THE IN-BETWEEN DOCTORS

Neither pediatricians nor adult doctors, these are specialists who
work with adolescents and are seeking recognition for their field in Canada

Growing up with a chronic disease is hard. So are depression, school
stress, and navigating the ups and downs of romance.

Add adolescence to the mix and life can get very complicated.
Sometimes even dangerous.

Sarah Ripley, 22, remembers. Diagnosed with diabetes at age 4, she
had adjusted to the daily ritual of blood-sugar tests, insulin and a
strict diet. Until teen hormones kicked in, and with them the urge to
fit in with peers, to party and push the boundaries.

"I was a stubborn teenager," says Ripley. "I was going to do what I
was going to do, regardless of what anybody said."

Enter Dr. Rahul Saxena, a specialist in adolescent medicine, who is
trained in the complexities of teen health, brain development,
behaviour and psychology. He loves the energy and challenge of that
age group, and the opportunity to provide the emotional and
psychological support that are as much as part of his practice as medical care.

"Dr. Saxena figured out how I could find a way to fit my adolescence
in with my diabetes," recalls Ripley. "He didn't talk to me like I
was a patient, and use all these medical words. I could really relate
to him and understand what he was saying."

Ripley met Saxena when she was in Grade 10, after a social worker
referred her to the Galaxy 12 Teen Consultation Clinic in
Scarborough, at the Centenary site of the Rouge Valley Health System.

She's gone regularly ever since -- through her toughest teen years,
during bouts of depression and acting out, when she left home and
then became a single mother at 19.

"He was the best thing that came into my life at that time," says
Ripley, now the mother of a 2-year-old daughter. "I don't know where
I'd be without him."

She's currently in school full-time taking a course in American Sign
Language and deaf studies.

There are many reasons for teens to have their own doctors primed in
the issues they're facing. Next to the early years, adolescence is
the most dramatic developmental stage, both physically and
emotionally. It's also a confusing and contradictory time, as youths
try to forge their own identities and break away from parents, but
still need adult guidance and support.

Reckless behaviour tends to peak at this time, whether it's
experimenting with drugs or sexual activity. Mental illness often
surfaces in teen years.

At the same time, this is the stage when kids with chronic diseases
need to take over the reins of their illness and learn to balance
safety with rebellion.

While adolescence used to refer to the teen years, it is now
considered a stage that can start in pre-teens and extend through the
early 20s, when, as recent research has shown, the brain is still
developing. That's why some adolescent physicians, like Saxena, still
see patients well into their 20s.

Despite increasing pressures and complex choices faced by modern
youth, adolescent medicine is largely unknown. And unless a child is
facing a specific problem like substance abuse, mental illness or an
eating disorder, it's hard to get access to an adolescent medicine
specialist. (See accompanying story for available options.)

"Adolescence today seems a hell of a lot more stressful and
complicated than when we were kids," says Saxena, 37. "And in
adolescent medicine we shy away from few topics."

Adolescence is an ideal stage to influence future health care
choices, says Sandy Marangos, manager of child and adolescent
ambulatory services at North York General Hospital.

"If you've had a positive experience in your younger years, you're
more likely to continue with health care and treat it as a part of
your lifestyle," she says.

Adolescent specialists are trained to speak without judgment and
treat youth with respect they don't often get at that age, she says.

Many teens in good health will get everything they need from a
pediatrician, who is trained to deal with children up to 18, or a
family doctor. But others may be reluctant to confide in a physician
they've known since infancy or one their parents use. And the result
may be they don't ask about topics like sexual health or drug use.

According to the Child and Family Services Act, kids age 12 and up
can seek medical care or counselling without consent of parents. But
some reluctant kids may be more likely to get the care they need in
the hands of an adolescent medicine specialist.

Debra Katzman, head of adolescent medicine at the Hospital for Sick
Children, says when teens come forward, it's often over problems that
are stigmatized such as sexually transmitted diseases, substance
abuse, unintended pregnancy or depression. So it's important there be
few roadblocks to providing care.

"It's not just seeing someone for an ear infection. It's recognizing
that when they come in for that ear infection there are actually lots
of other things going on ... it's never simple."

At hospitals like Sick Kids, physicians for adolescents work in
multidisciplinary teams that include psychiatrists and psychologists,
social workers, dietitians and nurses. Those with their own practice,
like Saxena, who also spends two mornings a week at Sick Kids, also
have access to other specialists.

Many physicians in the field would like to get recognition for
adolescent medicine as a sub-specialty in Canada. This would result
in standards of training and care across the country, more research,
funding and attention.

In the U.S., which pioneered adolescent medicine in the 1950s, it has
been an accredited pediatric sub-specialty since 1991. There are many
more services available to teens there.

That's where Saxena got his training. After the Toronto-born doctor
completed his pediatrics residency at Children's Hospital in
Winnipeg, he headed to Mount Sinai Hospital in New York to study
adolescent medicine for three years. He is one of a handful of
Canadian doctors who are U.S. board-certified in adolescent medicine.

Unfortunately, he says, there's little incentive beyond a passion for
the work to enter this field in Canada. Despite more training, he
earns less money than most pediatricians. He spends a minimum of 30
minutes with each patients and usually sees eight to 10 a day,
billing OHIP according to time codes. Pediatricians can bill per
service and usually have a steady stream of patients coming through
for routine problems like ear infections.

Katzman notes that those working with adolescents need to be flexible
and sensitive. Sometimes that means accommodating a patient who is
late or a no-show, or rearranging the schedule for someone in crisis.

"When you get a kid who's asking for help, you have to seize the
moment. Unlike with an infant, this might be the only time you're
going to get this kid."

Knowing their kids are in the hands of a trusted physician can be a
huge comfort for parents. Caroline, a Whitby mother of two teenagers
who didn't want her surname published, says she was relieved to find
Saxena after one of her daughters became depressed a few years ago at age 16.

"There's no way she could have sat down and talked to our family
doctor the same way," says Caroline, who occasionally gets included
in their sessions. "I could probably tell him anything and I think
the girls pretty much can, too."

Saxena says much of his practice comes down to preventive health
care. And often using a "harm reduction" approach.

"To me, harm reduction is the spectrum of, 'Ideally you shouldn't do
this negative behaviour at all. Pause. But ... if you're set on doing
it then let's discuss the various methods of minimizing the harm you
are about to potentially cause yourself.'"

That might mean teaching kids to be realistic about the risks of
recreational drugs and warning against daily use. It could be
promoting sober transportation from a party, and advising about safe
sex. It might be talking about the emotional side of sexual
relationships for young girls who are dating older guys.

"I think one of the big things that makes adolescent medicine useful
is it gives kids tools to strive for the independence and control
they crave in a safe way," says Saxena, a father of two young boys.

But he stresses that youth have to be motivated by something that
matters to them.

"As long as you can help them see change as a way to reach their own
goals or avoid their own perception of failure then you have a chance to help."