Assessments of girl's genital findings and the likelihood of sexual abuse: agreement among physicians self-rated as skilled

Final year dental students' self-assessed confidence in general dentistry

BACKGROUND

Self-assessment is an important introspective skill that dental professionals will utilise throughout their professional career. Its value lies in its ability to help individuals identify areas of strengths and weakness, and subsequently seek further development of professional skills where needed. The aim of this study was to investigate the correlation between self-assessed confidence and the assessment grade of final year dental students based on the professional attributes and competencies of newly qualified dentists outlined by the Australian Dental Council (ADC).

METHODS

Ethical approval was obtained prior to distribution of a questionnaire with 45 statements to final year dental students. The survey was created based on the learning outcomes of the ADC guidelines in the domains of "scientific and clinical knowledge" and "patient care." Participants indicated their level of self-assessed confidence by marking "X" on a visual analogue scale (VAS) from zero ("No Confidence") to 10 cm ("Very Confident"). The assessment grade was based on OSCE, viva voce, case report and written paper.

RESULTS

A total of 58 (71.6%) dental students participated in the survey. The reported self-assessed confidence over two domains were under "patient care": clinical information gathering 8.92 ± 1.07 cm (range =3.94-10.0 cm: n = 58; 100%), clinical diagnosis and management planning 8.26 ± 1.34 cm (range =0.50-9.95 cm: n = 55; 94.8%), clinical treatment and evaluation, 6.07 ± 1.69 cm (range =0-10.00 cm: n = 55; 94.8%), and "scientific and clinical knowledge": 6.98 ± 1.58 cm (range =0-10.00 cm: n = 58; 100.0%). Within these categories, high confidence was reported for routine dental care (caries management and preventive care) whilst lower confidence was reported for the management of oral medicine and pathologies, dental emergencies, trauma, paediatric dentistry and prosthodontics. Correlation between the assessment grade and the overall score of self-assessed confidence is low positive (r = .225) and not statistically significant (n = 46; P = .132, Spearman'sρ).

CONCLUSIONS

The final year dental students appear to have good overall self-assessed confidence in core areas of general dentistry. However, confidence seems to be over-estimated when compared with summative assessment.

Deliberate practice as an educational method for learning to interpret the prepubescent female genital examination

BACKGROUND

Correct interpretation of the prepubescent female genital examination is a critical skill; however, physician skill in this area is limited.

OBJECTIVE

To complement the bedside learning of this examination, we developed a learning platform for the visual diagnosis of the prepubescent female genital examination and examined the amount and rate of skill acquisition.

PARTICIPANTS AND SETTING

Medical students, residents, and fellows and attendings participated in an on-line learning platform.

METHODS

This was a multicenter prospective cross-sectional study. Study participants deliberately practiced 158 prepubescent female genital examination cases hosted on a computer-based learning and assessment platform. Participants assigned the case normal or abnormal; if abnormal, they identified the location of the abnormality and the specific diagnosis. Participants received feedback after every case.

RESULTS

We enrolled 107 participants (26 students, 31 residents, 24 fellows and 26 attendings). Accuracy (95 % CI) increased by 10.3 % (7.8, 12.8), Cohen's d-effect size of 1.17 (1.14, 1.19). The change in specificity was +16.8 (14.1, 19.5) and sensitivity +2.4 (-0.9, 5.6). It took a mean (SD) 46.3 (32.2) minutes to complete cases. There was no difference between learner types with respect to initial (p = 0.2) or final accuracy (p = 0.4) scores.

CONCLUSIONS

This study's learning intervention led to effective and feasible skill improvement. However, while participants improved significantly with normal cases, which has relevance in reducing unnecessary referrals to child protection teams, learning gains were not as evident in abnormal cases. All levels of learners demonstrated a similar performance, emphasizing the need for this education even among experienced clinicians.

UK Paramedics Confidence in Identifying Child Sexual Abuse: A Mixed-Methods Investigation

United Kingdom (UK) paramedics are in a prime position to identify children and young people who are victims or at risk of sexual abuse. Paramedics have access, by phone, or in person, to unprepared homes and communities which other health professionals such as social workers may not. Little research exists however, investigating UK paramedic confidence in identifying child sexual abuse. This mixed-method explanatory sequential investigation used the self-reported confidence levels of 276 UK paramedics to inform the design of seven semi-structured focus groups with 25 UK paramedics from a large ambulance service with operating models similar to all UK services. Multiple factors contribute to a lack of confidence in identifying child sexual abuse, child sexual exploitation, and female genital mutilation, including a perceived lack of exposure to sexual abuse, the perceived hidden nature of sexual abuse, and the lack of physical symptoms and examination. An overarching lack of knowledge is the most significant contributor to a lack of confidence which in turn perpetuates misinformation surrounding prevalence, location, and the signs and symptoms of sexual abuse. These findings suggest a lack of sufficient training and a need for further research evaluating the content of current training and its method of delivery.

Inter-rater reliability of physical abuse determinations in young children with fractures

As there is no "gold standard" in determining whether a fracture is caused by accident or abuse, agreement among medical providers is paramount. Using abstracted medical record data from 551 children <36months of age presenting to a pediatric emergency department, we examined the extent of agreement between specialists who evaluate children with fractures for suspected abuse. To simulate clinical scenarios, two pediatric orthopaedists and two child abuse pediatricians (CAPs) reviewed the full abstraction and imaging, whereas the two pediatric radiologists reviewed a brief history and imaging. Each physician independently rated each case using a 7-point ordinal scale designed to distinguish accidental from abusive injuries. For any discrepancy in independent ratings, the two specialists discussed the case and came to a joint rating. We analyzed 3 types of agreement: (1) within specialties using independent ratings, (2) between specialties using joint ratings, and (3) between clinicians (orthopaedists and CAPs) with more versus less experience. Agreement between pairs of raters was assessed using Cohen's weighted kappa. Orthopaedists (κ=0.78) and CAPs (κ=0.67) had substantial within-specialty agreement, while radiologists (κ=0.53) had moderate agreement. Orthopaedists and CAPs had almost perfect between-specialty agreement (κ=0.81), while agreement was much lower for orthopaedists and radiologists (κ=0.37) and CAPs and radiologists (κ=0.42). More-experienced clinicians had substantial between-specialty agreement (κ=0.80) versus less-experienced clinicians who had moderate agreement (κ=0.60). These findings suggest the level of clinical detail a physician receives and his/her experience in the field has an impact on the level of agreement when evaluating fractures in young children.

Practicing emergency physicians report performing well on most emergency medicine milestones

BACKGROUND

The Accreditation Council for Graduate Medical Education's Next Accreditation System endorsed specialty-specific milestones as the foundation of an outcomes-based resident evaluation process. These milestones represent five competency levels (entry level to expert), and graduating residents will be expected to meet Level 4 on all 23 milestones. Limited validation data on these milestones exist. It is unclear if higher levels represent true competencies of practicing emergency medicine (EM) attendings.

OBJECTIVE

Our aim was to examine how practicing EM attendings in academic and community settings self-evaluate on the new EM milestones.

METHODS

An electronic self-evaluation survey outlining 9 of the 23 EM milestones was sent to a sample of practicing EM attendings in academic and community settings. Attendings were asked to identify which level was appropriate for them.

RESULTS

Seventy-nine attendings were surveyed, with an 89% response rate. Sixty-one percent were academic. Twenty-three percent (95% confidence interval [CI] 20%-27%) of all responses were Levels 1, 2, or 3; 38% (95% CI 34%-42%) were Level 4; and 39% (95% CI 35%-43%) were Level 5. Seventy-seven percent of attendings found themselves to be Level 4 or 5 in eight of nine milestones. Only 47% found themselves to be Level 4 or 5 in ultrasound skills (p = 0.0001).

CONCLUSIONS

Although a majority of EM attendings reported meeting Level 4 milestones, many felt they did not meet Level 4 criteria. Attendings report less perceived competence in ultrasound skills than other milestones. It is unclear if self-assessments reflect the true competency of practicing attendings. The study design can be useful to define the accuracy, precision, and validity of milestones for any medical field.

Educating physicians internationally in the diagnosis of child sexual abuse: evaluation of a brief educational intervention in Malawi

We designed this pilot study to assess physician knowledge and comfort evaluating child sexual abuse in Malawi and to evaluate the feasibility of a brief educational intervention to improve physician knowledge. A survey was administered to 21 physicians before receiving training on child sexual abuse. The survey was administered again, 3 days later, to assess improvement. Prior to the training, 48% correctly identified the hymen in a photograph, and 24% correctly interpreted the photograph as normal. Of the 11 physicians available for the posttest 3 days later, significant improvement was found in their ability to correctly identify the hymen (6 of 11 pretraining and all 11 posttraining, p = 0.011) and to interpret the photograph correctly (1 of 11 correct pretraining, 9 of 11 posttraining, p = 0.001). This study demonstrates the feasibility of designing trainings on child sexual abuse in a low-income country.

Hymenal characteristics in girls with and without a history of sexual abuse

This article reviews the recent literature on physical findings related to the hymen in pubertal and prepubertal girls with and without a history of sexual abuse. Characteristics of normal hymenal anatomy, acute traumatic findings, and characteristics of healed trauma are discussed, particularly with regard to changes in the interpretation of these findings that have occurred over time.

Timing of the medical examination

The medical examination of the sexually abused child may have evidentiary, medical, and therapeutic purposes, and the timing of the examination requires consideration of each of these objectives. In cases of acute sexual assault, emergent examinations may be needed to identify injury, collect forensic evidence, and provide infection and pregnancy prophylaxis. Alternately, most sexually abused children are not identified immediately after assault, and the timing of the examination needs to balance physical and emotional issues with the availability of qualified examiners. In all cases, the best interests of the child should be paramount.

The contribution of children's advocacy centers to felony prosecutions of child sexual abuse

OBJECTIVE

To describe trends of felony sexual abuse prosecutions between 1992 and 2002 for two districts of a large urban city that differed primarily in their use of children's advocacy centers (CACs) for sexual abuse evaluations in children.

METHODS

Aggregate data for two districts of a large urban city were provided from 1992 to 2002 from the district attorney's office, child protective services (CPS) agency, and all CACs serving both districts. Summary statistics were calculated over time and compared between both districts for ecologic trends using negative binomial regression.

RESULTS

Over the time period of the study, substantiated reports of child sexual abuse declined: District 1 experienced a 59% decrease in the incidence of reports, while District 2 experienced a 49% decrease in the incidence of reports. Despite this decrease, felony prosecutions of child sexual abuse increased in District 1 (from 56.6 to 93.0 prosecutions/100,000 children, rate ratio 1.64, 95% CI 1.38-1.95), but did not significantly increase in District 2 (from 58.0 to 54.9 prosecutions/100,000 children, rate ratio 0.94, 95% CI 0.73-1.23); by 2002, the rate of felony prosecutions in District 1 was 69% greater (95% CI 37-109%) than the rate in District 2. In 1992, CACs in District 1 evaluated approximately 400 children, increasing to 1,187 children by 2002. The number of children evaluated by CACs in District 2 increased modestly from nearly 800 in 1992 to 1,000 in 2002.

CONCLUSION

Felony prosecutions of child sexual abuse doubled in a district where the use of CACs nearly tripled, while no increase in felony prosecutions of child sexual abuse was found in a neighboring district, where the use of CACs remained fairly constant over time.

PRACTICE IMPLICATIONS

Though many limitations exist when bringing together ecological data from different agencies, the strength of the association we observed between increased CAC use and increased felony prosecutions, and the stepwise fashion in which it occurred should support future research to confirm our findings and to delineate which attributes of CAC performance might impact the likelihood of prosecution of child sexual abuse.

Variability in expert assessments of child physical abuse likelihood

OBJECTIVES

In the absence of a gold standard, clinicians and researchers often categorize their opinions of the likelihood of inflicted injury using several ordinal scales. The objective of this protocol was to determine the reliability of expert ratings using several of these scales.

METHODS

Participants were pediatricians with substantial academic and clinical activity in the evaluation of children with concerns for physical abuse. The facts from several cases that were referred to 1 hospital's child abuse team were abstracted and recorded as in a multidisciplinary team conference. Participants viewed the recording and rated each case using several scales of child abuse likelihood.

RESULTS

Participants (n = 22) showed broad variability for most cases on all scales. Variability was lowest for cases with the highest aggregate concern for abuse. One scale that included examples of cases fitting each category and standard reporting language to summarize results showed a modest (18%-23%) decrease in variability among participants. The interpretation of the categories used by the scales was more consistent. Cases were rarely rated as "definite abuse" when likelihood was estimated at < or = 95%. Only 7 of 156 cases rated < or = 15% likelihood were rated as "no reasonable concern for abuse." Only 9 of 858 cases rated > or = 35% likelihood were rated as "reasonable concern for abuse."

CONCLUSIONS

Assessments of child abuse likelihood often show broad variability between experts. Although a rating scale with patient examples and standard reporting language may decrease variability, clinicians and researchers should be cautious when interpreting abuse likelihood assessments from a single expert. These data support the peer-review or multidisciplinary team approach to child abuse assessments.

The effectiveness of self-assessment on the identification of learner needs, learner activity, and impact on clinical practice: BEME Guide no. 10

BACKGROUND

Health professionals are increasingly expected to identify their own learning needs through a process of ongoing self-assessment. Self-assessment is integral to many appraisal systems and has been espoused as an important aspect of personal professional behaviour by several regulatory bodies and those developing learning outcomes for clinical students. In this review we considered the evidence base on self-assessment since Gordon's comprehensive review in 1991. The overall aim of the present review was to determine whether specific methods of self-assessment lead to change in learning behaviour or clinical practice. Specific objectives sought evidence for effectiveness of self-assessment interventions to: a. improve perception of learning needs; b. promote change in learning activity; c. improve clinical practice; d. improve patient outcomes.

METHODS

The methods for this review were developed and refined in a series of workshops with input from an expert BEME systematic reviewer, and followed BEME guidance. Databases searched included Medline, CINAHL, BNI, Embase, EBM Collection, Psychlit, HMIC, ERIC, BEI, TIMElit and RDRB. Papers addressing self-assessment in all professions in clinical practice were included, covering under- and post-graduate education, with outcomes classified using an extended version of Kirkpatrick's hierarchy. In addition we included outcome measures of accuracy of self-assessment and factors influencing it. 5,798 papers were retrieved, 194 abstracts were identified as potentially relevant and 103 papers coded independently by pairs using an electronic coding sheet adapted from the standard BEME form. This total included 12 papers identified by hand-searches, grey literature, cited references and updating. The identification of a further 12 papers during the writing-up process resulted in a total of 77 papers for final analysis.

RESULTS

Although a large number of papers resulted from our original search only a small proportion of these were of sufficient academic rigour to be included in our review. The majority of these focused on judging the accuracy of self-assessment against some external standard, which raises questions about assumed reliability and validity of this 'gold standard'. No papers were found which satisfied Kirkpatrick's hierarchy above level 2, or which looked at the association between self-assessment and resulting changes in either clinical practice or patient outcomes. Thus our review was largely unable to answer the specific research questions and provide a solid evidence base for effective self-assessment. Despite this, there was some evidence that the accuracy of self-assessment can be enhanced by feedback, particularly video and verbal, and by providing explicit assessment criteria and benchmarking guidance. There was also some evidence that the least competent are also the least able to self-assess accurately. Our review recommends that these areas merit future systematic research to further our understanding of self-assessment.

CONCLUSION

As in other BEME reviews, the methodological issues emerging from this review indicate a need for more rigorous study designs. In addition, it highlights the need to consider the potential for combining qualitative and quantitative data to further our understanding of how self-assessment can improve learning and professional clinical practice.

Which sexual abuse victims receive a forensic medical examination? The impact of Children's Advocacy Centers

OBJECTIVE

This study examines the impact of Children's Advocacy Centers (CAC) and other factors, such as the child's age, alleged penetration, and injury on the use of forensic medical examinations as part of the response to reported child sexual abuse.

METHODS

This analysis is part of a quasi-experimental study, the Multi-Site Evaluation of Children's Advocacy Centers, which evaluated four CACs relative to within-state non-CAC comparison communities. Case abstractors collected data on forensic medical exams in 1,220 child sexual abuse cases through review of case records.

RESULTS

Suspected sexual abuse victims at CACs were two times more likely to have forensic medical examinations than those seen at comparison communities, controlling for other variables. Girls, children with reported penetration, victims who were physically injured while being abused, White victims, and younger children were more likely to have exams, controlling for other variables. Non-penetration cases at CACs were four times more likely to receive exams as compared to those in comparison communities. About half of exams were conducted the same day as the reported abuse in both CAC and comparison communities. The majority of caregivers were very satisfied with the medical professional. Receipt of a medical exam was not associated with offenders being charged.

CONCLUSIONS

Results of this study suggest that CACs are an effective tool for furthering access to forensic medical examinations for child sexual abuse victims.

Clinical experience did not reduce the variance in physicians' estimates of pretest probability in a cross-sectional survey

BACKGROUND AND OBJECTIVES

In light of the increasing popularity of the threshold approach in clinical decision-making, this study assesses the role of expertise in physicians' agreement in estimating the probability of disease in patients.

METHODS

A cross-sectional survey of physicians of different specialties, attending weekly staff meetings in four teaching hospitals in Jerusalem, Israel. An anonymous questionnaire describing three case scenarios of patients with chest pain was administered and participants were asked to estimate pretest probabilities of disease.

RESULTS

Eighty-six physicians (practicing cardiology, internal medicine, and family medicine, as well as general practitioners and internists) out of 125 approached (response rate 69%). The mean estimated probabilities were very similar for residents and specialists; however, the standard deviation was higher for specialists in all three cases: 20.7, 21.0, and 19.1 among specialists and 16.4, 20.5, and 14.9 among residents, respectively.

CONCLUSION

This study, based on case scenarios, did not find that medical expertise improved agreement among doctors when estimating the probability of disease in patients-despite the common belief that senior physicians should have smaller interobserver differences in probability estimates. The wide variation observed calls into question the applicability of the threshold approach.

Criminal investigations of child abuse: the research behind "best practices"

This article reviews the research relevant to seven practices considered by many to be among the most progressive approaches to criminal child abuse investigations: multidisciplinary team investigations, trained child forensic interviewers, videotaped interviews, specialized forensic medical examiners, victim advocacy programs, improved access to mental health treatment for victims, and Children's Advocacy Centers (CACs). The review finds that despite the popularity of these practices, little outcome research is currently available documenting their success. However, preliminary research supports many of these practices or has influenced their development. Knowledge of this research can assist investigators and policy makers who want to improve the response to victims, understand the effectiveness of particular programs, or identify where assumptions about effectiveness are not empirically supported.

Evaluating child sexual abuse

We have learned much about the medical evaluation of suspected child sexual abuse during the past 2 decades. The physical examination still holds an important place in the evaluation but is secondary to a well-performed history. As the evolving literature increases our understanding, the relevance of various anatomic appearances of the prepubertal and pubertal genital examination will certainly become even clearer. The physical examination rarely is diagnostic by itself, with more than 92% of cases failing to demonstrate either acute or chronic signs of injury. Thus, the 1994 quote by Adams and colleagues, "It's normal to be normal," continues to ring true, now supported by a growing body of pediatric literature.

Do pediatric chief residents recognize details of prepubertal female genital anatomy: a national survey

OBJECTIVE

To evaluate how well a group of recently trained pediatric chief residents could label anatomic structures on two different photographs of female prepubertal genitalia. Additionally, the study sought to explore aspects of pediatric training in sexual abuse and clinical practice issues surrounding the routine genital examination.

METHOD

A 38-item questionnaire was mailed to pediatric chief residents at all of the officially listed pediatric residency-training programs in the continental US. Comparisons were made between this study and the responses to two previous surveys, which asked a more heterogeneous group of physicians to label one of the photographs used in the study. The second photograph was added because of its improved clarity of each anatomic structure when compared to the first photograph used in the previous studies. The study also asked about clinical practice issues surrounding the prepubertal genital examination.

RESULTS

An overall response rate of 73% was achieved and analysis was done on 139 respondents. One-half of chief residents thought that their training during residency on sexual abuse was inadequate for practice. Sixty-four percent of chief residents correctly labeled the hymen on the photograph used in the previous studies, which was not significantly different from the 62% and 59% of physicians who correctly labeled the hymen in the previous surveys. In the second photograph, which more clearly displayed the various anatomic structures, 71% correctly labeled the hymen.

CONCLUSION

Pediatric chief residents reported variable amounts of training on issues pertaining to child sexual abuse during residency, think that this time was inadequate, and, while doing slightly better than a more diverse group of previously studied physicians, did not achieve 100% accuracy in identifying basic genital structures correctly on two different photographs.

Factors impacting injury documentation after sexual assault: role of examiner experience and gender

OBJECTIVE

This study was undertaken to determine whether physician gender or level of experience is associated with the prevalence of trauma documented in victims after sexual assault.

STUDY DESIGN

All female patients 15 years or older reporting to an urban hospital with a complaint of sexual assault between January 1997 and September 1999 underwent a standardized history and physical examination by a second- or third-year resident in obstetrics and gynecology. Data were abstracted and verified. A chi(2) or Fisher exact test was used for categoric analysis.

RESULTS

The overall prevalence of genital trauma was 21% in the 662 patients available for analysis. The prevalence of genital trauma documented by second- and third-year residents was 50 of 191 patients (26.2%) and 90 of 471 patients (19.1%), respectively (P=.04), despite similar assault characteristics between the 2 groups. The prevalence of genital trauma documented by male examiners (105/499 [21.0%]) and female examiners (35/160 [21.9%]) did not differ (P=.8). All examiners documented a similar prevalence of body trauma (52%).

CONCLUSION

This study supports the hypothesis that the examiner's experience level may influence the prevalence of genital trauma documented after a sexual assault. Genital trauma documented was not associated with examiner gender in this study.

Genital examinations for alleged sexual abuse of prepubertal girls: findings by pediatric emergency medicine physicians compared with child abuse trained physicians

OBJECTIVE

This study compares abnormal genital examination findings made by pediatric emergency medicine (PEM) physicians to examinations by physicians with training in child sexual abuse in the evaluation of prepubertal girls for suspected sexual abuse.

METHOD

A prospective study was performed following the genital examination by a PEM physician of prepubertal girls suspected of being sexually abused. A physician with training in child sexual abuse re-examined those girls whose examinations were interpreted as abnormal by the PEM physicians. The findings and interpretations of the PEM physician were then compared to those by the physicians with training in child abuse.

RESULTS

Between October 1994 and October 1998, 46 patients diagnosed by PEM physicians with nonacute genital findings indicative of sexual abuse were re-examined by a physician with training in child abuse. The follow-up examinations were done 2 days-16 weeks (mean 2.1 weeks) after the emergency department visit. The physicians with training in child abuse concluded that only eight of these children (17%) showed clear evidence of abuse. Normal findings were noted in 32 children (70%), nonspecific changes were noted in 4 children (9%), and 2 children (4%) had findings that are more commonly seen in abused children than nonabused children but are not diagnostic for abuse (concerning for abuse).

CONCLUSIONS

There was poor agreement between the pediatric emergency medicine physicians and the physicians with training in child sexual abuse. This study suggests that emergency medicine physicians should consider additional training in this area. In addition, all children with abnormal ED examinations should have follow-up examinations by a child abuse trained physician.

Imperforate hymen: congenital or acquired from sexual abuse?

Imperforate hymen diagnosed beyond the newborn period may present a dilemma for the physician. Three case studies are reviewed in which children with the diagnoses of imperforate hymen presented for evaluation of suspected sexual abuse. Clear descriptions of genital anatomy documented at well-child visits may be critical to later interpretations of findings encountered during examinations for suspected sexual abuse.

The use of telemedicine in child sexual abuse evaluations

OBJECTIVE

To describe the advantages, disadvantages and current status of child abuse consultations conducted through telemedicine networks.

METHOD

The results of a telephone survey of seven statewide telemedicine networks are reported and discussed with respect to goals, funding, technical support and expertise, infrastructure, and extent of use. Quality assurance and liability issues concerning telemedicine child abuse consultations are also reviewed.

RESULTS

The goals of telemedicine networks in child abuse are to provide (1) expertise to less experienced clinicians primarily in rural areas; (2) a method for peer review and quality assurance to build consensus of opinions particularly in sexual abuse cases; and (3) support for professionals involved in an emotionally burdensome area of pediatrics. Problems encountered by existing networks include: (1) funding for equipment and reimbursement for consultation; (2) consistent technical support: (3) clinician lack of technical expertise, knowledge, or motivation; and (4) lack of network infrastructure. Legal considerations include licensure exemptions for consulting across state lines, potential for malpractice, patient confidentiality and security of images forwarded over modem lines, and liability of the equipment, consulting site, and the consultant in criminal proceedings.

CONCLUSIONS

Telemedicine consultations offer a unique opportunity to raise the standard of care in child abuse evaluations, but success depends on clinician motivation, appropriate infrastructure, and ongoing funding and technical support.

Influence of the history on physicians' interpretations of girls' genital findings

OBJECTIVE

Because physicians customarily obtain histories before examining children in cases of possible sexual abuse, and because the resulting diagnostic opinions can influence important social and legal decisions, we investigated whether clinical histories influence physicians' interpretations of girls' genital findings.

DESIGN

In mailed questionnaires, 1387 randomly selected Fellows of the American Academy of Pediatrics and all 802 members of four professional groups concerned with child abuse or pediatric gynecology were asked to interpret seven simulated cases. Respondents were asked to interpret seven additional cases in separate questionnaires mailed 4 months later. Both sets of cases involved the same seven photographs of girls' external genitalia. However, in six of the seven case pairs, the histories in the two questionnaires differed in the extent to which they suggested sexual abuse. In the remaining (control) pair, the same history was presented in both questionnaires.

RESULTS

Of 2189 physicians, 1114 (50.9%) responded. Responses from 604 physicians (54.2%) were eligible for analysis. Overall, the genital findings were interpreted most consistently by the most experienced physicians and least consistently by the least experienced physicians. The proportion of physicians whose interpretations of a photograph reversed in the direction suggested by the change in the associated history from "no indication of abuse" to "probable abuse," or vice versa, ranged for experienced physicians from none to 5.6%; for moderately experienced physicians from 1.6% to 19.8%; and for inexperienced physicians from 3.6% to 27.2%. This difference between the experience groups was statistically significant in four case pairs. Mean interpretation scores for genital findings changed significantly when the histories changed in two case pairs for the experienced physicians, in five pairs for the moderately experienced physicians, and in all six pairs for the inexperienced physicians.

CONCLUSIONS

In some cases and especially for less experienced physicians, diagnostic expectation appears likely to influence physicians' interpretations of girls' genital findings. Physicians should be alert to the possibility of diagnostic expectation bias and its potentially serious social and legal consequences.