Why Do Some Doctors Choose Confrontation Over Communication? AKA: The Consequences of a Botched Child Endangerment Report

It seems we have bestowed on any citizen, with special dispensation to doctors and teachers, the means and obligation to report any deviation they suspect might possibly lead to or result in some form of child neglect or abuse.  Keep in mind, doctors don’t need any proof to report.  They only have to have a reasonable suspicion or doubt or concern that something MIGHT be amiss or that there is a “potential” of neglect or abuse of a child.  Furthermore, physicians are under no obligation to make sure the facts are correct or check sources or confront the party or parties before reporting.  They also don’t have any onus to investigate extenuating circumstances or ask probing questions or double check a story.  No, none of this applies to them.  I know this because I am a doctor.  The courts (and child protection agencies) don’t question a doctor; they just take our word for it.

I know what you’re thinking.  You’re thinking doctors shouldn’t have to comply with any reporting standards because we can’t take any chances with children’s welfare.  Well, the courts take risks all the time with children’s welfare by sending them back to homes that are unfit or returning children to parents because they’ve “complied” with some court mandated program.   Furthermore, there is no proof that I’ve been able to find that shows all of this ability to report suspicions or report a “risk” of abuse actually cuts down on the real thing, unfortunately.

A regrettable incident occurred September 5th in our family that could have been totally avoided if the pediatrician would have asked the right questions, returned calls, given better guidance and collaborated with the mother of the newborn, our newest grandchild, instead of taking a confrontational approach.  Now, thanks to the pediatrician’s hasty decision, our family is now subjected to a 45 day monitoring period at the whim of DFaCS including home visits to make sure the kids (grandchildren) are clean, well fed and properly disciplined!  This, all because of poor communication skills and a rush to judgment by a doctor who barely knew the mother of the baby; with no reason to assume any neglect.  Yet with one capricious call, she set into motion an irreversible sequence of events.  This case now will be part of Mother’s “file” for a long time and has cast an embarrassing, and unnecessary, stigma on our household.

The situation revolved around a pretty typical case of newborn jaundice that worsened, of course, on a weekend.  As you read the progression of the timeline, ask yourself if anything about the story sounds as if it represents a neglectful mother or family.  Here is the time line:

Date of birth, Sunday August 25: Induced labor about 2 weeks early due to potential problems with a maternal condition.  Baby was fine at birth without any obvious complications.

Tuesday August 27: Bilirubin was noted to be elevated on second day necessitating baby & Mom to stay an extra day.

Wednesday August 28: Baby and Mother released home mid-day on.  Baby has follow up appointment with pediatrician next day.

Thursday August 29:  Results of blood work that day indicate bilirubin rising, but no other concerns.  Physiologic jaundiced was suspected.  Baby scheduled for follow up next day.

Friday August 30: based on exam and results of more blood work, a “bili-bed” light was ordered for home treatment.  It was delivered by the medical supply company approximately 9pm Friday night.  Mother had been previously instructed (order written) by the pediatrician to have the bilirubin checked again on Saturday at the Hospital outpatient lab.

Saturday August 31: Mother went to hospital lab with the baby and waited for about an hour, only to be informed that the lab was not open for outpatient tests on Saturday afternoon.  No other alternative arrangements had been made or suggested by the doctor.   When mother was told the lab was closed, she returned home with baby.  Sometime later on Saturday the doctor called to see why the lab test was not done and mother explained what happened.  The doctor insisted that mother take her to the ER or urgent care.  Mother called CHoA urgent care a couple of miles from her house and was told they only did that particular test Monday through Friday, but not on weekends.  After a bit of phone tag on both sides, the baby’s father called the doctor to inform her that CHoA could not do the test.  At that time the doctor insisted they go to ER to get the required blood work; she informed father that if they didn’t get it done that she would call Child Protective Services to enforce the order.   So, shortly after 11PM on Saturday night, Mother, Grandmother & baby went to ER to have blood test done.   The doctor insisted to be called when they were on their way, but despite multiple calls to her (4) over three hours, she did not answer or return any calls.  Thankfully, the results indicated levels had fallen slightly in the right direction.  The ER doc was helpful enough to give an order for special outpatient test the next day so that mother brought baby back to ER for test but did not have to see the doctor again or wait.

Sunday September 1:  Blood test repeated via order from ER doc given the previous night.  After not hearing back about results, Mother calls the pediatrician about 7pm to find out results.  The doctor wouldn’t tell her the result and kept repeating “she’s fine, she’s fine”.  She was very evasive about the results for some reason.  Her advice was to discontinue the light therapy and to repeat blood test the next day.  Later on the same night, the father got ahold of the other pediatrician in the group who readily informed him that the level was down to 15.  Her advice was to keep the light on and call for appointment in the morning.

Monday September 2:  There are no calls from or to the doctor’s office that day.  Due to getting conflicting advice from the two pediatricians the day before, Mother makes a parental decision not to subject baby to any more lab work that day.  Her reasoning is sound.  The baby is nursing well, seems comfortable, levels have fallen for two straight days and baby’s heels are swollen and bruised from repeated blood tests.

Tuesday September 3:  baby’s color is improving and nursing well, wetting diapers and sleeping peacefully.

Wednesday September 4:  Mother misses a call from Doctor’s office.  Mother calls back and arranges appointment for next day, Thursday.  Later on doctor’s office calls back to see if she can come in that same day; mother not sure due to transportation issues and ends up not being able to come in.  Appointment was set for next day, Thursday.  Bili-bed light picked up by the medical supply company.

Thursday September 5:  Mother feels uncomfortable and has lost trust in the doctor she is scheduled to see, so she calls to reschedule with the other pediatrician for Friday, whom she had more confidence in.  After the fact, we find out the “missed” appointment is reported to Child Protective Services; later on that afternoon, DFaCS workers show up at our house demanding to “see the baby and talk to mother”.  The interview results in a chaperoned trip to the doctor’s office to be told, “She looks so much better, her color is good, eyes look good, she if very active…”   and, “we will just do one more test to make sure it didn’t spike up, but I think she is fine and it will probably be OK”.

So, thankfully the baby is fine.  Everyone knew that the passage of time, with some extra light therapy, would probably take care of it.  There was no sepsis or hemolysis or drugs or metabolic issues causing the jaundice; that pretty much leaves physiologic causes, which is exactly what she was suspected of having.  The levels didn’t even reach hospitalization threshold.  They actually came down two straight days, in the face of clinical improvement.  This evidence, however, was not enough for the stethoscope-crusader(s) that felt obligated to call CPS, when a simple call the mother of their patient to discuss and form a plan would have avoided this whole mess.

But here is the fallout.  Now mother has an open CPS case and our household (Grandparents age 55 & 45) will be subjected to inquiries suitable for the likes of a Jerry Springer participant!  Now my wife (grandmother extraordinaire and full time student) will have to endure a refrigerator inspection at the hands of a county bureaucrat to make sure we are feeding our grandchildren; all do to the over-zealous, hasty decision of a careless doctor!  But, rest assured and know it’s all for the children’s benefit.

Robert W. Nelson, MD