After that, the patient’s mother talked more than he did. She provided articulate descriptions of her son’s symptoms, occasionally interrupting him to do so.
“He hasn’t told you this,” the mother said at one point, “but on weekends he drinks a lot with his friends and … well … I wonder if that relates to what’s going on?”
I had wondered the same thing. Also, I needed to get the patient’s mother out of the room.
Beyond these real risks to his care, I worried the mother was unintentionally keeping the patient from learning how to advocate for himself.
This wasn’t just a clinical intuition. A 2017 study showed that greater parental involvement in young-adult health care predicts lower young-adult independence.
The stakes are even higher for young adults facing chronic illness. A study of 252 adolescents with type 1 diabetes showed that young adults whose parents were less supportive of their independence were less adherent to insulin dosing and had poorer clinical outcomes.
This may be because young adults whose parents talk for them in the exam room know they don’t need to learn to advocate for themselves.
Fortunately, the doctor’s office is a safe place for young adults to develop independence.
I turned to the mother. “At this point," I said, "I’d like to have you step out so we can do a physical exam and talk in private.”
After the mother left, the patient immediately became more forthcoming. He said, “I know I was the one who suggested she stay in the room, but … she’s kind of cramping my style.”
In the safety of the exam room, doctors can emphasize the importance of independence, and help young-adult patients and their parents define healthy boundaries. This, with other guideline-driven ways of supporting young-adult patients, can lead to a successful transition to independent care.
Transitioning young-adult patients to independence in the exam room starts when they are adolescents. The American Academy of Pediatricians recommends that children 11 and older have time alone with their pediatrician “to talk about health and changes in his/her body and life. Private communication enables the pediatrician to assess health risk. It also gives adolescents experience in talking about health issues.”
There are, of course, exceptions to the idea that parents should step back and let young adults advocate for themselves in the exam room. Parents of young adults with intellectual disabilities, for example, may need to lean in more. Whenever parents suspect their young adult has not advocated enough for themselves, I suggest an open negotiation among the parent(s), young adult and doctor about next steps.
Encouraging a young adult speak for themselves in the exam room does not mean parents stop supporting them. In fact, parents play a critical role in young-adult health. The trick is to provide support in ways that reinforce autonomy. Parents can encourage a young adult to bring up an issue before a doctor’s visit and even brainstorm with them how to bring it up. In an open negotiation with the young adult and the doctor, parents can ask how they can best support their child and raise issues they might be tempted to touch on but aren’t because they expect the young adult will do so on their own.
When the 20-year-old construction worker’s mother returned to the exam room, she started to speak for the patient about a symptomatic concern. This time, the patient put his hand on her arm. “Thanks, Mom — but I can do this myself.”
Later on, the mother asked her son, “Did you talk to the doctor about …?” then trailed off, clearly waiting for her son to speak up. “Oh, yeah,” he said and went on to raise a question he had forgotten.
They were learning. In a safe space, with trust, she would step back, and he would step forward, into healthy adulthood.
Tim Lahey, MD, is an infectious diseases physician and director of ethics at the University of Vermont Medical Center.