One of the parenting truisms I have heard over the years is that there are two particularly challenging phases of childhood. The first is toddlerhood, and the second is adolescence. As the parent of a wonderful, charming, bright, inquisitive and often utterly infuriating almost three-year-old, I know the former has proved true in my experience. (He’s the greatest kid in the world, don’t get me wrong. Which is why he continues to survive such exploits as announcing his need to poop on the potty just as I was preparing my lunch and heading out the door for work yesterday morning.) For some reason, I have chosen to make the latter age group the subject of my professional subspecialization.
I mention all of this because I have genuine sympathy for harried, frustrated parents who are afraid their kids are on drugs. Though my son isn’t old enough to make me worried about this kind of misbehavior, I think I understand their perspective.
But I will not order drug tests on teenagers when the patients themselves withhold consent. (I have only ever made one exception to this, which I will discuss briefly later.) If there is concern about the teenager being acutely under the influence and at imminent risk to himself or others, then parents are advised to seek care in an emergency department, where the protocols and ethical obligations are different. But if there is no acute risk of harm, I don’t do the tests.
This is often the cause of great consternation and anger to parents. They still exercise legal authority over their children, after all, and they bring their children to me for care at their own discretion. Who am I to refuse their request? How dare I undermine their prerogatives so bluntly?
The first answer is strictly medical — if your question is “is my kid doing drugs?”, then a negative urine test won’t give you a definite answer. Urine clearance times vary widely [PDF] from drug to drug and with the frequency of use. If your teenager is using cocaine or methamphetamine sporadically, with the last ingestion several days ago, then her urine test could well be negative by the time you get her into my office. What’s the point of a test that cannot reliably answer the question at hand? If she’s lying to you, I cannot promise to uncover the truth.
The next answer deals with confidentiality, and the legal protections surrounding access to confidential care for adolescents. While the law varies from state to state, from what I gather all states offer at least some limited protections that allow for teenagers to access certain confidential health services, specifically with regard to treatment of sexually transmitted diseases. My Google skills have failed me once again, so I haven’t found a comprehensive list of which states have what protections for which services. General guidelines for adolescent confidentiality [sorry, another PDF] tend to focus more on reproductive issues. However, in states with a more expansive understanding of the “mature minor” doctrine, it is understood that drug testing and counseling fall into the same bucket.
This doctrine basically holds that teenagers who demonstrate a certain threshold maturity and understanding of the risks and benefits of their own care have limited capacity to consent for it. Conversely, they have some limited capacity to withhold consent if they feel it is not in their best interests to grant it. The one time I have explicitly overridden a teenager’s refusal to consent for a drug test is when I had a clear sense that he didn’t have sufficient maturity to grasp the implications of his situation, and it was really in his best interests to honor his mother’s wishes. (I am still not sure if I made the right call in that case.) If you live in a more conservative part of the country or have a provider who doesn’t focus on adolescents to a large degree and thus has a less sympathetic view of their autonomy, you may get a different answer.
But the last reason I don’t order drug tests against my patients’ wishes is that it conflicts with the physician-patient relationship. Adolescents are a unique population, one whose interests are not always congruent with those of their parents, who are nonetheless charged with safeguarding it. An adolescent’s interest in having certain behaviors kept secret conflicts with a parent’s desire to know what their child is up to. Insofar as I don’t want my patients to be engaging in risky behaviors, my goals as a medical provider broadly align with most parents’ wishes. But my ability to act as a resource for my patients relies upon their assurance of confidentiality and protection from punishment.
If a patient perceives me primarily as an agent of his parents, then they have no reason to believe that they can disclose sensitive information to me and keep it protected. I cannot realistically expect him to be anything close to honest with me (an assumption I am already hesitant to make in the best of circumstances) if I am obviously willing to act on his parents’ behalf to extract through lab testing information he wishes to keep secret. My obligations as a physician prevent me from complying with parents’ wishes in this regard, no matter how well-intentioned I believe them to be.
If a patient refuses, I do my best to explain why it may be in her long-term best interests to reconsider. A refused test is almost certainly going to be perceived as positive. Agreeing to a test, even with the expectation that it may be positive, may be the first step in rebuilding trust and mitigating some of the consequences that might follow bad decisions. But if I can’t change her mind and cannot honestly say she is in imminent harm, then I respect her right to refuse.
Heaven knows, there have already been plenty of times when my advice as a pediatrician has been hard to follow as a parent. (It is hard to be blithely indifferent to your child’s refusal to eat, and I’ve maybe gotten into an unproductive food battle or two.) I hope I always have the kind of relationship with my son where I don’t have to consider ignoring his wishes and seeking a drug test. But if I ever did end up asking for one, I hope I’d understand why his own medical provider would refuse.
Bravo. With my own kids, I told them straight up: you don’t have to tell me the truth. But you’d better not hide the truth from Dr. Song (family physician). You close the door on that exam room and it’s you and him and by God, if you don’t tell him the truth, you’re just lying to yourself.
Good for you. And, in fairness, that seems to be the attitude of the majority of parents at my practice, too.
I’ve wondered about this and thought about asking next time you put up a “call for questions.” Do you follow similar protocols when it comes to sexual activity of adolescents?
Absolutely. In fact, sexual (or, if you prefer the more common euphemism, “reproductive”) health matters are more explicitly covered by state law. This seems to be pretty well understood by most parents, and I can’t come up with a memory of a parent marching their kid to my office for an STD test in a similar manner to dragooning him into a drug screen.
(By the way, when I first saw the title of your post, I thought it was about parents wanting you to test new, unproven medicines on their children.)
That hasn’t happened… yet.
What if a parent approached you, sans child, with a cup of urine and asked you to test it? Would you? Could you?
I would not, could not with a fox. I would not, could not in a box. I will not, will not in the rain. I will not, will not on a train.
Er… sorry. We read a lot of Seuss in these parts.
And no, I would not test a urine sample under those circumstances. I will only run the test after receiving explicit consent from the patient, given to me without the parents in the room and after I have determined to my satisfaction that the patient has made an informed decision.
good on you, but are there a lot of pediatricians who would let the parent drive a decision like drug testing?
unrelated: how brutal is fox in socks? every time my 2 year old holds it up i cry a little.
The one I find most problematic is “Thidwick the Big-Hearted Moose,” in which the protagonist is not so much big-hearted as a completely spineless patsy, and at the end of which the antagonists end up dead. But the kiddo loves it, so there we are.
And yes, I’m sure there are lots of pediatricians whose answers would be different from mine. But I would disagree with their decision, for the reasons I list above.
Do you have any feel for which position is more common among pediatricians?
I think it varies a great deal by location and comfort taking care of teenagers, and is more informed by the latter than the former. I would imagine that the overwhelming majority of providers who specialized in adolescent medicine have a policy roughly congruent with my own, regardless of where they practice. And I’d guess that pediatricians in bluer areas are more inclined in the same direction. But the more likely the provider is to pretend that their patients end at the waist when they hit puberty, the more likely they are to acquiesce to this kind of demand.
whoa, i was unfamiliar with thidwick. that is rather harsh, in a beatrix potter sort of way.
curious george is the one that really irks me. clifford is dull (everything is merely a play on clifford being plus-sized) but curious george is strictly a lesson in “the ends justify the means”. that is not a great lesson to teach small children, or large ones, even.
i honestly am surprised that so many peds docs would consider something quite so invasive beyond having really, really solid reasons for doing so.
What do you know about tweedle beetles?
That book was one of my favorite to read to the boys. I got pretty good at it and would try to read it as fast as I could, no mistakes (my favorite part was the bit about cheese and fleas and trees).
http://ai.eecs.umich.edu/people/dreeves/Fox-In-Socks.txt
I’m now imagining people on the street randomly approaching the good doctor with cups of urine.
And people thought panhandlers were bad.
“I’m not going to charge you for any fancy-shmancy lab tests, but in my professional opinion, that’s piss.”
As someone who also works with children and their parents, albeit in a very different capacity, I also sometimes fall back to a “My house, My rules” philosophy. For instance, my school provides lunch for the children. Sometimes parents will make really extreme requests that are not based on any medical needs nor religious/cultural food restrictions. Something like, “Make sure my child eats broccoli every day.” I know the damage that engaging in food battles can cause. I also know my and my school’s philosophy on nurturing autonomy and decision-making ability. In these cases, I’ll politely tell a parent that I understand and respect their aims (which are usually about providing a healthy lunch for their child but are too often based on some new fad diet nonsense) and that I respect their right as parents to handle food situations in their own home as they see fit. But in our school and in my classroom, we’re going to work in a way consistent with our ideals and values. And they are not going to pressure me into violating those. End. Of. Story.
Of course, we are an independent school with a self-selected population who are free to self-select themselves out if they are unhappy with how we do things.
This post is leading me to reflect on a difficult patch in our relationship with our then-13-year-old son. I am still struck by the positive ripple effects that I perceive came from an over-the-counter parentally-administered drug test. Never considered asking our pediatrician to do this for us… It seemed that the whole point was for us to respond to obfuscation with a request for biological information, and at the time it felt like a terrifying and ultimately loving thing to ask. Not sure exactly what our next step would have been had he refused, but haven’t had to cross that bridge yet.
I have no trouble at all with what you describe, in which case I am no longer functioning as your agent and my relationship as your child’s physician is unharmed.
I was wondering if you could answer this. If a drug test in done by the Doctor for a controlled medication for a 16 yr old. Does the Parent have the right to know the results if asked. Considering the 16 yr old is driving on our insurance. Or does this fail under Doctor-Patient confidentiality?
1) As I say in the OP, I would not even order the test without the patient’s assent.
2) Presuming the patient has assented, I would not release the results without his further assent. And I would let the parents know that before I bothered to order it, so there would be no confusion.
This may not be the law, which is nebulous in this regard. But it is my policy all the same.
I don’t agree with your policy. Maybe I don’t understand.Possible you don’t understand. My child was given a script for Aderall without my knowledge. Along with this first months script a drug urine test, which I only found out about when the bill for $644 arrived. Tested positive for cocaine. You as a doctor wouldn’t feel obligated to tell me. A 16 year old seeking Aderall abusing street drugs. This is whats wrong this this generation. Doctors giving out medications without parents knowledge. Doctors knowing our children are abusing drugs and not informing the parents. Its just plain and simple bullshit!
I find your story confusing. Your child’s doctor prescribed Adderall without your consent, and as part of the prescription ordered a drug screen? That’s an entirely different issue than what I’m discussing, and not in keeping with my own practice. With the exception of contraception and treatment for STIs, I do not prescribe medications for my minor patients without involving parents.
As for my policy not to order drug screens without my patients’ assent, well… I’ve laid out my reasons for it in the OP, and you’re free to think it’s bullshit.
KellyLynn,
Could you not make your child’s insurance conditional on his willingness to take (and pass, I presume) a drug test?
I don’t know that I’d tack that tack, but if you are weary of insuring a driver who might be using illegal and/or dangerous drugs, it seems a reasonable approach.
Where is the practical advice for parents dealing with drug abuse in their hold instead of the ‘perfect world’ so many professionals live in? WHAT CAN I DO WHEN MY SON IS CURRENTLY STONED OUT OF HIS MIND?!?!?
Well, Joan, if your son were my patient, I would be happy to meet with you and him, separately and together, and offer what advice and management seemed appropriate. If you’re wanting advice from a blog post, sorry to disappoint but that’s not really my line.
Doc, I’m awed by your patience, as I’m sure you are by our patient’s parents’ patience. I wish you treated 20-something year olds who live on the legs of the curve; we’d be there for an appointment asap.