All About Adolescent Medicine with Dr. Loreta Matheo

About Adolescent and Young Adult Medicine | CHP.edu

The 5-Minute Clinical Consult 2021

“Whistling Vivaldi” by Claude M Steele

Policy Statement: The Impact of Racism on Child and Adolescent Health | The American Academy of Pediatrics

Developmental Milestones: Young Teens (12-14 years of age) | CDC

Developmental Milestones: Teenagers (15-17 years) | CDC

Reference Card: Minors' Access to Confidential Health Care In Pennsylvania | ACLU Pennsylvania

Confidentiality | Pennsylvania Department of Health

Cultural Competence and Ethnic Diversity in Healthcare | NIH National Library of Medicine

You can subscribe to That’s Pediatrics on Apple Podcasts, Google Podcasts, Spotify, and YouTube. If you enjoyed this episode, make sure to listen to others here and rate and review!

Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Arvind Srinath: Welcome to That's Pediatrics. I'm Arvind Srinath.

Dr. Amanda Poholek: And I'm Amanda Poholek.

Dr. Srinath: Today's topic is adolescent medicine. What it is, what it does, and who we are. Our guest speaker today is Dr. Loreta Matheo. Dr. Loreta Matheo graduated from New York University School of Medicine and went on to be resident and chief resident at Harbor UCLA Medical Center. She joined the division of adolescent and young adult medicine in 2005, having been on staff as a general pediatrician at UPMC Children's Hospital since 1992, while working as a lead physician at Duquesne University Health Services.

During her time with the division, she has served as program director for the adolescent medicine fellowship up to January 2022. During her tenure, the program went from a compliment of three fellows to five. Improving access to care has guided her career. She serves as the liaison for embedded model of adolescent medicine with Children's Community Pediatrics, has headed the task for transition to adult care, and currently sits on the telehealth steering committee. Access is part of inclusion for all most recently, as she was appointed Vice Chair for diversity, equity, and inclusion for the department of pediatrics. During this time, she has successfully worked to recruit and mentor faculty and trainees from historically marginalized communities, as well as facilitating programming to improve cultural competency in the department of pediatrics while working in collaboration with other DEI champions at UPMC Children's and across all UPMC. Dr. Matheo, thank you for joining us.

Dr. Loreta Matheo: Thank you for having me.

Dr. Srinath: So can we just start with a background? So what drew you to Pittsburgh after training at NYU and later Harbor UCLA Medical Center?

Dr. Matheo: Well, it is an interesting story, I will say, the short answer is my husband. The longer answer is that when I was a general pediatrician in practice in Santa Monica, I was very close with my patients and their families, I was single at the time, and the parents were always trying to set me up. And one day, one of the parents said to me, "Hey, I've got a great guy for you to meet." And I said, "If he's so great, what's the catch?" And they said, "He lives in Pittsburgh." And I said, well, you know, you know, I liked the person who was introducing us, I thought it'll at least be a fun dinner date. So I said, yes. And I met my husband, we fell in love obviously, and we had a decision to make about where we would be. He's a professor of Carnegie Mellon, and my family's in New York, and I really felt that, you know, raising children would be much more doable in Pittsburgh than Los Angeles, wanted to be closer to my family, and so I found out what I was flying over all those years from New York to LA, you know, I landed here, but that was a bit of a shock, compared to landing in New York and LA, there were no lights back then anywhere near the airport. But that is how I got there.

Dr. Poholek: Oh, what a fun story.

Dr. Matheo: Yeah.

Dr. Poholek: Yeah.

Dr. Srinath: Outside of Pittsburgh, you know, I think about you as the quintessential adolescent medicine physician. When I see, when I hear Dr. Matheo, I think adolescent medicine and advocacy and diversity and equity inclusion. What drew you to your respective fields?

Dr. Matheo: Yeah. So, you know, it was actually for me, a very windy path, getting to adolescent medicine, I did not take the typical path, and I'm happy to talk about what the typical path is, that was not me. I was a baby doctor, that's what I wanted to be, going back to high school, and I started out being in general practice in Santa Monica, as I said, and I came here and I was in general practice and I took a job at Mercy Hospital, which was separate hospital at that time, it was not in the UPMC family, and I had a great opportunity there, and right before I started, I was called and they said, "Hey, you know that job that we promised you? We'd like you to do something different. We'd like you to cover Duquesne University's health service because the doc who does that for us is leaving." And I thought, hmm, “I don't take care of anybody taller than myself,” but I really wanted to be with this group, and, you know, I tend to say yes to things, so I said, “sure, but I want my original contract back if I'm not happy in six months.”

And really by six months, I had fallen in love truly with taking care of young people. These are much more older adolescents, young adults, all really, you know, 18 to, you know, I was actually comfortable to 26, 30, I would say, and the honesty, the need, these are young people accessing care for the first time often by themselves, and it was such a range from very straightforward, to very complicated cases, it was incredibly stimulating intellectually from a medical point of view.

And fortunately we had the Five Minute Clinician to get me through the things I didn't know, but this was before the Internet. Yes, I'm old, and needed the Five Minute Clinician, and I just really fell in love with the honesty of young people.

And then at some point I started doing more and more college health, less gen peds, and at one point my department had said to me, "So Loreta, how about, you know, can you take over our division of adolescent medicine?" It was a division of one at the time, the person who did that job was leaving, and I said, yes, again. And he said, "You know there's a catch. You have to be board certified, of course. And this is the last year you can sit for boards ‘based on clinical experience.’"

So I had to sit for boards without a fellowship and passed that test, which I, you know, managed to do. And then I took over that division for a while. And then eventually the contract shifted to Children's, I followed, and here I am.

Dr. Poholek: Oh, wow. That's great.

Dr. Srinath: That's amazing.

Dr. Poholek: So I would like to admit to you that I am the parent of a nine-year-old-girl. And so I am wondering, can you share with us a little bit about what someone like me might be thinking about needing to expect, especially in light of thinking about what it is that our young people are facing today?

Dr. Matheo: It is a challenging, challenging time. I mean, we, you know, socially, politically, economically, you know, so much is going on in the world, and young people are so much more in-tuned.

Now I grew up in a bubble and I grew up in New York, and you know, my world was so small. You know, my immediate family, my immediate friends, my grandmother, that's what we did every Sunday, I mean, that was life, right?

You know, your daughter, depending on how much you've allowed her to be in social media, you know, she's exposed, and even if she's not, her friends may be, and so they're sharing. And so they are seeing all the tumult going on in this world, which can affect young people.

But it's also a time though, when you know, your daughter's starting to think about who is she, where do I fit in here, who am I? Such profound questions that are starting to come, so being open is the single most important thing for your young, your pre-teen going on to teen life. Just listening – listening to what they say, paying attention, of course, to what's going on in their lives, being there, but the listening is critical. Non-judgmental listening.

So when they say something, you think, oh my God, no. Or where is that coming from? Who told you that, to try and not do that as best anybody can, it's not like I didn't do that, plenty of times, none of us is perfect, and understanding our children don't expect us to be perfect, which is also critical to know, right? Critical to know, your children don't expect you to be perfect, but children and adolescents are incredibly forgiving. But so when you hear these things to listen, and be curious, so what do you think about that? What are your thoughts?

Dr. Poholek: Okay.

Dr. Matheo: Let them know you respect them.

Dr. Poholek: Okay, excellent advice. So let's pivot now to thinking more like a clinician, which I am not, but tell me, as a clinician, what are the things that you are thinking about when you're dealing with adolescent medicine, with these people as they're coming in at this time?

Dr. Matheo: Yeah. So certainly the body is changing rapidly, and so we want to make sure that a young person is developing normally, which the vast majority of young people do, but we wanna be on the lookout for any delay, any speeding up, too slow, too fast, not developing correctly is a very big part.

It's also a time we do know when mental health issues can become, excuse me, come into play, and you want to be paying attention to any really significant changes in how your young person is acting day-to-day. Are they not hanging out with friends that they used to hang out with, are they not communicating the way they did before? So being on the lookout for those things, because again with what's going on in our culture, in our country, in our world, there's so many questions that affects young people, and just, we know, even without those things, it's a time of change.

Certainly she will be entering puberty yeah at this time, and so it's important to be paying attention, it's important to have the conversation about what's happening with her body and the changes and how normal they are, and if you have a boy it's also very important to tell our young men what's happening with their bodies, and how normal that is, because kids have a lot of questions about that. Depending on the school your child attends, they may or not be getting information there, but the parent is definitely the best source.

Dr. Srinath: I so appreciate that concept of listening, because as parents, you know, we are here to protect our children, and our natural inclination is to hear something and fix, fix, fix, right? And it's, I so appreciate you reinforcing that. With healthcare providers who are also listening too, what cues or concerns or even issues, should they be thinking about reasons to refer to you and your colleagues?

Dr. Matheo: So certainly from the, a very common referral for us revolves around menstruation, right? And when the first period and you know, the American Academy of Pediatrics considers it the fifth vital sign. I will say that back in the day when I was at Duquesne, I made it our fifth vital sign way before, because certainly going into a room, you wanted to know.

And so, you know, making sure that your young person is obtaining this developmental, physical milestone, typically two years after breast development, one can expect menarche, and certainly by 15, some will say 16, if there is no menarche, this needs to be looked at, but I like to focus a little bit more about, you know, is there breast development, because that will be more commonly happening, in two years after that, more or less. There's a lot of genetics behind this, so some people will take longer to start their period, some people will have their period much younger, but you do wanna be paying attention to that, because there are medical conditions that will get missed, if one is not paying attention to whether puberty is advancing on time. It's a tempo, things move in a certain way, and if they're not going in the direction that they should be, that's a reason to refer. If period is coming too early, if period's coming too late.

And we all know that we talk about the irregularity of periods in the beginning, but that's not to say that all irregularity is okay, right? It's never okay to miss three months in a row, once a young woman has had her first period. It may be normal for them, but the onus is on us to prove that. So if they're going past three months, please either refer or start investigating. And also if they're having two periods a month, you know, they're going to get anemic potentially very quickly, so that should be checked, as well. And also cramps, I had somebody the other day for years, really missing school because of terrible cramps. We don't, there's no reason for that in this day and age. And so young people don't need to suffer.

Dr. Srinath: And by ages, is there a certain age cutoff that you would consider would be appropriate or appropriate starting to consider referral, or is it more --

Dr. Matheo: Yeah, so our standard, typically speaking, we say 12 to 26th birthday. I've certainly have taken care of younger folks than that, because it depends on what's going on in their lives developmentally, it may be appropriate for us to be seeing them, and so we've certainly seen, you know, nine-year-olds, 10-year-olds, 11-year-olds, but typically speaking, it's 12 to 26 for our clinic.

Dr. Srinath: Got it, thank you.

Dr. Poholek: So I feel like there's these terms going around that I've heard a lot of lately, consent and confidentiality. I was wondering if you could kind of talk a little bit about that and what it means, and what's important to know for both parents and clinicians.

Dr. Matheo: Yeah, super important. This is a cornerstone for us in adolescent medicine, and this of course varies state-to-state. So what I'm talking about is what matters in Pennsylvania.

So in the state of Pennsylvania, a young person under 18 may not consent for care. Their parent must consent for the care. The exceptions would be emergency or an emancipated minor. Someone who is pregnant, in the military, has graduated high school. There's one more I can't think of at the moment. I apologize.

So, but there is an exception to consent, and confidentiality should back up and say, confidentiality follows consent legally. So the first thing you must decide is can this person consent for the care in the state of Pennsylvania? And once you say yes, this person can consent, then that person then has control of their medical records, and so they have confidentiality.

So in the state of Pennsylvania, if you are under 18, you may consent for birth control, care of pregnancy, you may also consent for screening and treatment of sexually transmitted infections, assistance with substance use, mental health. Mental health actually starts at 14, and that's primarily outpatient. But the key here is that for reproductive health in general, minors can consent and because they can consent, they are entitled to confidentiality, and that must be protected as an adult physician would protect the confidentiality of their adult patient.

Dr. Poholek: Interesting.

Dr. Matheo: Very difficult for parents, really challenging, I will also, I want to add to this, it's not a free for all, okay? Meaning as I tell my patient though, there are limits to everything we do, there's an upside and a downside, “There's no free lunch.” I've got lots of metaphors for this. So there are caveats and it is very, very important to explain the limits of confidentiality to the patients and the parent, okay? Because it's not a game of “gotcha” either, right? We never want a young person to divulge something to us that we must then report, and they were not aware that this could happen.

And so the limits, as I explained to my patients and parents is all about harm. If a young person is harming themselves, if someone is harming them, and the most rare is they're gonna go harm somebody else, which has happened, you know, then if I can't make that stop working with this young person, then we need to bring a trusted adult into the conversation. And of course I'm a mandated reporter in the state of Pennsylvania.

And then I always add, and the state of Pennsylvania says who can have sex with whom at what age. And that age in Pennsylvania is 13. Between the ages of 13 and 15, a partner may not be more than four years older than the person consenting. After 16, a young person can consent to have sexual activity with whomever they choose.

So that's kind of a mouthful, but it's very, very important. And when I'm talking with patients and parents, and we're about to have a confidential conversation, I like to get all of this out with both patient and parent in the room up front, so they know what's happening, and that they are not cut out of this loop, that there are reasons why we may need to be talking, I also let the young person know, I would never reach out and say, "Hey, Ms. Smith, Mr. Smith, you know what so and so is doing?" I would always be going, talking to the young person first, and then I want everybody's cell phone numbers, I wanna make sure that they have their voicemail set up, and that their voicemail is not full because as you know, our phones are one way and our young people can't just hit call back if I'm calling from the hospital, so ...

Dr. Poholek: Right. Do you find that this is a conversation you need to have with every adolescent that comes through the door-

Dr. Matheo: Yes.

Dr. Poholek: -whether they have something to share or not?

Dr. Matheo: Correct.

Dr. Poholek: And do you find that that conversation is harder to explain to the young person or to the parent?

Dr. Matheo: You know, I do it with them together, and I will say every once in a while, you know, a parent may feel uncomfortable, but I have found, you know, parents, you know, parents want the best for their young people. And so, and hopefully they're trusting me. And so many parents will, you know, “Yes, go,” you say, “Tell her, all right, just tell her whatever you want.” And some parents, you know, feel very strongly, you know, "In our family, we discuss these things among ourselves."

I want families to know that this is part of what we do with all children, I am always asking young people, one of my standards is, “What are the value systems of your family? What has your family told you about X, Y, and Z?” That's a place that I will often start, particularly with my younger adolescents, and so I encourage parents, you know, I'm asking questions, I'm not telling young people what to do, I'm asking questions and my goal's to keep them safe. Right, it's about safety. The most important thing is for parents to discuss their value systems with their young people because parents matter.

Dr. Poholek: Yes.

Dr. Matheo: So I do think it's important and yes, every single new patient we see hears this.

Dr. Srinath: So that brings up a really important concept of how comfortable children are at times without their parents, particularly on the younger end of the folks you see, and techniques that you've learned, and what assistance you have with the other infrastructure within your clinic, i.e. behavioral health, and what role they play in helping patients?

Dr. Matheo: Yeah, so I mean, certainly if a young person, so typically we're starting at 12, but most of those young people are ready to separate. Every once in a while, a young person does not want their parent to leave the room, and that is their prerogative. They're in the driver's seat. If a young person is fine with their parent leaving the room and the parent is not so fine, that's a much more challenging situation, and I will try and explain that this is again, normative, we do this with everyone.

But ultimately, you know, if a family is not comfortable at that visit, I'm saying, well, I hope that the follow up visit we'll be able to have established enough trust that we can do this. In terms of comfort, when I have a young person who, you know, particularly during a confidential conversation, you know, is disclosing challenges with anxiety, depression, maybe they're questioning their gender identity, their sexual orientation, their sexual attraction, we will have a conversation about those things, where this is what we take care of in Adolescent Medicine all the time.

Sometimes a young person may need help beyond what we could do in terms of any of those. And so, fortunately, incredibly fortunately for us, we have embedded behavioral health in our division, and incredibly fortunate, spoiled if you will, that we have an amazing colleagues just across the other end of the waiting room.

And so I can bring someone in for what we call a “warm handoff,” more diagnostic conversations than I can do as a physician, this is what our behavioral health folks will do. And so being able to bring somebody in, in the moment to talk to someone who may be in crisis or need more help, or just a “warm handoff.” We've discussed a young person having depression or anxiety, we've come up with a plan, the parents are typically aware of this, and they're gonna follow up with therapy, there's nothing like having someone from behavioral health come be introduced by the provider and say, "Here's someone I trust. Here's a professional with more expertise than I have, and why don't you guys touch base and talk a little bit?" And then I exit. And then they get to meet that behavioral health specialist who may or may not be the one who does the therapy, but at least we're making that bridge, which is really just tremendous.

Dr. Srinath: That's super helpful.

Dr. Poholek: So we've been talking about young people really collectively at this point. And I wanna make sure we have an opportunity to touch on issues that you feel are specific to certain groups of young people, particularly given the last two years in thinking about diversity and inclusion. Can you share with us anything regarding that?

Dr. Matheo: You know, it is challenging, particularly these years with COVID, right? COVID really shown a light for everyone to see what folks in the Black and Brown community have known about the issues of structural racism that go on in our country. And that's just the honest truth.

COVID, you know, today the mast, the flags are half mast, you may have noticed our President has done that because we are marking one million people dead from COVID. It's just mind boggling, right? And we do know that the disparities exist there. Black and Brown people died from COVID at rates higher than any other group. And, you know, if you drill down like, well, why was that? It has nothing to do with genetics, because we are 99.9% the same genetically. But opportunities are not equally distributed, right? Talent is, opportunities, not so much.

And so young people lived this. They know that their parents were in the service industry, considered essential workers, not making necessarily a lot of money, and they had to go out during COVID before we knew even what was going on. They got sick. They had many people from Black and Brown communities have because of social determinants of health, higher risk factors than other folks. And so they were getting sick more easily, they were having more severe disease. They were dying. And young people know this. They live this.

And during adolescence, when you're young, maybe you feel what is going on in terms of what's happening in my neighborhood, what happens to my family, what do I see going on. As you become an adolescent, you start to live this, you start to understand that maybe I'm being followed in a store. Why is my school, why does my school not have all the whistles and bells that other schools have, right? How do we get to this? Young people know this. They know that there's discrimination. And you go from being a child and sort of seeing it, but not understanding it, but now you're internalizing it. And it affects our young people.

They understand. There's a book called “Whistling Vivaldi.” And it's about a young man in college, actually, I believe it's Chicago, someone can correct me if I'm wrong about the city, and it talks about being a college graduate, college student or an undergrad walking through predominantly White neighborhoods and not wanting to draw attention to himself as a large, physically large Black man and whistling Vivaldi, because that would make others feel less worried about him because of course he knows classical music, and so less othered, right? As opposed to singing something else.

So this is the life of a day-to-day young person of color in this country, and whether you are Black, whether you're LatinX, or AAPI community, there are challenges. And our young people come to us with this as part of their life. And so we need to understand that in addition to, you know, what's going on with puberty, what's going on with their headache, what's going on with their periods, they are also dealing with realizing that their so-called place in this world is different. And how am I going to navigate that?

Dr. Poholek: So looking into the sort of future, how do all of these things, particularly this last, you know, portion we've talked about, of how people, young people are recognizing that, you know, there is systemic racism, how does that change the field of adolescent medicine? How does that, you know, focus you in the care?

Dr. Matheo: So, you know, I think like, I think that adolescent medicine in general, as society for adolescent health and medicine has been working on this pre-COVID for a long time. This has been who we are. Advocacy is a very, very big part, it's a big part of pediatrics, and it's a very big part of adolescent medicine.

I can, you know, refer folks to the incredible policy statement by the American Academy Pediatrics group was headed by the amazing Dr. Maria Trent from Hopkins, talking about the effect of racism on children, and adolescence, this is an amazing document. And, you know, we need to meet our young people where they are, we need again to listen. We need to educate ourselves, become culturally competent, make sure that the staff, our office, our providers are culturally competent, and understand what young people are dealing with. And it means we also advocate, that we stand up.

We all, we get invitations to talk at different places, our voices matter, and so accepting those invitations to speak is very important. Talking to folks in the legislature locally, nationally, speaking up, using our bully pulpit, I think is very, very important. Understanding that despite all the challenges, young people are amazing. They are amazingly resilient. And so, as you, on the one hand, you want to understand and be prepared, on the other hand, please lead with the strength, right? Understand there are challenges, but that's not where we start. We start with the strength, a strength-based counseling and care, family-centered care, this is what helps our young people. Understanding the challenges, but always lead with the strengths, because every day they amaze me.

Dr. Srinath: Dr. Matheo, I feel like we've only looked at the tip of the iceberg in terms of the complexities that we've covered today, and we cannot thank you enough for taking the time to give us this amazing overview and detail and rightfully so really highlight some really key issues pertinent to right now, too. Thank you so so much.

Dr. Matheo: Well, thank you, thank you, always love talking about amazing adolescents. No two days are the same and we're never bored.

Dr. Poholek: Thanks so much.

Dr. Matheo: Thank you.

Dr. Srinath: Thank you.

Voiceover: You can find other episodes of That's Pediatrics on iTune, Google Play Music and YouTube. For more information about this podcast or our guests, please visit chp.edu/thatspediatrics. If you've enjoyed this episode, please be sure to rate, review, and subscribe, to keep up with our new content. You can also email us at podcast.upmc@gmail.com with any feedback or ideas for topics you'd like our experts to cover on future episodes. Thank you again for listening to That's Pediatrics. Tune in next time.