JOURNAL OF ADOLESCENT HEALTH CARE 1986;7:377-380

President's Address

Society for Adolescent Medicine Annual Meeting, March 15, 1986

It is a distinct honor and privilege to address you, the Membership of the Society for Adolescent Medicine, on this occasion as I assume the presidency for the coming year. It is especially meaningful for all of us to be meeting in Boston, the city that we all acknowl- edge as the birthplace of our interests and focus in medicine. It is particularly fitting that our meeting theme, Adolescent Growth and Development, is quintessential to all our academic efforts and is the foundation of the interest that Dr. J. Roswell Gal- lagher espoused in many of his landmark writings in the pediatric literature. He put adolescents on the map of pediatric and developmental medicine, and as a result we have been given the building blocks for many of our varied interests in our professional aca- demic endeavors. We all are appreciative and grate- ful to Dr. Gallagher for his pioneering efforts and to the Boston Children's Hospital Medical Center Ado- lescents' Unit that he founded. Both have greatly influenced all of us.

The history of the origins of the Society, from small, annual, research-oriented meetings held in Washington, D.C., in the 1960s under the leadership of Dr. Felix Heald (all of which I was privileged to attend), to the formation of the Society as we sat around a large table on April 25, 1969, to the annual meetings held in association with the American Academy of Pediatrics (AAP) as we struggled to de- velop our credibility in San Francisco, and to our first really independent and most successful meeting last year in Denver, guided by our outstanding outgoing program chairman, Dr. Lonnie Zeltzer, have so ably been reviewed and documented by various past presidents, especially so by Sam Yancy, our immedi- ate past president, that I do not have to review with you in depth this exciting growth and development of our Society, but use it more as an introduction to my theme today, which is to consider with you some thoughts about our future rather than our rich past as we enter early adulthood as a society. In his presi- dential address to the American Pediatric Society in 1978, Dr. C. Henry Kempe stated:

Some say that adolescent medicine is really nothing more than a time period not deserving special recog- nition and that the adolescent is just "an older

child." This is what internists said about pediatrics for a long time, "the child is a small adult." And that is what was said later about the field of neonatology, "the neonate is a small child." Time has shown that there was a lot to be gained scientifically, educa- tionally, and in terms of excellent patient care by giving recognition first to pediatrics as a specialty, and then to neonatology as a subspecialty. The field of adolescent medicine can no longer be denied.

Yes, it is clear we have come of age. Our identity has been established. Now what are our challenges and future objectives? How can we best achieve them? How can we maintain and enhance our vigor and image in the professional and lay community? These are some of the important questions for which we must seek solutions and which I would like to consider with you.

The Society for Adolescent Medicine counts among its membership health-care professionals-- physicians, nurses, psychologists, social workers, nutritionists--a comprehensive group who have ac- cepted the responsibility of providing a high caliber of care to the adolescents of our nation and indeed beyond. Our Society has spurred not only national but international interest in adolescent health care. Our support and endorsement is sought by many persons and organizations because we have achieved the recognition of our colleagues as the "ex- perts" in knowing how to meet the health needs of our constituency. Examples of this recognition in- clude our representation being sought on such groups as the Council of Pediatric Research of the American Academy of Pediatrics and the exciting federal grant to establish a national center to assist those who work with youth with disabilities in tran- sition to adulthood that we received in conjunction with the University of Minnesota. The upcoming na- tional invitational conference, Adolescent Health Fu- ture Directions, cosponsored by the Institute for Continuing Education of the University of Min- nesota and SAM attests to our position as leaders in adolescent health care.

Yet the adolescent patient represents a continuous challenge to us as we speak today. Adolescent mor- tality continues to rise, the only age group in which

© Society for Adolescent Medicine, 1986 377 Published by Elsevier Science Publishing Co., Inc., 52 VanderbiltAve., New York, NY 10017 0197-0070/86/$3.50

378 SHENKER JOURNAL OF ADOLESCENT HEALTH CARE Vol. 7, No. 5

this is occurring. Money and programs (albeit too little) directed at stemming the increase in teenage pregnancy are not wrought with success. Adolescent risk-taking behavior--a normal part of experimental behavior--will not cease. Can we devise ways to make it less hazardous? The prevention of teenage drug abuse and of the tragedy of teenage suicide is elusive. New ideas, new experimental designs, and creative solutions--these are the things we as a soci- ety of professionals should continue to promote, support, and reward. Our leadership in the provi- sion of high-quality postgraduate educational pro- grams such as we are having at our scientific and research meetings here, help enhance our recogni- tion on an international scale. The individual and combined talents of our membership (which our awards committee is charged with recognizing) will be needed to solve the numerous medical and soci- etal issues interfering with an optimal state of health and wellness in our youth.

But we need more help! We need greater input from our nonphysician professionals in this knowl- edge-explosion era. We should seek to expand our membership in this area, in addition to encouraging those physicians and other scientists with expertise in adolescent health, growth, and development to join us. In providing for a fellowship status as well as membership in the Society, we hope the Society has been able to be responsive to, and fulfill the needs of, many more of us. The Society can serve the mem- bership and will make every effort to do so for each individual member. But let us agree that individual needs should never be achieved at the risk of reduc- ing our credibility in the medical and aeademic com- munity. The issue of subspecialty certification should continue to be explored and studied. Let us also reaffirm the principle of "walking tall," as Dr. Elizabeth McAnarney stated in her presidential ad- dress in 1983. We should be proud of our achieved status, aggressive in our leadership, and open to new directions in solving the crises needs, and medi- cal needs of our youth.

With this in mind I would like to ask: Is every physician in a position to adequately care for teen- agers? Are all pediatricians (the majority of our mem- bership) able to care for adolescents? The American Academy of Pediatrics is promoting the pediatrician as the best physician to care for adolescents. We phy- sicians in the pediatric community have been active in educating the public and the political establish- ment that adolescent health is our domain. As Dr. Kempe indicated in the aforementioned address, "many adolescents are deeply troubled, and the

health care of this group is particularly deplorable." He goes on to add that the Task Force in Pediatric Education clearly was influential in fostering the con- cept of pediatricians caring for adolescents until the age of 21. But as those of you involved in training pediatricians well know, there is a varied level of interest and skill among house-staff trainees in is- sues of adolescent health. In speaking with internal medicine colleagues, I suspect the level of interest and training is even more diverse.

The lead headline in the January 1986 issue of Pedi- atric News states, "General Pediatricians Must Be- come Premie Care Experts." A juxtaposed headline reads "Competition Creating More Opportunities Among Pediatricians." In this report Dr. Robert J. Haggerty, the immediate past president of the AAP, talks of the need to educate families about such is- sues as accident prevention and teenage suicide. This preventive-care role for pediatrics will be pro- moted by a public relations effort so that consumers will demand these services from pediatricians. It is anticipated that the pediatrician is to become expert at how to prevent smoking, how to cope with di- vorce, how to resist peer pressure, etc. But an old problem still exists. Who is to reimburse for these services? One must also ask, is the pediatrician able to do it well?

How many of you have had the experience of being called by an exmember of your house staff who has entered into pediatric practice, making inquiry about an issue of adolescent care that in practice is critical but in training was never seen as important? How many former house-staff officers wish they had been more interested in adolescent medicine during their training? Is it, therefore, sacrilegious to suggest that we learn from our neonatology friends and re- strict the care of adolescents to those of us who have had at least some demonstrable training in adoles- cent medicine? Would the adolescents of the future benefit if such a goal were established? As members of the Society for Adolescent Medicine we should be asking these questions. They effect us individually and as a group no matter what our professional disciplines.

As we enter the era of new health-delivery plans with their myriad and euphemistic names, the era of cost containment, the world of HMOs, PPOs, IPOs, etc., as we become a profit or not-for-profit provider, what is to become of the adolescent who we know to be at risk and generally underserved, but who is still considered by the lay public and administration of most health schemes as a very healthy segment of the population and not in need of many services? We

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have a major educational task before us that has to be accomplished as we each negotiate our own roles in the new delivery systems. Those of us in the Eastern part of the country have the least experience in these matters and should seek guidance from our own more knowledgeable membership and other appro- priate consultants.

The Society has a responsibility to promote the highest level of expert care to the teenage popula- tion. When the adolescent is seen under these newer health-delivery programs we must strive for and en- sure an expert level of treatment and preventive ser- vices. We are the specialists in adolescent medicine. We have special expertise and must communicate that expertise to those who seek to reorganize the priorities and costs of American medicine. We do, however, have a basic and fundamental issue to re- solve that has taken on especial import under the new delivery systems. Are we generalists or spe- cialists? I suggest the answer may have to change with the times. We should be, and should represent ourselves as, that which will be best in the new scheme ahead, and we should try to avoid the mis- takes of the past. In the era when specialization was most rewarded we have been considered generalists. In the marketplace of medicine, a terminology that even to the most academic among us can not be anachronistic any longer, we must create a demand for our services. We need to mount and promote a public relations effort not only among the profes- sional community, but among the lay community as well. Knowledge of the existence of adolescent medi- cine should become more universal. High-quality adolescent medicine services should be as in demand as high-quality neonatal medicine. Who of us cannot think of individual adolescents whose treatment was less than optimal because of their physicians' inade- quate training or experience in adolescent medicine?

Acute, episodic care is inadequate for adolescents. Is the patient admitted to the hospital with an over- dose of drugs or alcohol served well by emergency treatment and stabilization of his or her vital signs and then discharged? This "filling station" approach to acute care needs is, all too often, seen as definitive treatment. If we as leaders in adolescent health can- not teach the majority of providers, be they pediatri- cians, internists, or family practioners, more appro- priate basic adolescent medicine, then we should shift our traditional emphasis and train more profes- sionals in our own subspecialty. I carefully use the term subspecialist because that is what I believe we are. As the new economics of medicine portends to favor generalists, we certainly will be seen as non-

generalists. Out predicament vis-a-vis reimburse- ment for our service will remain a problem, as will funding for our academic programs. The solution may come by way of increasing demand for our ex- pertise. We, too, need more favorable public rela- tions and may have to support such an effort.

Our constituency is politically weak. Adolescents don't vote, nor do they capture the imagination of politicians. Their adverse behaviors frequently cause a public outcry. The value of our services also may not receive recognition for years after our individual patient encounters. Preventive services are hard to measure. Therefore, we need to influence the public and those administering the new health-delivery systems that we have much to offer that our youth need to achieve their full potential. Public education should be supported to help create demand for our services, which only then will promote support for our training programs.

We all face declining funding for fellowships. Cost containment means little support beyond the core years of postgraduate education. Adolescent medi- cine should seek ways to create more demand for its personnel so that we will not be underprivileged in support for our training programs and services. These are critical issues for our future as we approach the end of the decade and what appears to be a major shift in the financing of health care. If we can deliver a superior product more people will want it. The Society has a responsibility to promote the skills and quality of its practitioners.

As we pursue our patient-care and service respon- sibilities, we must continue to foster our academic endeavors, which are moved forward by research. Our academic challenge is to encourage and suppor t several levels of investigative efforts. Many of us seek answers to clinical questions in clinically de- signed studies. The improved research quality of our Society is easily documented. However, we need to encourage more basic research efforts to enhance our standing in the scientific community. We should en- courage our newest trainees to be more uniformly exposed to the fundamentals of basic investigations during their fellowship years. This is particularly important as it appears more and more clinical ques- tions will find solutions at a biochemical, molecular, or genetic level. Current threats to adolescent health, such as eating disorders and drug abuse, are exam- ples of problems that may find practical solutions by the aid of these disciplines. We should not hesitate to enlist the help of our basic science colleagues in some of these efforts, as we do with other clinical col- leagues in other subspecialties. Our colleagues have

380 SHENKER JOURNAL OF ADOLESCENT HEALTH CARE Vol. 7, No. 5

much to offer us, but we also have a great deal to offer them from our developmental vantage point. Collaborative research efforts will be most produc- tive, as many of us appreciate. We should seek as a Society to include among our membership the brightest and most talented of our colleagues--no matter what their discipline. "Cross-fertilization" may help answer the clinical problems for which we seek solutions.

In his presidential address to the American Pedi- atric Society in 1982, Dr. Henry Barnet addressed the issue of the divergence of primary and tertiary care research and biomedical and psychosocial research. It is vitally important for us in adolescent medicine to seek communication and strength from each other as we do in this annual meeting, but it is also desirable for us to interact at the national, regional, and local level with other academicians who can help us ad- vance knowledge to enhance adolescent health. The executive council should consider on an ongoing basis periodic annual meetings, which, in conjunc- tion with other groups, enhance their and our oppor-

tunities for interdisciplinary efforts. Our reputation as an academic society and the desirability of mem- bership in it will be enhanced, an ever-present goal for the leadershi p of your Society. The more we as a Society flourish, the greater will be the benefits not only to ourselves but to the adolescents of our nation and other countries.

During the year ahead it will be my aim to main- tain the highest quality of leadership that this Society has enjoyed since its inception. I look forward to your help and input as we work together to achieve the purpose that is stated on our membership certifi- cates: "To foster and stimulate the highest quality of medical care for adolescents and to increase the un- derstanding of the adolescent period of growth and development."

I look forward to hearing from each of you and working with you. The executive council seeks your input, suggestions, and criticisms, but especially your active participation to enhance our mutual goals.

I. Ronald Shenker, M.D.