procedure of Training in adolescent Medicine where formal training program is not adolescent Medicine where formal training program is not available”available” The program includes a hospital and community based The program includes a hospital and community based multidisciplinary adolescent health service and a diploma course multidisciplinary adolescent health service and a diploma course (6 semesters of weekly 4 hours meeting). The course creates (6 semesters of weekly 4 hours meeting). The course creates physicians who are able to operate adolescent clinics and teach physicians who are able to operate adolescent clinics and teach adolescent medicine.adolescent medicine.

Fellowship programs in Fellowship programs in Adolescent MedicineAdolescent Medicine

Developed in USA since 1994 by the Developed in USA since 1994 by the Boards of Pediatrics, Family Medicine and Boards of Pediatrics, Family Medicine and Internal Medicine and lead to Adolescent Internal Medicine and lead to Adolescent Medicine Certificate. The ABP issues the Medicine Certificate. The ABP issues the certificate to Pediatricians after a 3 years certificate to Pediatricians after a 3 years fellowship and successful examinations. fellowship and successful examinations. 25 institutions in 15 states operate 25 institutions in 15 states operate fellowship programs. Up to 2007 more fellowship programs. Up to 2007 more than 500 pediatricians have been than 500 pediatricians have been certified, distributed unevenly within the certified, distributed unevenly within the 50 states. The physician to child ratio 50 states. The physician to child ratio ranges from 0 to 3.7 per 100.000 children. ranges from 0 to 3.7 per 100.000 children. Only in 7 states the ratio is more than 1.Only in 7 states the ratio is more than 1.

Efficacy of training in Efficacy of training in Adolescent Medicine during Adolescent Medicine during

pediatric residency and pediatric residency and Adolescent Medicine fellowship Adolescent Medicine fellowship

programs in USAprograms in USA Significant variations and gaps disclosed Significant variations and gaps disclosed

in both programs throughout the USA. in both programs throughout the USA. The main gaps affect: The main gaps affect:

The coverage of topics important to The coverage of topics important to adolescent health care (injury and violence, adolescent health care (injury and violence, prevention, mental and behavioral health prevention, mental and behavioral health and others)and others)

The availability of facility to teach The availability of facility to teach adolescent medicine especially in pediatric adolescent medicine especially in pediatric residency residency

The ambulatory care training experienceThe ambulatory care training experience

Proposed Reform options to Proposed Reform options to improve Education Training improve Education Training in Adolescent Medicine in in Adolescent Medicine in

USAUSA Extending the one month Adolescent Extending the one month Adolescent

Medicine rotation in pediatricsMedicine rotation in pediatrics Introducing more flexibility in Introducing more flexibility in

residency programsresidency programs Covering a combined Covering a combined

pediatrics/adolescent medicine pediatrics/adolescent medicine residencyresidency

Supplementation of pediatric Supplementation of pediatric residency with one year adolescent residency with one year adolescent medicine clinical training programmedicine clinical training program

Commentary on: Commentary on:

““Meeting the needs of Adolescents: Meeting the needs of Adolescents: Pediatric Medical Education and Workforces Pediatric Medical Education and Workforces Development” in Pediatrics concludes: Development” in Pediatrics concludes:

““Preparing future pediatricians to provide Preparing future pediatricians to provide high quality adolescent health care is high quality adolescent health care is necessary, but not sufficient for improving necessary, but not sufficient for improving adolescent health services and reducing adolescent health services and reducing existing disparities. Adolescent access to existing disparities. Adolescent access to care and a coordinated primary care care and a coordinated primary care system linked to community programs are system linked to community programs are also essential”also essential”

Conclusions (1)Conclusions (1) The health of adolescents is an issue of:The health of adolescents is an issue of:

quality carequality care professional educationprofessional education personal, family and society responsibilitypersonal, family and society responsibility

A priority for those responsible for A priority for those responsible for adolescent health is to ensure support and adolescent health is to ensure support and provision of innovative well assessed youth provision of innovative well assessed youth friendly service.friendly service.

Conclusions (2)Conclusions (2)

Quality of health care for adolescents varies widely.Quality of health care for adolescents varies widely. USA, Canada and Australia are notable exceptions USA, Canada and Australia are notable exceptions

with dedicated multidisciplinary adolescent health with dedicated multidisciplinary adolescent health care centers, active appropriately trained care centers, active appropriately trained adolescent health physicians and active adolescent adolescent health physicians and active adolescent medicine societies.medicine societies.

In well developed countries Institutions, Societies In well developed countries Institutions, Societies and others are working on initiatives to improve the and others are working on initiatives to improve the quality of health care for adolescents in their quality of health care for adolescents in their regions.regions.

Reforms for advanced training in Adol. med in all Reforms for advanced training in Adol. med in all levels of medical education are of primary levels of medical education are of primary importance to improve the quality of health care importance to improve the quality of health care services.services.

Conclusions (3)Conclusions (3)

A major objective of MAGAM is to support A major objective of MAGAM is to support member countries of Mediterranean and Middle member countries of Mediterranean and Middle East regions, to develop and implement East regions, to develop and implement programs of adolescent health care and improve programs of adolescent health care and improve education and training in adolescent medicine. education and training in adolescent medicine.

The recent predominating issue of MAGAM and The recent predominating issue of MAGAM and Italian Society of Adolescent Medicine concerns Italian Society of Adolescent Medicine concerns the upgrade of collaboration of member the upgrade of collaboration of member countries in research and education in countries in research and education in adolescent medicine. adolescent medicine.

The establishment of a permanent School of The establishment of a permanent School of Adolescent Medicine , by Prof Raiola , will Adolescent Medicine , by Prof Raiola , will facilitate the integration of the major objectives facilitate the integration of the major objectives of the two Societies . of the two Societies .