Robert Brown's patients may be obese or anorexic; sexual innocents or infected with chlamydia; male or female; jocks or goths; abusers of alcohol, Ecstasy, or over-the-counter drugs; tattooed, pierced, pimpled; surly and stressed; or just mortified by their molting, rebelling bodies.
Diverse and challenging, they share at least one common factor, which brings them to the attention of Brown and his colleagues. They are all adolescents.
"We do dermatology, sports medicine, psychology, gynecology, orthopedic issues, psychosocial issues, substance abuse, and address problems of developing sexuality," said Brown, a specialist in adolescent medicine who is chairman of pediatrics at Crozer-Chester Medical Center, in Upland, Pennsylvania.
"We're highly trained generalists for a specific population — like gerontologists," he said. "But either we've done a poor job of marketing ourselves or there is something about the field."
Adolescent medicine might be expected to be booming. The US has about 40 million people ages 10 to 19, a patient population that experts say is vulnerable to a growing array of behavior-related health problems.
But a decade after adolescent medicine became board certified in the US as a subspecialty, it is in little demand by doctors seeking to advance their careers. Small wonder the public is generally unaware of the field: according to the American Board of Medical Specialties, only 466 certificates in adolescent medicine were issued from 1996 to 2005. In the same period, 2,839 were issued in geriatric medicine.
Most major teaching hospitals have adolescent clinics: pediatric residents have to spend a month in an adolescent rotation. A few health maintenance organizations have stand-alone adolescent clinics. Occasionally, a pediatrician in a group practice or in a community may have a special affinity for teenagers, and be the go-to doctor for them.
But the availability of doctors and nurse practitioners dedicated exclusively to adolescent care is still the exception. Their numbers are so limited that many cannot take on adolescents as primary-care patients; the patients see them on a temporary referral basis. Of those teenagers who are insured and who continue to see a primary-care doctor, a vast majority remain with the pediatricians or family doctors who have cared for them since diaperhood.
That job has become more time-consuming and complex. "Adolescents are not big children and they're also not little adults," said Walter D. Rosenfeld, an adolescent medicine specialist and chairman of pediatrics at the Goryeb Children's Hospital, in Morristown, New Jersey.
They are not just a bridge population, he and many others maintain, but their own stop in the road. During adolescence, people need to learn how to take responsibility for their health and, eventually, to become health care consumers, independent of their parents.
At programs that are sensitive to adolescents, this changing dynamic is negotiated deftly but firmly. Recently, at an eating disorder clinic at the Goryeb Children's Center, at Overlook Hospital in Summit, New Jersey, a nutritionist beckoned to a teenager in the waiting area. The girl's mother stood to follow. But after the girl slipped into the exam room, the nutritionist closed the door.
"Oh, I thought I was going in with her," the mother said to no one in particular. "Guess not," she added with a small laugh of embarrassment.