Communicating effectively with patients to optimize their care
Examination of a mature minor
Type of activity: Text case
This text case describes a physician who becomes aware of sensitive information when examining a teenage female. The teenager's mother requests information about the clinical diagnosis and treatment plan but the patient does not wish to share this information. The trigger questions and suggestions to faculty encourage discussion about informed consent, mental capacity (competency), duty of care, and the mature minor doctrine (and in Québec, the minimum age for consent of 14 years) as it relates to a minor patient's right to determine who may access their medical information.
Jackie is a 14-year-old female who is accompanied by her mother to the emergency department. She presents with vomiting and a two-day history of abdominal pain and low-grade fever. Dr. Greene, wishing to interview the patient alone, asks Jackie's mother to step out of the room. Jackie's mother refuses, stating, "My daughter and I have no secrets; I'm staying." Jackie rolls her eyes but remains silent.
After further discussion, Dr. Greene convinces Jackie's mother to wait in the hallway and speaks to Jackie in the presence of a nurse. Dr. Greene inquires about Jackie's sexual history and determines that she has had voluntary sexual intercourse with more than one boy her age over the past 2 months. She is worried she might be pregnant. Dr. Greene discusses the need to conduct a pelvic examination, to collect cervical cultures, and to perform blood work.
Jackie appears to understand the rationale for the proposed care and agrees to it, however she forbids Dr. Greene from discussing the situation with her mother. Jackie has not told her mother that she is sexually active and fears her mother's reaction.
After several minutes Jackie's mother storms into the room and demands to know what is taking so long. She is worried about her daughter and wants to know what Dr. Greene is thinking, including what tests the physician intends to undertake.
- How would you handle this difficult scenario?
- Can a 14-year-old patient impose limits on her physician's communication with her parents? Discuss.
- Should Dr. Greene refuse to abide by Jackie's request and speak to her mother? Discuss.
- If Dr. Greene does not speak to Jackie's mother, how will she ensure appropriate follow-up of the patient?
- Would it make a difference if Jackie was 12 or 16 years old? Discuss.
- Describe some techniques that Dr. Greene might use to get Jackie's mother to leave the room.
- Can a physician admit a teenager to hospital or perform surgery without first discussing it with the teen's parents? Discuss.
Suggestions to faculty
Ask learners to role play the physician's conversation with Jackie's mother. During the role play, ensure learners consider the mature minor doctrine (and in Québec, the minimum age for consent of 14 years).
This case may also be used to discuss documentation of informed consent. Ask learners to consider:
- How should Dr. Greene document the care provided?
- How can the medical record be helpful in establishing that Dr. Greene acted in Jackie's best interest?
Consider how this scenario might be used as just-in-time bedside or ambulatory care teaching.