AMA Journal of Ethics^®

Case

Jimmy, a 2-year-old toddler, was taken by his mother to his pediatrician, Dr. Wagner, because he had been holding his wrist and crying that it "hurt real bad." Dr. Wagner had been the family's pediatrician for the past year and was just getting to know them. Jimmy's father sat on the board of directors for the hospital, so Dr. Wagner always went the "extra mile" to provide the best care and tried to portray the Department of Pediatrics in the best light.

When Dr. Lawrence, the pediatric radiologist at the same hospital, analyzed Jimmy's X-ray, she noticed signs of two healed fractures in addition to the new fracture. The child's bones otherwise appeared normal.

Dr. Lawrence called Dr. Wagner to discuss what she had found and mentioned abuse as a possible cause for the fractures. Dr. Wagner made light of the situation, saying that it would not be appropriate to make such an accusation of a member of the hospital's board of directors.

Dr. Lawrence was frustrated. If the pediatrician wasn't going to follow up on suspected abuse, what steps should she take?

Commentary

The case presents a dilemma that many pediatric or general radiologists face—to whom do they owe their allegiance? Is the radiologist's professional obligation to the ordering physician, the parents of the minor child, the child, or to a third party, such as the state? When does suspicion of child abuse demand that a radiologist go beyond the usual specialist-primary care relationship to the point at which an outside investigation is sought and social services or law enforcement intervention may result? What happens to the radiologist's referrals and her professional reputation if she bypasses the child's physician and reports the case for investigation and her suspicion is correct? What happens if she reports and her suspicion is groundless? These are all difficult, real life questions that need to be examined from societal, medical, ethical, and legal perspectives.

Child abuse and neglect are national health problems that affect thousands of children every year. Of at least one million reports filed annually with various protective services, approximately 330,000 are, upon investigation, judged likely to be child abuse [1]. About half of the abuse cases are physical, and the other half are neglect, making the incidence of proven abuse about 150,000 cases per year. And about one-third of those—50,000—are sexual abuse [2]. The preponderance of physical abuse occurs in children younger than 4 years of age, a population which numbers roughly 10 million children in the United States. In this age group the estimated rate of physical abuse approaches 1 child per 100—a proportion that far exceeds that of many serious childhood diseases. The gross mortality from abusive injury is not easily established, inasmuch as many cases are not recognized; however, most estimates put it at about 2.8 per 100,000 U.S. children per year, underscoring the importance of physicians' noticing disturbing trends or signs, questioning parents and young patients about home life, and, if necessary, reporting suspicions to authorities [3]. The morbidity, both psychological and physical, far exceeds the mortality in prevalence, and almost every abused child probably suffers some degree of morbidity.

Despite the physical and mental dangers of child abuse, a false-positive report is not without cost to the child and family. Both the radiologist and the pediatrician must realize that, if they disclose their suspicions to social service agencies, the family will be investigated and, in the majority of cases, no further action will be deemed necessary. But even if the suspicion is determined to have been groundless, the investigation will disrupt the family's standing in the community, will probably erode the patient-doctor relationship, and can have a detrimental impact on spousal trust within the family. Once the report is made, the situation is out of the doctor's control, so the decision to report is not a trivial one.

Legal Considerations

From a legal standpoint the responsibilities of the radiologist are clear. As a licensed provider of health care, a physician is obligated to report suspected child abuse. Dr. Lawrence, in this case, does not fulfill this obligation by making her concerns known to the referring physician; she has an implicit duty to the patient—in this case the child—just as she would be expected to accurately diagnose and report any other suspected serious condition, such as a cancer. The usual medical path for reporting child abuse is through the pediatrician. If the pediatrician disagrees, and the radiologist is still uneasy, as a mandatory reporter, he or she is obligated to report the case to the local child protection investigation agency. This move is not without risk to the radiologist, inasmuch as her actions might disrupt her practice, hurt her relationship with her referring physicians, and imperil her standing with the hospital. Nevertheless, the legal obligation to report is clear.

All states have shield laws protecting a "good faith" mandatory reporter from civil or criminal liability for reporting child abuse. These laws were enacted owing to a national recognition that the harm caused by a good-faith, mistaken report was far less than the potential damage or death of a defenseless child-victim. Many states also have provision in their reporting laws that include potential for sanctions ranging from adverse licensure actions to misdemeanor criminal penalties when a mandatory reporter knowingly fails to report. While the justice system has generally been loath to prosecute mandatory reporters for failure to fulfill that duty, there are some examples where civil liability has been assessed or alleged for failure to report child abuse [4].

The Radiologist's Duty to Inform

Judging whether any particular case is an instance of abuse is difficult for the radiologist, since she is not the patient's primary (or direct) care physician and therefore may not be privy to parts of the patient's medical information that could influence her opinion on suspected abuse. Consider an analogy: a radiologist sees an unexpected malignant tumor on a CT scan of the chest and notifies the referring physician, who refuses to believe the finding. What is the radiologist's responsibility to the patient? The communication guidelines of the American College of Radiology state that, when the referring physician cannot reasonably be notified of a serious life-threatening condition, the radiologist must communicate directly to the patient, or in this case the caretaker of the minor child [5].

The meaning of the guideline is clear; the radiologist's responsibility to the patient goes beyond issuing an image or scanning report. Rather, he or she must reasonably ensure that the patient or responsible caretaker is aware of adverse findings. In the example of the tumor, many radiologists would stop at the point of documenting the discussion with the referring physician and making certain that the patient's primary physician understood the implications of the diagnosis. A minority would bypass the referring physician and directly inform the patient if they had a high suspicion of malignancy with which the referring physician disagreed. If there were evidence that the referring physician was somehow incompetent or completely misguided, the radiologist would most likely go directly to the patient. Following that argument, since (1) the referring physician disagrees with the radiologist but offers no compelling evidence to dispel the radiologist's suspicions, (2) the radiologist has no access to the patient's records, (3) in the eyes of the law the child is incompetent to care for himself, and (4) the law requires direct reporting, the radiologist must comply with the law.

A physician is given great power by society, and with that power comes great responsibility. The protection of a defenseless victim is the responsibility of the physician-caretaker even if it involves the risk of alienation from colleagues, loss of professional opportunities, or personal discomfort. Physicians are duty-bound to protect their patients and that principle, to care for those in need, must be the beacon in this case. The radiologist must independently report the case and protect the child.