Developing Leaders in Adolescent Health

The majority of teen health concerns — pregnancy, sexually transmitted diseases, substance abuse, suicide, violence and car accidents — stems from behavioral choices. That’s why providers have traditionally armed themselves with an array of prevention messages and programs when approaching teens. It’s a sensible approach, but recently something important has been added to the mix, according to Erica Monasterio, clinical professor of pediatrics and nursing and nurse faculty member in the Leadership Education in Adolescent Health (LEAH) program at the UCSF medical school’s Division of Adolescent Medicine in the Department of Pediatrics. In addition to academic appointments in the schools of nursing and medicine, Monasterio provides clinical services in the UCSF Teen Clinic, the Young Women’s Clinic at Mount Zion and Cole Street Youth Clinic. “Rather than looking at teens as problems to be solved, we’ve begun approaching them in a more positive way, as unique individuals with something to offer,” she says. The theory is that by giving teens a sense of belonging and the opportunity to make a contribution — using everything from employment, academic support and recreational programs to service learning experiences and serving as mentors for younger children — they will develop the confidence and knowledge to make healthier choices. It’s an approach that is fully in line with the trend toward more patient-centered care. “The locus of control for improving health is with the individual — something clinicians can easily forget when working with teens,” says Monasterio. “We use our clinics to model how to do more listening, find the teens’ strengths, and help them determine what they want to work on and how they want to work on it.” While research has not yet had time to establish clear links, the latest reports from the National Adolescent Health Information Center at UCSF indicate an encouraging nationwide decline in teen mortality, pregnancy, STDs, suicide, violence and accident rates. Training leaders who understand the latest techniques and findings can help ensure that those trends continue. That’s where LEAH and Monasterio come in.

Interdisciplinary Approach

In 1977, UCSF became the site of one of the first LEAH projects funded by the Maternal and Child Health Bureau in the Health Resources and Services Administration. UCSF has retained LEAH funding ever since. The project provides interdisciplinary leadership training for graduate (master’s and PhD degree) and postgraduate students in five disciplines: adolescent medicine, psychology, nursing, nutrition and social work. The idea is to prepare these students for leadership roles in clinical services, research, training and development of health services for adolescents. For the UCSF School of Nursing, this means that each year, about 20 students with an interest in adolescent health become LEAH trainees. “Short-term” trainees take a three-quarter-long, interdisciplinary core seminar that covers everything from youth development to adolescents’ social context and adolescent health policy. A select few each year apply to become long-term trainees, where they design individual one- to two-year programs that typically include additional coursework, independent study, interdisciplinary rounds and a clinical rotation in a faculty-run teen clinic. Having led the nursing component of the program for a decade, Monasterio believes that because teens’ behavioral choices emerge from a complex bundle of factors, an integrated understanding yields the best clinical results. Consider obesity. Due to their training, many physicians and nurse practitioners typically think of obesity from a pathology perspective, focusing on such things as endocrine problems and how childhood obesity can lead to a myriad of health problems in adult life. A psychologist might consider obesity in the context of how young people perceive themselves and what techniques can motivate behavior change. A nutritionist has the best grasp on how to do effective dietary counseling, while a social worker understands best how to get the family to support incremental steps toward weight loss. “The [LEAH] trainees have the opportunity to see and work with experts in all of these fields,” says Monasterio. This gives them practical skills and perspectives that can make them more effective when dealing with patients. After all, it’s rare in health care that all of these experts would be in a room with a patient together. Most of the time, providers are alone with a patient and have to draw on all of their knowledge to deliver the best care possible. “Trainees tell me that the best thing about the program is the exposure to different ways of thinking about a medical problem and solution,” says Monasterio. Monasterio believes there’s another crucial value in interdisciplinary training: developing the confidence and comfort level to work effectively with other disciplines. “The reality is that the system is still hierarchical, and new nurse practitioners are often intimidated by docs and have a hard time owning their area of expertise,” she says. “The training helps them all interact as equals and makes it easier to communicate.” Monasterio describes a former trainee from the Family Nurse Practitioner program who, during her time as a LEAH nurse trainee, made connections that led to her being hired as the first-ever nurse practitioner at a prominent hospital-based adolescent medicine clinic. Within a year of starting there as the “reproductive health clinician,” the former trainee was able to convince her colleagues to integrate reproductive health services into the general adolescent medicine clinic in order to reduce the barriers to care. “She talks about how this was possible, in part, because of the level of comfort she developed in dealing with other disciplines,” says Monasterio. It is experiences like these — the LEAH program’s ability to expose advanced practice nurses and nurse researchers to the latest interdisciplinary thinking on adolescent health — that provide trainees with an experience that is hard to come by anywhere else in the country. “One of the great advantages at UCSF is we have a nationally prominent adolescent training program,” says Monasterio. “It’s an environment where I’m continually challenged to understand how people are thinking, what they’re writing, what they’re finding in research. All of that gets shared in interdisciplinary work, and all of us — the trainees especially — are immersed in that environment and fertilized by it.”

Photo by Elisabeth Fall