Recognizing Abuse-related Fractures: Why Do Pediatric Trainees Decide to Report?

Background: Child abuse is a public health epidemic with significant morbidity and mortality. However, pediatric trainees report feeling underprepared to accurately identify abuse. Currently, there is a poor understanding of trainees' reasoning when attempting to accurately identify injuries such as fractures and bruising that have resulted from child abuse. The objective of this study is to explore pediatric trainee reasoning on whether to report child abuse in simulated fracture cases.

Methods: An expert panel of pediatric emergency medicine (PEM) and child abuse physicians selected six cases involving children ages 0-3.99 years old with fractures from an existing database. Their injuries were classified as abuse-related or accidental by expert consensus. From these six cases, educational experts created six simulation cases. Sixty pediatric trainees, equally distributed across three years of training, were eligible to participate in these simulations, followed by a questionnaire. The ultimate question was a free-text question regarding drivers of whether to report. These data were analyzed qualitatively using line-by-line coding (RMC, AK), then grouped into focused codes to identify major themes and understand trainee reasoning.

Results: Forty-one pediatric trainees (PGY1: 20; PGY2: 9; PGY3: 12) participated in simulations. In the two cases determined to be abusive fractures, 97% of trainees (n = 40) recognized abuse. For the sole trainee who did not report abuse, they recorded a desire to seek social work evaluation prior to reporting. For the cases deemed to be accidental, 47% would have reported to the Department of Children and Family Services (DCFS). Pediatric trainees' reasoning for reporting included feeling that the history did not match the physical exam, the patient had prior traumatic history or multiple fractures in the past, or injury pattern on physical exam was suspicious, specifically bruising in high risk areas.

Conclusion: When presented with simulated cases representing both abusive and accidental fractures, pediatric trainees consistently identified injury patterns consistent with abuse but there was greater variability in the cases that represented accidental fractures. Interestingly, trainees who are unsure of their findings are more likely to report and allow a third party (e.g., social work, DCFS) to make the determination regarding abuse. Most pediatric trainees used similar language and reasoning for reporting if they reported in cases that were ultimately accidental. Reporting accidental injuries may have unintended consequences such as mistrust of the healthcare system and reluctance to seek care. Further initiatives should include educating trainees about the risk of bidirectional error when attempting to identify abuse.