Abstract
This article explores how child abuse physicians (CAPs) experience the unique challenges of the emerging field of child abuse pediatrics. Practicing CAPs completed a written survey about known challenges in their field. Fifty-six CAPs completed the written survey and reported experiencing many negative consequences including: threats to their personal safety (52%), formal complaints to supervisors (50%) and licensing bodies (13%), negative stories in the media (23%), and malpractice suits (16%). A purposeful sample of CAPs participated in telephone interviews about these challenges. The 19 physicians who were interviewed described the challenges, while they spontaneously expressed satisfaction with their career and described some strategies for coping with the stresses of child abuse pediatrics. The findings highlight the stressors and challenges that may affect the ability to maintain an adequate CAP workforce. Better understanding of the challenges should help prepare physicians to practice this subspecialty.
Keywords
Introduction
Child abuse physicians (CAPs) face particular stressors that may affect their ability to continue working in the field. With more dependable regularity than in many areas of medical practice, the physician–parent relationship may become adversarial because physicians make judgments that may result in the termination of parental rights and even imprisonment. Despite legislative protections, physicians occasionally suffer negative consequences as a result of child abuse reporting (Flaherty & Sege, 2005; Flaherty, Sege, Binns, Mattson, & Christoffel, 2000; Flaherty et al., 2006).
In Great Britain, physicians who report child protection issues have been subjected to various forms of intimidation. Formal complaints to the General Medical Council increased dramatically between 1995 and 2003 (Kmietowicz, 2004). According to the Royal College of Pediatrics and Child Health, a formal complaint had been made against 14% of British pediatricians around child abuse issues (Williams, 2007). Further, about one-third of the positions for CAPs were unfilled in Great Britain (Kmietowicz, 2004).
In Canada, about two-thirds of the hospital-based child protection professionals (physicians, nurses, psychologists, social workers, administrators, child life, secretaries, and researchers) indicated they have considered leaving their job or making a job change, such as reducing hours in their program. Professionals who had left the field said that the high level of job stress and burnout caused them to leave or reduce their hours in the field (Bennett, Plint, & Clifford, 2005). The American Board of Pediatrics recently recognized the subspecialty of child abuse pediatrics making an exploration of the challenges faced by U.S. CAPs particularly timely. The findings of a study of CAPs may inform the ability of pediatric programs to train and retain the subspecialists required to provide this expertise (Block & Palusci, 2006). This study explores the challenges confronting CAPs and how they cope with the consequences.
Method
Subjects, Observations, and Measurements
Physicians identifying themselves as CAPs who attended the 2006 Helfer Society meeting were invited to complete a 10-question survey about stressors experienced through evaluating children for possible child abuse. The survey collected demographic information and asked questions about possible consequences of their work with child maltreatment. The Helfer Society is an honorary society for CAPs. In 2006, the society had 220 members; 89 attended the conference. The results of these surveys were used to develop a conceptual model of challenges for CAPs that informed development of the telephone interview guide used in the next phase of the study (Huberman & Miles, 1994).
In 2007, a request for participation in the telephone interview portion of the study was disseminated during the 2007 Helfer Society meeting and electronically through the Helfer Society Listserve. Included in this request was a basic survey similar to the one used in 2006 to determine the experience and challenges of the CAPs who volunteered. Using criterion sampling (experience of a negative consequence) along with maximum variation sampling (geographic locations of practice and number of years in practice), volunteers were selected for telephone interviews. The study subjects who volunteered for the interview were not required to have participated in the 2006 written survey.
The 2006 survey was categorized as “exempt” by the Tufts University IRB. The 2007 portion of the study was approved by the Children’s Memorial Hospital IRB.
An independent qualitative analyst (RDJ) conducted in depth and probing 80–90 min telephone interviews of each CAP. The same general questions and probes were used for all interviews to insure reliability. Participants were asked to describe in detail the challenges they experienced, how they had adapted their practice, and mechanisms they used to cope with the challenges. The telephone interviews were recorded and transcribed. After transcription, the tapes were destroyed and the transcripts were deidentified.
Data analysis
The surveys distributed in 2006 and 2007 were analyzed for frequency and breadth of responses. Following a grounded theory approach, the telephone transcripts were read and analyzed for common themes and categories of responses integrating responsive evaluation into this naturalistic inquiry (Lincoln & Guba, 1985). Authors reviewed the transcripts and discussed the insights that had emerged in the interviews. In order to minimize bias, the researchers worked to explicitly acknowledge past experience and perceptions and the potential impact on our evaluative roles. We worked to minimize the bias through four formal reviews by three child abuse pediatricians and a social scientist with expertise in qualitative analysis. This process itself allowed for disclosure and discussion of concerns that may have the potential to direct the research and resulting manuscript and therefore ensure that our work was data driven. The words of the practitioners drove the analysis—the stressors they experience and their strategies and resources used to manage these stressors in their personal and professional lives. Through a process of expert adjudication, the authors confirmed that the themes had repeated and reached saturation and thus were representative of the ideas expressed by the participants. During four formal reviews with all authors, a “check coding” process was used (Huberman & Miles, 1994) to ensure agreement in the coding of responses and solidify intercoder reliability. This peer debriefing and member checking was done to insure the dependability of the analysis. Through this iterative review process, consensus was reached. These themes and categories were summarized to express the variety of challenges faced and coping strategies used by these CAPs. Illustrative verbatim quotations were chosen to demonstrate the main categories and themes.
Results
Of the eighty-nine 2006 Helfer meeting attendees, 56 (63%) completed the 2006 survey. The majority (66%) were female and had practiced an average of 16 years (range = 1–40) as a CAP. Only 38% had completed fellowships in child abuse pediatrics. More than three-quarters of the participants (77%) had experienced negative consequences as a result of their work on behalf of maltreated children (52% feared for their personal safety on one or more occasion; 50% said a parent complained to their employer; 23% had been the subject of negative media; 16% were sued for malpractice; and 13% had a complaint filed with the professional licensing body).
In 2007, 19 CAPs (58% female) from various geographic locations participated in semistructured telephone interviews because they had experienced negative consequences related to their practice. These CAPs had practiced an average of 17 years (range = 1–30) and 26% had completed child abuse pediatric fellowships. In contrast to the initial respondents, 90% of the telephone participants reported fearing for their personal safety, 74% had been sued for malpractice, 68% said a parent had formally complained to their employer, 47% had been the subject of negative media, and complaints had been filed with the professional licensing bureau against 42% of them. Representative quotations are taken from the telephone interviews.
Overall Perceptions of Challenges
The CAPs perceived that their doctor–patient relationship was different from other doctors. (The normal health physician patient relationship is . . . a collaborative effort in which both the patient gains the satisfaction of knowing what’s wrong and getting better quickly and the doctor gains the satisfaction of making the diagnosis and having a patient that gets better as well.) CAPs remarked that families generally do not express appreciation for the CAP’s care. (I will never be a physician who get[s] candy . . . and thank you cards from their patients.) The CAPs described keeping a fine balance between creating an alliance with parents while also ensuring that it is understood that they are mandated reporters working on behalf of the child’s interests. CAPs described that they needed to define and use standard language to explain their role to families as a means of minimizing conflicts and misunderstandings.
CAPs shared that colleagues have both supported (It’s just comforting for them to know that somebody else is dealing with it so they’re not going to end up in court and they’re not going to end up getting complaints to the medical board) and undermined their role. (I continue to encounter docs in the community who think that I have no business reporting on their families.) CAPs reported that stress results from the combination of the serious implication of their judgment about maltreatment and the inherent uncertainties of those judgments. Because often the diagnosis is neither clearly abuse nor clearly unintentional, they worried about making the wrong diagnosis. (. . . the mental anguish that we go through in terms of if we’ve made the right kind of assessment and if we’re adequately protecting children. The subject is fraught with some emotional stuff plus the lack of absolute black and white.)
In addition to working with other medical providers, CAPs work with external professional agencies, especially law enforcement, child protective service (CPS), and the legal system. The CAPs often expressed frustration over the quality and responsiveness of CPS investigations and differing system goals and validation thresholds. (“Most CPS workers are new grad social workers that are thrown into a new job with not enough training. They are overwhelmed with their case loads and get very little support and they’re given a job where they are making life and death decisions about kid’s lives.) When cases went to court, CAPs described how opposing lawyers tried to discredit them in order to defend their clients’ position. The CAPs reported that they were either uncompensated or undercompensated for the time required for legal proceedings. The time spent preparing for court and actual court appearance pulled them away from their clinical and academic responsibilities.
Threats to Personal and Professional Well-Being
CAPs experienced physical threats and intimidation from disgruntled parents, malpractice suits, and negative media attention in response to their child abuse evaluations.
Physical threats
About half (52%) of the CAPs surveyed in 2006 indicated they were verbally or physically threatened between 1 and 10 times. These were mostly verbal threats including threatening or harassing phone calls, but 9 (31%) said they had felt physically threatened and 3 CAPs reported a weapon was displayed. Almost all of the physicians said these threats made them concerned about their safety or the safety of their family. Encounters where CAPs informed parents about their suspicions of child abuse were most frequently the occasion when they feared for their safety.
Complaints to supervisors and licensing boards and malpractice suits
Half of the CAPs responding to the 2006 initial survey said families had filed a formal complaint with their employer and 13% said formal complaints had been filed with the state licensing agency, because they reported suspected abuse or testified as an expert witness at a trial involving child maltreatment. They described these complaints in more detail when they were interviewed. (“They make complaints to the hospital board, complaints to state medical disciplinary boards, complaints to the department and social health services, congressmen, legislators, governor, and complaints to the hospital and university about research and propriety. . . Complaints to the State Hospital Commission . . . Complaints to JCAH [JACHO, Joint Commission on Accreditation of Healthcare Organizations].”)
Nine respondents to the original 2006 survey (16%) said they had been sued for malpractice up to 7 times, because they reported suspected child abuse. In their interviews, CAPs reported spending a few hours to hundreds of hours preparing to defend themselves in court. (“Anytime you get sued it’s very painful”) (“Doctors who are liked better by patients are less likely to be sued and I’m not sure we’re often in a position to make friends.”) In the cases that had been concluded at the time of the survey, no CAPs had been successfully sued.
Media
About one-quarter of the physicians initially surveyed in 2006 said that negative stories had been published or presented in the popular media including newspapers, magazines, radio, and television about their work with child maltreatment. They discussed these stories in their interviews. (“[stories suggest] you don’t know what you’re talking about. You see abuse under every tree [and as a result] there are innocent people going to jail.”) The stories often did not provide the CAP’s perspective on the case. Legal and ethical constraints related to personal privacy led some CAPs to feel unable to effectively communicate their position to the press. Some physicians described how they engaged the press to raise awareness about issues or used media consultants to handle questions and probes.
Coping With Challenges
Professional
In their interviews, the CAPs said that it was important to set limits at work and use all vacation days. Some CAPs described how accepting the limitations of their role helped them (“keep in mind that there's still a lot that we don't know regarding medical issues in child physical abuse”). Other CAPs shared that the challenges motivated them to keep up with the medical literature and advance the field through research projects.
Personal
Outside of the work setting, the CAPs pursued several strategies for coping with the challenges of their work including physical activity, viewing movies, song writing, social drinking, and gardening. One respondent suggested that being able to “see the results” of her personal activities helped to counterbalance the uncertainties experienced at work. (“My coping strategy is to live two different lives [one] where nothing ever happens that has anything to do with interpersonal violence . . . and my other life is what I do at work.”)
Organizational
Most CAPs described the value of creating and using support networks. Support networks were developed within hospital teams, across systems, and nationally with colleagues at other institutions. They found the support team useful in processing cases, processing emotions, maintaining perspective, sharing the case burden, and reducing feelings of isolation. (“The power of a multi-disciplinary team is that you have people that you can work on these cases with that function together. You have to get people together on a regular basis and know and trust each other and have ways to work out systemic problems.”)
Career Satisfaction
Although the survey and telephone interview questions were designed to ask about the challenges faced by CAPs, the physicians spontaneously described in their telephone interviews the positive aspects of their work. They said that the work was fulfilling because (“it’s very challenging”). They described liking other people in the field. Many found it rewarding, because child abuse pediatrics is a new field and research is evolving rapidly. (“. . . we’re doing better research and we’re doing a better job.”) The CAPs enjoyed the field because of the range of skills needed (“physical doctor skill. science . . . family dynamics . . . child development . . . interface with people outside your field”). They described appreciating how they (“work with colleagues in the community to improve things for families and kids”).
Discussion
More than three-fourths of the CAPs who participated in this study reported experiencing negative consequences because of their work. Most had experienced multiple types of negative consequences and many consequences occurred more than once. Although the CAPs described many challenges resulting from their work with child maltreatment, they described several ways they addressed the challenges and spontaneously shared why they found the work rewarding.
CAPs described a number of challenges that are a regular feature of working with child abuse, including conflictual relationships with patients’ families, inherently adversarial courtroom experiences, and economic pressures of their practice including spending hours of uncompensated time working with nonmedical professionals. In addition, similar to the experience described by Great Britain pediatricians (Haines & Turton, 2008), these CAPs said that they are often the focus of complaints to their employers or to the state licensing board. They reported that these challenges were an expected part of the job, and prompted both practice improvement and served as motivation to pursue research.
Although child abuse reporting laws protect reporting physicians from liability, the laws do not prevent the initiation of lawsuits. Generally good physician–patient communication should decrease the risk of a malpractice suit (Levinson, Roter, Mullooly, Dull, & Frankel, 1997), but effective communication requires partnership building between the physician and family (Levetown & Committee on Bioethics, 2008). It is difficult to engage a family, when the physician thinks a child is possibly maltreated and a family member may have perpetrated the maltreatment.
The CAPs in this study shared professional, personal, and organizational strategies for coping with the challenges of their field. The CAPs in this study described developing good balance between professional and personal life including setting clear boundaries, a strategy that is recognized to develop resiliency and prevent burnout (Jensen, Trollope-Kumar, Waters, & Everson, 2008; Kuerer et al., 2008). Personally and professionally, they appeared to have developed strong support networks and supportive relationships, another feature associated with physician resiliency. Jensen et al., 2008; Johnson, 1999).
Limitations
This manuscript represents an exploratory study of the stressors experienced by child abuse practitioners. As such, the findings reported in this study rely primarily on interview data of a select, purposive sample of physicians who were invited and agreed to participate in this study. The CAPs who participated in the study averaged 16 years of experience in child abuse pediatrics. This study reports only the subjective experiences of CAPs, and therefore does not attempt to validate or quantify the experience reported. Although the challenges were explored in an in-depth manner, the recruitment method likely limited the study to physicians who were still actively engaged in caring for children who may have been maltreated, thus excluding the experience of physicians who had left the subspecialty. A future study should include these physicians.
The use of this protocol with a small sample may pose a potential limitation of the generalizability of the resulting outcomes. However, we believe these findings represent a strong foundation for further understanding of the CAP experience in the United States. Further study could focus on the efficacy of the different ways CAPs address their challenges.
Footnotes
Acknowledgements
We appreciate the support of the Anthony E. and Christine Speiser Family Foundation for helping to fund this research. Robert Sege is supported in part by the Harvard Youth Violence Prevention Center. The funding sources had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. We thank the Child Abuse Physicians who participated in this survey; we are especially grateful to the physicians who shared their stories for their thoughtful perspectives.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.