Deborah Ottenheimer, MD

Let's face it; after a while, medicine can become routine. Most women have similar complaints, and most of the remedies are the same. From time to time, we'll encounter a challenging case that really takes thought and creativity, but usually not. So how do we stay engaged? Diversify!

I've struggled with this for a while. When I was in a large hospital setting, I had a full-scope practice, was on call a lot, taught residents and medical students, fought the bureaucracy, and tried to find my niche. After 8 years, I no longer wanted to be in a large institution and set out on my own. The first 5 years of private practice were fascinating. I had to restrict dramatically my scope of practice because of the cost of malpractice insurance in New York. I no longer taught, delivered babies, or did surgery. However, I learned so much about business in those early years that I didn't really mind the monotony of the patient care in the office. Further, the intellectual blandness of the medicine practiced was more than offset by the opportunity to spend more time with my patients and really get to know them in a way that had never been possible in a busy clinic.

Nine-plus years into private practice, I have learned everything I'm going to learn about running a small business. I built it from scratch, and I did so successfully. But for the past 2 years, I've been utterly miserable. It took a while for me to figure out why I was unhappy. I had built a solid practice from the ground up. I enjoy my patients. I have a wonderful staff. But the challenge was missing.

As I considered the rut I was in, I realized that I would never make it another 20 years as a physician if something didn't change. I spoke to many friends in other fields of medicine and realized that we were all feeling the same way. It was sad to realize that my generation of doctors was feeling stifled and uninspired. As I considered my options, they were rather overwhelming. I could go back to school for an MBA or MPH; I could get training in acupuncture or integrative health; I could do a fellowship; I could expand the office to the next level with multiple locations-the list was endless. After a year of mulling over possible career changes, I realized that what I missed most was public service and teaching. 

I went into medicine to do public health. My transition to private practice was really a practical necessity for my family but had never been an aspiration. Yet, the personal freedom it affords is not to be taken for granted. As I searched for an outlet for my desire for public service, the 2010 Haitian Earthquake happened. As a native French speaker who had worked in Francophone Africa, the opportunity to go to Haiti was perfect in its scope and timing. I went, “fell in love" with the work and the people, and have returned twice a year since then.

But, it wasn't enough. The high I got from going to Haiti didn't sustain me through the other 50 weeks a year. I decided to pursue teaching. I have had several nurse practitioners in my practice from the Columbia University School of Nursing and had gotten to know the head of the program. I approached her about teaching some classes and became an invited speaker for several class sessions.

Around the same time, I had the opportunity to expand my work with Physicians for Human Rights, with whom I had worked for years providing medical affidavits to victims of female genital mutilation (FGM) seeking asylum. I began doing lectures, expanded my case load, and ultimately joined the Human Rights Clinic at Mt. Sinai

So now my plate is spilling over. I have much more work, I sleep less, I cram way more into every day, but I'm so much happier. I feel challenged, worthwhile as a physician, and more satisfied with my life. For the first time in years, I can imagine the next 20 years of my professional life without dread. Of course, nothing is without a price. None of these "extracurricular activities" are paid. Fortunately, my office is doing well enough that I have not had to bear a pay cut, but I'm certainly not getting a raise anytime soon. But even so, despite being the primary wage earner in my family, it is worth it-to me, my husband, and my sons. I've said, "I had a great day!" more in the past year than I had in the preceding 5 put together. That alone is priceless.

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In this blog, one OB/GYN details how she pulled herself out of a professional rut and became re-inspired after 20 years of clinical practice.

Diversification Key to Avoiding Professional Boredom

I started medical school in 1990 with a clear dedication to the practice of women’s healthcare in the inner city. I completed my MD at the University of Pennsylvania, went on to do my residency in OB/GYN in New York City, and subsequently worked as a staff physician at Bronx Lebanon Hospital, serving some of the poorest women in the nation. After eight years, I left to do what I never thought I would do…open a private practice.

While at Bronx Lebanon, I was happy with the service part of my job, but I didn’t like working for a large institution. I chafed at the lack of flexibility and lack of encouragement for innovation. I was always stressed about whether or not I would be able to be off for my kids’ birthdays or for school plays. And the commute was very, very long.

By 2005, when I left the Bronx, I had had a child, gotten divorced, gotten remarried, and gotten pregnant with my second child. With that second pregnancy, the rigidity and stressors of hospital practice became overwhelming. After a year of soul searching, I took the plunge and “hung out my shingle.”

I started out in a subleased office that I shared with a dermatologist. I was determined to practice medicine in a way that was not possible in the inner city clinic, where patients with complex medical and social needs were booked every 15 minutes with little access to consistent follow-up. I have chosen to participate in most insurance plans. I book patients for 30 minutes at a time, and I return calls and emails within 24 hours. For the most part, my patients are aged 20 to 50 years with some pediatric referrals, a fair number of adolescents, and a sprinkling of women older than 50. I now have my own office in Manhattan, with 2 nurse practitioners, an RN, a medical assistant, and an administrative staff.

 birthday, I have begun to re-evaluate my career-again. While by all counts my move to private practice has been a success, it did not happen without a cost. I have my independence and the flexibility that I wanted as the mother to my two boys. I earn about what I would earn as a hospital employee. I still work about 60 to 70 hours a week, but it's on my own terms. However, I no longer practice to the full extent of my training.

In New York City, annual malpractice insurance for a full-spectrum OB/GYN practice is $200,000+ (completely unaffordable). I knew that going in and accepted from the outset that I would have to give up my obstetric practice. As the first two years in private practice unfolded, however, it became clear that it was financially impossible to continue to do GYN surgery in light of the enormous costs of the malpractice insurance coupled with the poor reimbursement for surgical procedures. I could either give up private practice and go back to being a hospital employee or give up doing much of what I was trained in and maintain my independence. I chose the latter.

I practice medicine the way I think it should be practiced, taking time with each patient and addressing both their medical and social needs whenever I can. I am proud of the practice I have built, but the practice of medicine in America is changing fast. It is not clear that a private practice model is viable in the long term. Will I need to live under the umbrella of a hospital or large multispecialty group? Will I need to open a second location? How will we maintain our patient base if pap smears are no longer a yearly ritual? What other office-based services can we offer that are appropriate or reasonable? (I flatly refuse to enter the world of cosmetic procedures.) Will we become a “concierge” practice? How can I maintain my moral integrity and commitment to my patients and still make a living that will allow me to offer my children the life they are entitled to? How can I incorporate teaching and public health into my career again?

As I struggle with these questions, I realize that all of my friends are thinking similarly. I hope that in the coming years we will find our way to a practice of medicine that is 

 professionally and personally rewarding while staying true to our principles. Only time will tell.

In this blog, one OB/GYN discusses her move from a hospital staff physician to a solo private practice, a decision that hasn't come without costs.

The Price of Private Practice

The Supreme Court Hobby Lobby decision is astounding in its breadth. Not only did it deliver a killing blow to the Obama administration’s promise of universal contraceptive coverage, but as Rep Nancy Pelosi points out, “SCOTUS took an outrageous step against women’s rights, setting a dangerous precedent that permits corporations to choose which laws to obey. Allowing CEOs to limit the medical procedures available to employees is a gross violation of workers’ religious rights.”

While the justices in the majority insist that this is a limited ruling, the day after the decision was delivered, the court has recommended re-evaluation of a number of diverse cases already decided by lower courts. Furthermore, a flood of new cases has begun to be filed on everything from contraception to the right to discriminate against homosexuals should that lifestyle be in conflict with employers religious beliefs.

The Hobby Lobby decision holds that closely held corporations may be regarded as individuals with the religious protections usually afforded to humans, not to legal entities. So, what is a “closely held” corporation? The IRS defines it as a company that has more than 50% of the value of its outstanding stock directly or indirectly owned by five or fewer individuals at anytime during the last half of the tax year. The 

 points out that 90% of all companies in the US are closely held!

In the majority opinion, the decision protects the religious liberty of the owners of the companies. SCOTUS (Supreme Court of the United States) rejected the argument that organizing as a corporation eliminates companies from the protections given to individuals. So, in effect, corporations are now free to exercise their religious rights. Closely held corporations are not necessarily small mom and pop stores on the corner either. Hobby Lobby employs about 30,000 people. In her dissent, Justice Ginsburg points out that the candy giant Mars, Inc, is also a closely held corporation, employing about 72,000 and taking in $33 billion in revenue.

At issue in this case, specifically, is an objection to the “morning after pill” and the IUD, as the companies involved believe that these forms of contraception act as abortefacients. While medically incorrect, the court chose to accept the assumptions of the companies over the actual science. The court also accepted the argument that there was a substantial burden placed on the companies by asking them to provide health insurance that included contraceptive coverage.

In her dissent, Justice Ginsburg points out that simply opting out of insurance coverage and paying the penalty was actually cheaper than providing health coverage for their employees, with or without contraceptive inclusion. So the court has accepted religious assumption over medical fact as well as a bizarre calculation of “economic burden” and allowed individuals to impose their religious beliefs on their employees.

It is, of course, true that women can find contraceptive care elsewhere, but it is not that simple. When I worked in the south Bronx, Fidelis managed a substantial portion of the city’s Medicaid plans. Fidelis, as a catholic corporation, declined to cover any contraceptive or family planning service for their enrollees. Generally, this was not explained fully at the time of enrollment and many women in our clinic were astounded to find that these services were denied under their plan. While there was an administrative way around this restriction, it was complex and not readily available. As a result, many of our patients were unable to obtain contraceptive services. Of course, that put them at risk for unplanned pregnancy and an increased use of abortion services.

While the vast majority of closely held corporations in this country will not impose contraceptive coverage restrictions on their employees, this ruling, at a practical level, will necessitate a new level of caution when searching for a job. It will now be necessary for an employee to ask whether or not contraceptive coverage is offered in their benefits package. In the past, this was simple; if you applied for a job with the arch diocese, you knew, a priori, that contraceptive coverage would not be part of your insurance package. Now the waters will be murkier. And, in this time of slowed economic growth, will employees be forced to choose between employment and contraceptive coverage?

It is currently illegal for an employer to ask a potential employee about their marital status, religion, pregnancy status, or sexual orientation. Will potential employees be allowed to ask about their potential employers’ religious beliefs and family planning coverage? Or will those employees find out after the fact that these essential services are effectively denied them?

Realistically, this will affect not just employees, but their wives and female children as well. Will nonmedical uses of contraceptives also be denied? Will women with menorrhagia be denied coverage for a Mirena IUD? Will adolescents with acne be denied coverage for birth control pills? In the final analysis, this supposedly narrow ruling has a potentially enormous reach, and we have only just begun to see how far its limits will be tested.

The Supreme Court justices insist that their decision for Hobby Lobby is limited and narrow in scope. Find out why gynecologist Deborah Ottenheimer, MD, doesn't buy it.

Corporations Have Religion Now?

Once again, rape on college campuses has risen to public consciousness. On March 31, 2014, in an anonymous 

, a female Harvard student described her sexual assault by a fellow student whom she had considered her friend. She goes on to expose the university hierarchy as unwilling to initiate a proper investigation of her claims and as being unable to deal with what had happened to her in a supportive and sensitive way. Instead, the university is cited as choosing to brush the incident aside, essentially rewarding the perpetrator for his actions.

Rape on college campuses has long been known to be a problem, but it is not one we like to admit to. These young people represent the intellectual elite of our society; how painful for us to admit that this has become an issue of epidemic proportions. 

Health Cares About IPV: Intimate Partner Violence Screening and Counseling Toolkit

Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic, Reproductive Health Care Settings

ChildTrends Data Bank: Adolescents Who Have Ever Been Raped

Teen Dating Violence-Awareness and Prevention: Office of Adolescent Health

Know Your Rights: Title IX Prohibits Sexual Harassment and Sexual Violence Where You Go to School

The Rape, Abuse & Incest National Network (RAINN) reports that the U.S. Department of Justice estimates that 20% to 25% of all women in college or graduate school will experience a sexual assault.

 According to the results of the 2008 National Crime Victimization Survey, more than 75% of women who reported a rape were younger than 25 years old at the time of their assault. Of those, more than 25% of the victims of reported rapes were between 18 and 24 years of age. Less than 5% of these incidents are ever reported, which is far below the 40% reporting incidence for the general public. Furthermore, as with most sexual assault, the victim and assailant know each other.

Unfortunately, high school students are not immune to assault either. In 2011, almost one in eight female high school students reported ever having been raped. Sexual assault and rape are crimes that disproportionately affect girls and women between the ages of 12 and 24 years. Regardless of race, they are two to three times more likely than adults older than 25 years to be raped or sexually assaulted.

A Call to Action: Women, Religion, Violence, and Power

 “The tragedy is that most on campus rapes are perpetrated by serial rapists who can safely assume that their crimes will not be revealed.” He goes on to ask how this can be and notes that the “Hopkins Undergraduate Research Journal of March 2012, which reported that one in three college assaults that get reported are committed by student athletes, who are often popular and influential.”

In response to these devastating statistics, the White House has released new and stricter guidelines regarding the treatment of sexual assault victims and reporting of such crimes in annual campus crime statistics.

In addition, Sen Kirsten Gillibrand (D, NY) and Sen Claire McCaskill (D, MO) have now turned significant attention to such problems on the nation’s campuses. “After a year of working hard to reform how the military handles sexual assault cases,” Senator Gillibrand said in an email, “the stories I have heard from students are eerily similar. Once again the problem is systemic, survivors feel twice betrayed, and reform is required.”

In light of all of this, what is our role as ob/gyns? Our first obligation is to simply ask the question. In checking in with our patients about any past history of sexual assault, we give them permission to speak about what is generally a taboo subject. In the same way that we are obligated to ask about and act upon issues of domestic violence, we should be talking about sexual violence as well.

When a patient reveals that she has been assaulted, I ask her when the event occurred. If it was recent, we discuss STD testing, referral for counseling, police reporting, referral to a crime victims’ service, an assessment of her safety, and any other medical concerns. If it was a more distant event, I inquire about her need for counseling, whether she has flashbacks, what impact the assault has had on her ability to date and maintain healthy relationships, and whether or not she feels safe.

Neither the justice system nor the medical system serves victims of sexual violence well. As the primary medical contact for young women, ob/gyns are the front line for the medical and psychological well-being of survivors of sexual violence.

1. Waldman K. Harvard student writes about being sexually assaulted, then ignored by administrators. April 1, 2014. Available at: 

http://www.slate.com/blogs/xx_factor/2014/04/01/harvard_student_writes_in_the_crimson_about_her_sexual_assault_and_the_school.html

2. Rape, Abuse & Incest National Network (RAINN) website. Campus safety. Available at: 

https://www.rainn.org/public-policy/campus-safety

http://www.childtrends.org/wp-content/uploads/2012/07/31_Rape.pdf

3. Chamberlain L, Levenson R. Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic, Reproductive Health Care Settings. Third Edition. Available at: 

http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Reproductive%20Health%20Guidelines.pdf

A Call to Action: Women, Religion, Violence, and Power.

6. Steinhauer J. White House to press colleges to do more to combat rape. New York Times. April 28, 2014. Available at: 

http://nytimes.com/2014/04/29/us/tougher-battle-on-sex-assault-on-campus-urged.html?_r=0

Sexual violence on college campuses may be more prevalent than you think. Are you asking patients the right questions about their sexual health?

Rape on Campus: How Ob/Gyns Can Help Survivors

[[{"type":"media","view_mode":"media_crop","fid":"23854","attributes":{"alt":"","class":"media-image media-image-left","id":"media_crop_2888185651972","media_crop_h":"188","media_crop_image_style":"-1","media_crop_instance":"1982","media_crop_rotate":"0","media_crop_scale_h":"134","media_crop_scale_w":"250","media_crop_w":"350","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; margin: 0px; float: left;","title":" ","typeof":"foaf:Image"}}]]In the past year, my staff and I have seen a dramatic increase in the use of both marijuana and electronic cigarettes, or e-cigarettes, among our patients, consistent with nationwide trends. As a result, we now include very specific questions about their use on our intake forms as well as in our patient interviews.
 

Marijuana use has been on the rise among adolescents for many years. From 2008 to 2009, the rate of current illicit drug use among young adults aged 18 to 25 climbed 8%, from 19.6% to 21.2%, driven largely by a 10% rise in marijuana use (from 16.5% to 18.1%).

 At the time of that survey, 16.7 million people aged 12 years and older had used marijuana in the past month.

When speaking to my own patients, I find that adolescents (and adults) in my practice generally regard marijuana use as equivalent to alcohol use in their daily lives; this underestimation of harm is echoed in national surveys as well. However, marijuana has evolved since it first gained wide popularity in the United States in the 1960s. Through genetic manipulation, the potency of marijuana has doubled from 1998 to 2008.

Marijuana is now a very different drug than it once was, with a much higher potential for addiction and harm. Studies have suggested an association between chronic marijuana use and increased rates of anxiety, depression, suicidal thoughts, and schizophrenia. Other research has shown marijuana smoke to contain carcinogens and to be an irritant to the lungs. In a prospective birth cohort study, researchers showed that, among adolescent initiators of marijuana use in New Zealand, persistent cannabis use was associated “with neuropsychological decline broadly across domains of functioning, even after controlling for years of education, suggesting a neurotoxic effect of cannabis on the adolescent brain.”

Use of electronic cigarettes, or e-cigarettes, is on the rise as well. E-cigarettes, also known as vaping pens or hooka pens, are being aggressively marketed to younger users. According to the CDC, e-cigarettes are battery-powered devices that provide doses of nicotine and other additives to the user in an aerosol.

 E-cigarette cartridges typically contain nicotine; a component to produce the aerosol, generally either propylene glycol or glycerol; and flavorings, such as fruit, mint, or chocolate.

 The percentage of high school students who reported ever using an e-cigarette rose from 4.7% in 2011 to 10% in 2012.

 Altogether in 2012, more than 1.78 million middle and high school students nationwide had tried e-cigarettes.

It is well known that early addiction to nicotine, regardless of the delivery system, is more likely to produce addictive behavior. The effects of nicotine on the adolescent brain are quite different than those in adults, according to Theodore Slotkin, PhD. “Adolescence represents a unique period of vulnerability for nicotine-induced mis-programming of brain cell development and synaptic function. Effects of nicotine on critical components of reward pathways and circuits involved in learning, memory and mood are likely to contribute to increased addictive properties and long term behavioral problems seen in adolescent smokers.”

Currently, e-cigarettes are not regulated by the FDA. As a result, manufacturers are not accountable for the accuracy or consistency of the dose of nicotine and are not limited by the laws prohibiting the marketing of tobacco products to teens. Testing of e-cigarette cartridges has shown highly variable and inconsistent nicotine content, often higher than indicated by the label. In addition, a significant percentage of teens believe that flavored vaping pens do not contain nicotine, and many also believe that vaping is good for you.

[[{"type":"media","view_mode":"media_crop","fid":"23855","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_7711321967653","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1984","media_crop_rotate":"0","media_crop_scale_h":"266","media_crop_scale_w":"200","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"line-height: 1.538em; margin-left: 0px; margin-right: 0px; float: right;","title":" ","typeof":"foaf:Image"}}]]While cigarette companies say they don't market to kids, e-cigarettes flavored with cherry, strawberry, vanilla, and cookies and cream milkshake are clearly not aimed at adult users. In addition, advertisements such as the one shown here, which appeared in 

’s swimsuit edition, are clearly aimed at making the use of these devices sexy to younger users.

 In targeting younger consumers, e-cigarette manufacturers (often subdivisions of “big tobacco”) are actively recruiting a new generation of nicotine addicts.

The health hazards of e-cigarettes are concerning for teens, but also worrisome is the opportunity for younger siblings to get their hands on the liquid nicotine cartridges, which are not required to be childproof. The candy and fruit flavors appeal to young children, and evidence backs this up. The CDC recently reported a 41.7% increase in monthly calls to poison control centers involving e-cigarettes from September 2010 to February 2014.

 More than half (51%) of these monthly calls involved children 5 years and younger. Poisoning from liquid nicotine can occur through ingestion, inhalation, or absorption through the skin or eyes and can be deadly.

Not only are teens using more marijuana and more e cigarettes, there is a growing use of vaping pens for smoking marijuana. Many “vaping” devices are able to accept alternatives to nicotine cartridges, including marijuana, dried herbs, and essential oils. Because there is no ash or smoke produced by e-cigarettes, there is little to no smell. That makes marijuana use via these devices almost undetectable. There are a remarkable number of articles in the press in which comments are made to the effect that vaping marijuana makes it possible to get high almost anywhere, including in school.

In short, we are facing a new era in teen drug use and accessibility. Clearly, increases in nicotine and marijuana use are not as worrisome as the heroin epidemic sweeping the United States, but their use is significant. While we are gynecologists and obstetricians, not pediatricians or family doctors, we nonetheless care for the whole patient.

In the case of adolescents, drug use, school performance, psychological state, and sexual activity are all intricately related. We can’t confine ourselves to “just” the gynecological issues. As physicians, we have an obligation to address these more global issues with our teen patients as well.

1. Office of National Drug Control Policy. Marijuana: Know the Facts. October 2010. Available at: 

2. Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological decline from childhood to midlife. 

3. Centers for Disease Control and Prevention. Notes from the field: electronic cigarette use among middle and high school students-United States, 2011–2012. 

 September 6, 2013;62(35);729-730. Available at: 

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6235a6.htm

4. Centers for Disease Control and Prevention. Tobacco product use among middle and high school sudents-United States, 2011 and 2012. 2013;62(45):893-897. Available at: 

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6245a2.htm

5. Slotkin TA. Nicotine and the adolescent brain: insights from an animal model

6. Elliott D, for National Public Radio. E-Cigarette critics worry new ads will make 'vaping' cool for kids. March 3, 2014. Available at: 

http://www.npr.org/2014/03/03/284006424/e-cigarette-critics-worry-new-ads-will-make-vaping-cool-for-kids

7. Chatham-Stephens K, Law R, Taylor E, et al. Notes from the field: calls to poison centers for exposures to electronic cigarettes-United States, September 2010–February 2014. 

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6313a4.htm?s_cid=mm6313a4_e

Marijuana and e-cigarettes can cause harm in more ways than you may think. Do you ask your patients about their marijuana or e-cigarette use? The numbers may surprise you.

Marijuana and E-Cigarette Use in Teens

Navigating the complexities of privacy in the adolescent gyn patient can be difficult and frustrating for clinicians as well as for the patient and her parent(s). As much as we would like to offer absolute privacy to our adolescent patients, our health care system isn’t set up to guarantee such an offering.

However, there are steps that we can take to better balance the needs and legal rights of our adolescent patients with those of her parents.

Most of the teen patients I see come in for their first visit with a parent, usually their mother. After we have gone over the primary reason for the visit, I steer the conversation to the rights of the teen patient as related to privacy. My practice is in New York City, and my adolescent gyn patients are entitled to privacy with respect to STD screening and treatment, as well as to family planning services and evaluation/treatment after sexual assault.

I explain to both parent and patient that my primary relationship will be with the teen and that I will maintain that privacy except in very specific circumstances in which I feel that her life or health is in serious jeopardy. I also go over examples of health care decisions in which the parent will be involved, such as vaccinations, treatment of (nonsexual) medical conditions, and surgical consultations. Finally, I explain that, regardless of the circumstances, I will always insist on including my patient in any communication I may have with her parents.

About 50% of the parents/guardians are already aware of this need for privacy and are able to respect their child’s rights and independence. The other 50% go pale, grind their teeth, or otherwise show their displeasure with me. I always am quick to reassure parents that I am, in fact, on their side: I am interested in the safety and well being of their adolescent. I reassure them that I am not interested in keeping secrets and always encourage young patients to talk to their parents. I emphasize that my role is to provide a safe and confidential place for their child to come with questions or issues that they are facing.

Without fail, once our discussion is over and the parent has left the room, the adolescent slumps in her chair with relief and thanks me for protecting her privacy. We then can go on to talk openly about the issues that she is concerned about that she may not have been comfortable sharing with her parents.

Once I am alone with my patient, I assess whether or not the “real” reason she is in my office is the same one she presented with her parent present. For example, is she really there to start the pill for her acne, or is she, in fact, sexually active and seeking contraception? This is also the time that issues of sexual abuse, depression or anxiety, or trouble in school may come out. Reassuring her that I will keep the discussion private is crucial to building trust and to ensuring that she is able to access the services she needs.

To paraphrase the observations of Abigail English, Director of the Center for Adolescent Health and the Law, “Findings from more than two decades of research has consistently documented that … privacy concerns can lead adolescents to delay seeking care or forgo care entirely and can affect their choice of provider, the candor of their responses to questions about sensitive topics, and their acceptance of specific types of care.” 

Learning the privacy and confidentiality laws in the state in which you practice is crucial to taking proper care of adolescent patients. There are three primary areas of privacy addressed by law: the ability of adolescents under the age of majority to consent to medical care without parental knowledge; the ability of parents to request copies of their adolescent’s medical records; and the issues presented by current billing practices of health insurance companies when the parent is the owner of the policy.

Every state has some provision that allows minors to seek medical care based either on the status of the minor or on the type of care they are seeking. 

 A minor can be classified as: emancipated; living apart from their parents; married; pregnant; and parents. Most states have statutes allowing these minors to consent to some or all of their health care. Every state has laws allowing all minors to consent to specific types of health care, including general care, family planning, STD/HIV care, drug/alcohol services, mental health services, and care for sexual assault. While many states allow minors to consent for family planning services, many also restrict access of minors to abortion services without parental consent. The 

,” gives a brief overview of state laws regarding services and minor status.

In principle, care consented to by a minor should also be protected by privacy laws. Unfortunately, a state-protected right to privacy does not always translate into real-world confidentiality.

 In some states, the parents can access medical records regardless of who (they or their teen) consented to the care. Transgression of privacy may also be accidental: for example, a busy practice may accidentally release records to parents that contain private aspects of a teen’s medical care. The expanding use of EMR’s may make this even more common, since there are often no safe-guards that allow this “restricted” content to be separated from the rest of the chart. Issues also arise when messages are left for the teen patient at home. It is crucial to be sure that you have the teen’s email and cell phone, rather than the parents’, on file.

Even when privacy in the office has been protected, a teen using her parents’ insurance may still have her confidentiality breached by the diagnosis/procedure codes on the explanation of benefits. Manipulating coding to hide the true nature of a teen’s visit is not advisable. In addition, laboratory billing is another source of privacy violation that is completely out of our control. It is important to always be honest with adolescent patients about the possibility that their insurance company billing may violate their privacy.

Navigating the complexities of privacy in the adolescent gyn patient can be difficult and frustrating. We need to balance the needs and legal rights of our patient with those of her parents. It is vital for anyone caring for adolescents to become familiar with the privacy laws of their state and to have a clear protocol for confidential medical care. In the end, however, if a teen patient insists that she needs 

 confidentiality, it is best to refer her to a local teen clinic, Planned Parenthood, Title X clinic, or other service that is able to provide free services unencumbered by parental involvement or third party billing.

Sensitive Information in Medical Records: Protecting the Interests of Adolescents: Presented before the National Committee on Vital and Health Statistics Subcommittee on Privacy, Confidentiality, and Security

 (June 15, 2010) (testimony of Abigail English, JD, director of the center for adolescent health and the law. Available at: 

2. Dailard C. New medical records privacy rule: the interface with teen access to confidential care. 

http://www.guttmacher.org/pubs/tgr/06/1/gr060106.html

3. Gudeman R. Adolescent confidentiality and privacy under the Health Insurance Portability and Accountability Act. 

http://www.teenhealthlaw.org/fileadmin/teenhealth/teenhealthrights/yln/03_yln_3_gudeman_confidentiality.pdf

Navigating the complexities of privacy in the adolescent gyn patient can be tricky. Here, Deborah Ottenheimer, MD, a specialist in adolescent gynecology, shares her protocol for providing confidential medical care to teen patients.