Case Scenario

A 15-year-old girl came into the office for a third visit in two weeks; it was, however, her first visit with me. Her mother, who was concerned about her daughter's constant vomiting, had accompanied her to each visit. The girl's last menstrual period was noted in the chart as having occurred about one month ago. A stool culture, including ova and parasites, had been performed, and results were negative. Diarrhea was not a complaint. In fact, other than frequent nausea and vomiting, with associated exhaustion, the girl said she felt “pretty well.”

I was indeed puzzled by the clinical scenario.“When was your last period?” I asked her despite the charted information. The girl answered, but this time gave a date four weeks earlier than the date noted in the chart. “We have our diagnosis,” I thought. At that point, I turned to the mother and asked if I could spend a few private moments with the daughter. The mother agreed. After she had left, I asked the girl if she thought she could be pregnant. The girl lowered her head and said, “Yes.” Results of her pregnancy test were positive. When I told her the results, I also suggested to her that this was really something her mother should know about. When I asked for permission to bring the mother into the room, the girl agreed.

As soon as I told the mother about the pregnancy, she turned reproachfully to her daughter and said, “But I asked you if it could be that and you said, ‘No. No, no, no.’ That's what you told me every time!” I reminded the mother that now was the time for her to reestablish trust with her daughter and that they should not waste this time. I then asked them to spend the weekend thinking about the pregnancy and any questions they might have for me and return on Monday for a complete examination.

Commentary

This case represents an all too common reality in family physicians' offices around the country. The 15-year-old's symptoms were still present at her third office visit in two weeks. As such, the physician did well to personally review all aspects of her history. In so doing, the physician was able to recognize the girl's inconsistent response regarding the date of her last menstrual period. This led to a request for a private discussion of her history, at which time a more candid response was elicited.

Whether the same question could have been asked and answered truthfully with the mother present is not known. While conventional wisdom dictates that adolescents should always have some private time with the physician, I believe that most family physicians still make this decision on a case-by-case basis and that this decision hinges on their personal knowledge and the history of the adolescent and the family. This strategy may or may not be appropriate depending on the setting, the skills and the sensitivity of the physician, as well as the duration and quality of the doctor-patient relationship.

One of the most important aspects of this case is the reality that a lack of communication existed between the girl and her mother. While the physician recognized the need to improve communication and explicitly conveyed this idea to the mother, I believe the advice to the mother and daughter—that they should think about the news over the weekend and return on Monday with any questions—was inadequate.

Regardless of other schedule pressures, I think that the physician is missing a critical opportunity to explore the feelings of both the mother and the daughter. The mother's question to her daughter indicates a degree of astonishment and reproachfulness. If the physician is willing to take the time, talking with the mother (in the presence of the girl) may establish new insights for both of them. For example, while the mother may be angry, she may not necessarily be devastated by the news and may, in all likelihood, be able to accept and forgive her daughter. At the same time, if the physician takes the time to explore the daughter's feelings, other concerns and even fears about the reaction of her peers, her school and her relationship with the baby's father may be revealed. While it is unlikely that any closure will (or should) be reached during this initial encounter, I believe that a groundwork can be laid during this visit that will play an enormous role in the subsequent decisions that need to be made. I believe that it is necessary for the physician to make the time to begin this process during this initial contact.

In my experience, if the significant adults in a pregnant teen's life react in a supportive and accepting manner, the “crisis” soon begins to seem less overwhelming. At the same time, if the teenager or the adult appears to be unable to cope, the physician needs to provide assurance that he or she will provide ongoing care or make referrals to other health care agencies if additional support is needed.