In taking care of minors, pediatricians need to be alert to possible child abuse, and navigate the land mines of parental consent.
Internist Joseph P. McMenamin was working his way through law school when he saw a 10-or 11-month-old boy in a Philadelphia emergency department. "The parents complained that the child seemed listless and had stopped pulling himself into a standing position," says McMenamin, who's now a partner in McGuireWoods' Richmond, Va., law office. In examining the boy, McMenamin didn't notice any bruises, and the parents said he hadn't sustained any recent injuries. But his right arm seemed tender to the touch, and an X-ray revealed a fractured humerus.
With the parents still insisting that their son hadn't been injured, McMenamin, who'd had little experience with pediatric patients, shuffled through the med-school note cards in his head. He considered metabolic abnormalities, calcium deficiency, and endocrine problems before the truth hit him, as McMenamin puts it, "like a ton of bricks": The child had been abused.
He called the local child protective agency, which promptly began an investigation. But before the inquiry was complete, the boy's grandmother charged into the ED, threatening to sue the doctor and the hospital for everything from "malicious prosecution" to "abuse of process."
On the alert for abuse
As a physician, you're required to report suspected child abuse or neglect to the child protective agency in your area. And while many physicians worry about causing a family grief by erroneously filing a report, some states-Virginia, for one-penalize healthcare professionals who don't notify authorities when they have good reason to believe a child has been abused.
"It doesn't happen often, but physicians have been held liable for violating reporting requirements," says Joseph McMenamin, and-even rarer-physicians have been targets of civil suits filed on behalf of children whose abuse went unreported by the doctor who treated them. There was even a case of a health care provider who faced criminal charges for failing to report a pattern of bruises on a toddler-which turned out to be just one indication of the abuse that ultimately led to the child's death.
To encourage reporting, most jurisdictions give explicit legal protection to physicians (and other professionals with similar mandates) who submit a report of child abuse in good faith. Judith M. Huerta, loss prevention manager for Medical Insurance Exchange of California, says she knows of no instances where physicians were penalized for reporting suspected abuse, even if child protective agency investigators were unable to substantiate the charge.
Child abuse can be difficult to diagnose, Huerta concedes, but there are signs to be aware of:
Neglect, McMenamin notes in "Children as Patients," a chapter he co-authored for the textbook Legal Medicine (Mosby, 2004), is more likely to be characterized by malnutrition, recurrent pica, chronic listlessness, lack of weather-appropriate clothing, poor school attendance, and inadequate medical care.