To Their Good Health: Key Points About College Health Care for High School Grads

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On a warm spring day, Chris comes to your office for his "pre-college" physical examination and immunizations. Looking through his problem list, you remember rounding on him when he was hospitalized for asthma at age 5, counseling him about pubertal changes when he was 11, and treating his infectious mononucleosis when he was in high school. You are proud to see him growing into a fine young adult, but the sentiment is bittersweet when you realize that this may be one of the last times that you take care of him as your patient. Like many of your graduating high school seniors, Chris will need to go to the college health service to meet his future health needs.

You sign his required college forms and give him his meningitis vaccine. As you prepare to say "good luck," you wonder what counsel you can offer to help him become a healthy and educated medical consumer and patient.

As a graduating high school senior prepares for college, his or her thoughts are inevitably focused on the exciting prospect of a new dormitory, roommates, college food, parties, friends, and (of course) academics. Unless the student has a chronic medical condition, he will probably spend little time thinking about what he would do if or when he gets sick.

Unfortunately, most students need to enlist the aid of the university health services at some point in their college careers and this may be the first time that they see a clinician who is not their own pediatrician. Furthermore, this will probably be their first time navigating the US health care system without their parents' guidance. While most college students relish their independence, they are frequently overwhelmed by the responsibility of managing their own health care-especially in an environment with myriad insurers, all with their own complicated rules and procedures.

So when "Chris" comes in for his pre-college physical examination, what kinds of anticipatory guidance and counseling-beyond advice about good sleeping and eating habits, reproductive and mental health, and use of illicit drugs and alcohol-might benefit him most? This brief review will provide an outline of key issues that you may wish to discuss with your patient and his family.

COLLEGE HEALTH PROVIDERS

Approximately 1600 colleges and universities have a student health service that provides a variety of health services for their students. Frequently, the institutions' needs and funding determine the breadth of services offered. Some universities may simply provide a small office for urgent care services. Other institutions may offer a broader variety of services that may include specialty services such as orthopedics, gynecology, mental health services, and alternative health modalities.

Undergraduates often have a difficult time transitioning their care from their pediatrician to a different provider. Their first visit to the college health clinic can be daunting. For some students, this may be the first time they have visited a health provider without a parent-or even the first time they have had to make and keep their own appointments. In any case, the experience is likely to be vastly different from their norm.

Key Discussion Points:

• Decide with the patient what role, if any, the home pediatrician will play in meeting a patient's health needs while he attends college. Some physicians don't mind practicing long distance medicine, while others will not do so. The outcome of this discussion can have an important impact on a patient's transition to adult care.

• Nurse practitioners (NPs) or physician assistants (PAs) frequently help staff a student health practice. This may seem unusual to the patient who has only seen a physician. It is important to reinforce that NPs and PAs can provide excellent patient care and that not all illnesses require physician intervention.

• Occasionally, students mistakenly believe that physicians would only work in a university health care setting because they lack clinical skills or they could not succeed in a private practice setting. In reality, many university physicians are accomplished physicians who practice college health because they consider it a wonderful, challenging environment.

PAST MEDICAL HISTORY AND FAMILY MEDICAL HISTORY.

The pre-college physical examination is a great time to review past medical history and family medical history. Undergraduates are frequently oblivious; as the adolescent prepares for college, it may be important for him to understand significant and relevant details (such as a family history of alcoholism or mental illness) so as to make the best overall health decisions.

Key Discussion Points:

• Review any pertinent medical history with the family and patient. Parents occasionally withhold family medical history from their children as they are growing. Now may be the time to facilitate a revealing discussion about such matters.

• Review any pertinent medical history. Some schools require parents or physicians to complete a medical health background form before matriculation. Others rely on the student to provide relevant medical background. Because many adolescents are poor historians, this information gap can potentially delay diagnoses and the implementation of treatment.

• Review the student's medications. The student should understand why he is taking certain medications and what the dosages are. Ideally, this is a good time to discuss potential adverse drug effects and how to manage them if necessary.

MENTAL HEALTH AND CHRONIC DISEASE MANAGEMENT

Students with chronic medical problems or mental health issues have probably seen their specialist for years before they start college. Before the student leaves for school, explore how he plans to manage these health issues. Make sure that some transitional care plan is in place before the student leaves home. Ideally, this plan should include some written communication between the specialist and the college health service. This may seem like stating the obvious. Nevertheless, I frequently see freshmen in crisis because of a lack of planning.

Key Discussion Points:

• Consider whether the specialist will continue to follow the patient's chronic medical problems when he leaves for school-or whether the specialist will arrange for transfer of care to a local specialist in the collegiate community?

• If medications need to be continued, who will arrange for the refills? If the student changes health insurers (see below), will the home clinician be able to continue as a provider under the new insurance plan?

HEALTH INSURANCE ISSUES

Seventy percent of college students have health insurance-either through a sponsoring educational institution or through their parents. Unless insurance has been a problem in the past, most pediatricians probably do not discuss the topic with the college-bound patients. However, many families must consider either enrolling in student insurance or keeping their child on their current plan. The family should review these policies with their child ahead of time: a sick visit during final exam week is not the time to learn that there are potential snafus in coverage.

Key Discussion Points:

• If a student decides to purchase a university-sponsored insurance plan, he must make sure that it meets any anticipated needs. For example, if the student has been taking a medication for a long time, will it be covered under the new plan? If the student wishes to continue seeing a certain specialist for a chronic medical condition, will the specialist accept the new plan?

• Almost all health plans have some limitations, and the student must understand those limitations. Some plans require that the subscribers designate the student health services as a primary physician. Will this limit access to their home pediatrician? How will you manage that situation with your patient and his family?

• If the family plans to keep their child enrolled in their own health plan, they need to review the contract carefully for any restrictions it might impose on their child in college. In particular, if the student needs a specialist referral, can this be generated by the student health services or must the home primary care provider do this?

• After a student sees a health care provider, an explanation of benefits (EOB) is frequently mailed to the primary policy holder-which may be the student or parent (depending on who holds the policy). Occasionally, details of procedures or lab test results may be listed on the EOB. If the parent is the policy holder, how might this affect the student's right to confidentiality and subsequent access to care?

• Finally, the family needs to consider the impact that an unanticipated academic leave of absence may have on their child's coverage. Some plans cover adult children (older than 18) only if they are enrolled in college. Conversely, many university- sponsored plans provide coverage only if the student is actively enrolled in their school. While most high school seniors do not plan for this contingency, it is not uncommon and is best considered ahead of time if possible.

CONFIDENTIALITY IN COLLEGE HEALTH

Without wishing to state the obvious, a quick note on confidentiality in college health is appropriate. Most college freshmen are at least 18 years old when they start college; as such, they are afforded the privileged right to confidentiality that comes with adulthood. With those rights, however, comes the responsibility for their own health care.

From a medicolegal standpoint, strict confidentiality must be maintained in college health settings. Regardless of who pays the tuition and insurance bills, college health providers cannot legally discuss a clinical encounter with an outside party- unless the patient gives them express permission to do so (in writing). If your patient has a medical issue that requires you to communicate with the student health service, make sure that all confidentiality releases and permissions are granted before the patient leaves for college. Unless the student's health and life (or another person's health and life) are jeopardized, confidentiality is rarely (if ever) broken in these settings.

IN CLOSING

A patient's departure for college is a bittersweet experience for all involved. The pre-college physical is a great time to ensure that any clinical care loopholes are closed and that your patients (and their families) are adequately prepared for any unanticipated health issues. Appropriate preparation can ease a difficult transition and help ensure that your patients will remain happy and healthy as they take their first real steps to independence and adulthood.

FOR MORE INFORMATION:

• Goldstein MA. Preparing adolescent patients for college. Curr Opin Pediatr. 2002;14:384-388.

• Neinstein L, Swinford P, Farrow J. Overview of health issues for college students. In: Neinstein L, Gordon CM, eds. Adolescent Health Care: A Practical Guide. 5th ed. Philadelphia: Wolters Kluwer/ Lippincott Williams & Wilkins; 2008:1080-1110.
  

• Stashwick CA. The pre-college visit: make the most of it. Intern Med. 1997;14:89.