Ten minutes to trust a stranger: adolescent care in general practice

In England, an appointment with an NHS general practitioner lasts around ten minutes. During these ten minutes, the GP must understand their patient’s concerns, explore a potential diagnosis, complete a physical examination, document the encounter, and write referrals or issue prescriptions.

These ten minutes were not designed for modern-day medicine. They were designed for single, straightforward problems, not sensitive, complex, or adolescent health concerns.

While all patients can be affected by shorter appointments, adolescents are usually the population affected the most.

The (quiet) assumptions

Ten minute appointments rely on a number of assumptions that, in most cases, cannot be made or are incorrect. These assumptions are based on how a patient will present their concerns, assuming the patient fully understands their issue and can describe their symptoms clearly. It also assumes they are fully comfortable raising their concerns and that no further investigation is needed.

This model works well, but only for clear problems (like ear infections or tonsillitis). In adolescent patients, these assumptions cannot be applied and are less effective. Most adolescents present with concerns that are uncertain, sensitive, or complex. In most (if not all) cases, the timing of the consultation can limit the amount of information the patient shares.

It’s rarely just one problem.

Adolescents rarely book an appointment for a single issue. Usually, the issue that brings the patient through the door is just the part that’s easiest to explain. However, there are usually other symptoms, worries, or questions that aren’t said — because there simply isn’t time, or because the patient doesn’t feel comfortable/know how to raise them.

Young people often lead with the least embarrassing or most obvious symptom. This might be fatigue instead of low mood, or “just checking something” instead of a true concern they are worried about. During adolescence, hormonal activity is at its peak, which can contribute to a range of issues, from changes in energy levels and not being sure what is “normal” for their age, along with worries like peer pressure and sexual health.

Adolescents may not understand how their symptoms can be connected, like how fatigue, low mood, acne, or energy changes can all be connected to hormonal activity or stress.

Time pressure in these consultations discourages the disclosure of potentially serious symptoms. Many young people can sense when a GP is rushed or when the appointment is nearly over. This makes them less likely to raise the “by the way…” concern.

The result of this is a constant cycle where eventually, significant problems remain undiscussed, which leaves a delayed diagnosis and consultations (potentially with different doctors) become fragmented and split.

The main message is that a consultation is rarely just one problem.

The “it’ll be fine” approach

The “it’ll be fine” approach is certainly not exclusive to young people. It’s seen in adults too, but affects young people the most — usually due to embarrassment or misinformation among peers, or the internet.

This approach is incorrect. It misses potentially critical symptoms that can progress over time or be symptoms of something much more serious — for example, cancer.

Many young people believe that their symptoms will self-correct over time, and they wait until they become serious (in their mind) to seek advice. This means a GP will only see a partial picture of the issue, and any early intervention treatments may be missed.

For example, medical insurance provider AXA Health reported that 48% of individuals in the UK self-diagnosed their condition through the internet, with 18% of 18–24 year olds diagnosing themselves more than four times in a year. That’s nearly one-fifth.

The internet is useful in many circumstances. However, for patients with concerns, it’s not. Many patients use the internet or social media because of an inability to get an NHS appointment or because they feel their topic is too sensitive to discuss with a GP. Medicine is a very complex subject, and the internet is full of conflicting advice, which just confuses patients and makes them more worried about their concerns.

This impacts adolescents by making them struggle to know what is normal (for their age, or in general).

Sensitive topics require trust.

Many adolescents feel it is difficult to raise sensitive concerns without prior trust and confidentiality. The short consultations don’t often leave room for these conversations, because the patient may not fully trust the clinician in that space, or feel like their issues may be disclosed to other parties, like their parents or school.

Topics such as sexual health and mental wellbeing are extremely important in adolescence.

However, the National Institute for Health and Care Excellence (NICE) reported that 46% of men and 63% of young women aged 15–16 years old felt embarrassed about attending a GP appointment for sexual health matters.

The embarrassment from these topics usually stem from stigmas. Sexual health still remains a taboo topic in modern-day society, which means many adolescents do not know where to seek help about these concerns. This is similar to mental health issues too — however, the main concern towards this is the fear of disclosure to parents/guardians.

Even though intimate areas are just body parts and are treated by clinicians like any other part of the body, many adolescents still find intimate examinations embarrassing, even when a parent or chaperone is present.

Ultimately, a clinician will rarely gain the patient’s full trust in ten minutes or less, which can limit the amount disclosed by the patient which can significantly hinder a potential diagnosis. Addressing this anxiety requires explanations, reassurance, and normalizations. Many adolescents who require an intimate exam may have never experienced one before (that they can remember). This is the same for interventions like therapy. The key to solving this anxiety is exposure, not avoidance.

Confidentiality and privacy

Even when adolescents raise sensitive concerns, worries about confidentiality are still usually present. Many fear this information might be shared with their parents or school.

The understanding of legal rights around the NHS and confidentiality is low. Although the law allows competent under-16s to consent to sexual or mental health care confidentially, many are not aware of this, which can stop them from seeking help at all. The effects of this can be harmful — e.g. missed mental conditions or opportunity for early therapy.

The future

In conclusion, we’ve determined that ten-minute consultations are not long enough. They were never designed to capture the full picture of adolescent health, as concerns raised are usually not singular or simple. Embarrassment, (lack of) trust, and confidentiality all contribute to the delayed or limited disclosure of symptoms. This means that diagnosis and early intervention are limited.

In a longer appointment, GPs can build trust, normalise sensitive discussion, and provide the guidance required. They cannot do this in ten minutes or less.

Longer appointments means that more can be discussed and more trust can be gained, allowing for the “by the way” and “also” to be disclosed.

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Disclaimer: this article uses sources, which are mentioned. These may become out of date, and they will not be updated by the author. The author is not responsible for any incorrect statistics or facts within this article. Always seek medical advice if you need it.

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