When Joann Alfonzo, a pediatrician in Freehold, N.J., walked into her office recently she mentally rolled her eyes when she saw her next patient: a 26-year-old car salesman in a suit and tie.
"That's no longer a kid. That's a man," she recalls thinking.
Yet, Alfonzo wasn't that surprised. In the past five years, she has seen the age of her patients rise, as more young adults remain at home and, thanks to the Affordable Care Act, on their parents' health insurance until age 26.
"First it was 21, then 23 and now 26," Alfonzo says. "A lot of them can't afford to live on their own and get their own insurance, or even afford the co-pay. And if insurance is offered at work, there's generally a cost share involved, if insurance is provided at all."
The idea of young adults continuing to see their longtime pediatricians has been around for quite some time — it was a laugh line on "Friends" in its last TV season in 2004. Rachel takes her child to a pediatrician, she sees the child's father, Ross, in the waiting room and realizes he's still a patient.
But these days that's pretty realistic, Alfonzo says. "We have people who have had children, and they still see us, so we're seeing the parents and their children, concurrently," she says.
So when is it time to leave your pediatrician? Talon Manfredini, 22, says he only left his pediatrician, who is a woman, this year because he moved from his family home in New Jersey to begin a new job in Miami.
But he didn't think twice about continuing to see her, even though he'd finished college. "She just felt like a regular doctor," he says. "It didn't feel odd at all or different or weird or anything like that."
Debbie Weinberger DeFrancesco, 41, a regional sales manager for Tyson from Marlboro, N.J., says she continued to see her pediatrician until she was about 27.
"The thing I remember very clearly, especially towards the end of my time there, was how the moms were the same age as me - and not thinking that I was too old for the doctor but that they were too young be having babies," she says.
She finally decided it was time to get an "adult" doctor when she got married. "I thought it was a good idea for my husband and me to share the same doctor and have our files under one roof," she says.
Aside from some potentially awkward moments in the waiting room, is there anything wrong with pediatricians continuing to treat their patients once they become adults?
A little, Alfonzo says.
"We're now treating people for adult diseases, things we weren't trained to treat," she says, such as adult hypertension, Type 2 diabetes, high cholesterol, pregnancy, even depression and anxiety. If she encounters something she can't handle, Alfonzo says she will refer the patient to a specialist.
"Actually, I think it impacts them more in a positive manner, because I think pediatricians are very thorough in their assessment," she says.
It's certainly more thorough than an urgent care center, which is where many 20- and 30-somethings wind up when they don't have insurance and are no longer seeing their pediatrician, Alfonzo says.
The American Academy of Pediatrics (AAP) attempted to address the issue of transition from pediatric care into adult care in a policy statement in 2017 and concluded "the age of transition" should be based not on a number but on the patient's individual needs.
The decision "should be made solely by the patient (and family, when appropriate) and the physician and must take into account the physical and psychosocial needs of the patient and the abilities of the pediatric provider to meet those needs," the policy statement said. In addition, it said that 'the establishment of arbitrary age limits on pediatric care by health care providers should be discouraged. Health care insurers and other payers should not place limits that affect the patient's choice of care provider based solely on age."
The statement was written and published because more pediatricians were seeing older and older patients, and because insurers and health-care providers had begun to draw arbitrary lines as to the age at which a patient should no longer be seen by a pediatrician, said Jesse Hackell, the AAP's vice president and a co-author of the statement.
"There are no official, legal rules," Hackell says. "Sometimes the insurance companies will try and make rules. Sometimes the hospitals will make rules. But there's nothing to say we couldn't keep seeing them. We're licensed as physicians, not pediatricians."
Hackell, a pediatrician in Pomona, N.Y., says he has patients who definitely don't want to leave, and most of their problems are ones he is equipped to deal with. Often, he'll keep the patients through their college years. Why should they have to find a new physician if they get sick while they're home on break? he asks.
"I won't take on a new patient after about the age of 18 or 20, but I will certainly see my patients who I've seen since they were kids," he says.
Once they graduate, though, he generally tells them it's time to start looking for a general practitioner who treats adults, he says.
"We have to gently nudge them out," he says.
Living at home and remaining on parents' insurance policies aren't the only reasons 20-somethings stay with pediatricians. Medical advancements over the past decade are extending the life expectancy of those with chronic childhood illnesses, such as congenital heart issues, cystic fibrosis, hemophilia and diabetes, and the pediatricians who cared for children with these conditions sometimes remain with them as they get old, says Michelle Hofmann, medical director in pediatric services at NeuroRestorative in Riverton, Utah.
Hofmann says when she was training in a pediatric intensive care unit, she had to resuscitate a 50-year-old man who was in her children's hospital because he'd had congenital heart disease since he was a child. When it was time to do heart surgery, he wanted to have it there.
"One of the things that I think they do really well in pediatrics is establish those lifelong relationships, because your visits are so frequent when you're growing up. If you don't move around a lot, you do tend to stay with the same doctor," Hofmann says.
The care can also be different. Her patients with cerebral palsy, for instance, have neurological issues from birth that may require supportive technologies such as feeding tubes or ventilators, technologies that when used on adults are often not to prolong life but rather in the face of a traumatic accident or a life-ending illness. And who would a patient with cerebral palsy, caused by brain damage that occurred before birth or during a child's first three to five years, see? Hofmann asks.
For those without major issues, though - a college student or graduate about to embark on working life - the transition can be abrupt, sometimes precipitated by a "Sorry, you've aged out" response when they call to make an appointment or by a sign in the waiting room.
Debra Blau Reicher, a school psychologist, says she continued to consult her childhood pediatrician about her health issues well after she began taking her daughter to see him. If her daughter had strep, the pediatrician would do a throat culture on Reicher as well.
"He would see me in his waiting room so he wouldn't have to charge me," she said. "But then one day he had a sign up," she recalls, saying "I can no longer see parents."
She was 30 when the sign was posted.
There are better ways than posting a sign for transitioning patients who need to move on, says Jonathan Trager, a pediatrician in Great Neck, N.Y., whose practice includes adolescent medicine.
"Throughout the teen years into the college years, you let your patients know that you are happy to see them as long as they are comfortable," says Trager, who sees patients until age 30. When a patient is ready to switch to an internist, or is dealing with issues that may require an internist, Trager and the patient will make that transition decision together, he says. It should be a change that they gear up for over the years, he adds.
A pediatrician, Trager says, is the ideal person to guide the young patient through that transition into adult medical care.
"They know the patient," he says. "They know the family, and they're well equipped to handle issues of someone they have been seeing for a long time. Young adults are often extended adolescents. They still could benefit from seeing the pediatrician who knows them well."
For older pediatric patients, it's not the doctor so much as the waiting room, usually geared toward toddlers and young patients, that starts to feel awkward. "While the doctor may be equipped to see them medically and know them well, the patient may feel out of place and doesn't want to come," Trager says.
Jake Ambrosio, 21, is one of those patients. He has been seeing his pediatrician since he was born but has outgrown the office.
"There's a lot of babies in the waiting room, and also all of the rooms have a theme. I'll be getting a checkup and there'll be like, the Candy Land room, this light pink room with these little candies all around, and I'm like, 'Yeah, I think I'm ready to be in just a normal doctor's office.' "
So why has he stayed with his pediatrician this long?
"I like her. And it's a lot of work finding a real doctor. It's just easier to stay," he says. "But I know I have to stop going to the pediatrician eventually. I just feel like since I'm 21, it's time for me to find an adult doctor. Even though I do really like my pediatrician. It's part of growing up, I guess."