A Multidisciplinary, Experiential, Educational Curriculum in Child Abuse: The Pediatrician's Role in Early Recognition, Documentation, Management, and Legal Advocacy

摘要

Setting and Problem Pediatrics residents are educated in the care of abused children, yet exposure to patients with signs of abuse, particularly in the outpatient setting, may be highly variable. Frequently abused children are not recognized on their first encounter with the health care system. Many residents report that they do not feel comfortable assessing and reporting abuse. In addition, residents' exposure to legal aspects of child abuse pediatrics may be limited, or of variable educational benefit. Using a general pediatric practice as the setting, we developed a curriculum for pediatrics residents to enhance their knowledge of caring for the patient with suspected nonaccidental trauma.;Intervention We developed a standardized, multidisciplinary, experiential curriculum incorporating clinical recognition of child abuse, instruction in and evaluation of physician documentation of child abuse, communication skills in cases of abuse, managing cases of child abuse, and navigating interface between the pediatrician and the legal system. The first portion of the curriculum was presented as a standardized patient encounter with a parent presenting to the clinic with an infant with “new onset irritability.” Residents were unaware of the purpose of the encounter, which occurred in the context of their scheduled didactic conference time. The standardized patient scenario included many of the possible “red flags” residents should recognize as potential for abuse. Dolls were purchased from a retail store, and fingerprint bruising was simulated on the back and thigh. In addition, the thigh was stuffed with cotton so that it appeared to be swollen. The standardized patients were given a short script describing their role as the parent. The patient's clinic chart, including the growth chart, was given to the residents and each resident then had 20?minutes to complete the clinic encounter. The sound of a crying, inconsolable baby was streamed during the encounter. The resident was instructed to document the encounter, including an assessment and plan, and to communicate their plan to the standardized patient. The standardized patient then provided feedback on the residents' communication skills. For the second portion of the curriculum, documentation was reviewed by faculty physicians as well as legal counsel from the local district attorney's office. The following week, the residents were taken to the county courthouse and 2 residents were chosen to “testify” regarding the simulated encounter based on their documentation. The residents were questioned by the prosecution and defense to simulate an actual courtroom experience. The assistant district attorney stressed to the residents the importance of how the accuracy of their documentation could impact a child's life and the outcome of a trial. In addition, residents were given instruction from the attorney regarding providing testimony in a trial.;Outcomes to Date Feedback from the residents was generally positive regarding the utility of the curriculum and the mode of implementation. All residents found the experience beneficial. Prior to the experience, 48% (10 of 21) of residents felt confident that they would recognize abuse in the primary care setting, while after the experience 71% (10 of 14 residents completing all stages of the experience) reported they were confident in their ability to recognize abuse. Several residents indicated the standardized patient evoked significant anxiety for them. Residents reported that their skills in the appropriate management of suspected child abuse improved as a result of the experience. The importance of accurate and complete documentation was also reinforced. Pediatrics faculty, including a child abuse specialist, and attorneys reported positive informal feedback from the learners and meaningful questions.