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Thread: mandated reporting - when to tell my patient?

  1. #1
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    mandated reporting - when to tell my patient?

    I'm a first-year medical student, and I recently learned that I'll be a "mandated reporter" as soon as I'm licensed to practice. This means that if a patient comes to see me with injuries that are the result of violence, by law I am required to report the incident to the police, who will follow up with an investigation, as well as social workers who will counsel the victim on possible next steps.

    My question is this: at what point in the conversation with my patient should I disclose my role as a mandated reporter? Before or after the person has explained that they were harmed?
    I hope to always earn my patients' trust. This means "no tricks"...right? But it seems as though my fellow students and my professors all agree that it is best to withhold the details about being "mandated reporters" from our patients so that they won't fear the consequences of telling us they've been abused physically. By this reasoning, if we tell a patient that we must report any instance of physical abuse to the police, we run the risk that they won't tell us anything.

    Since I'm not a survivor of physical abuse, I can't form an opinion on how this should be handled. What is ethical? To inform the patient about the police involvement after or before they disclose that they've been abused? Any advice would be greatly appreciated. I want to be prepared so that I can be the best support that I can for a patient who comes in with such traumatic wounds.

    Any advice would be greatly appreciated. Thanks.

  2. #2
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    hey

    thanks for posting this, i think its a great topic, am curious how others feel

    cant really give advice, especially about legal issues, but can share personal experience.

    first of all, im no lawyer, but i believe in my jurisdiction if im over 18 - pressing or not pressing charges is my call to make, and nobody has the authority to go over my head and do it against my will. unless they go declare me legally insane and unable to make rational choices, which takes a court hearing, not an easy task. so all that would happen practically, when you report me, is that id have to sit and talk with social workers, victim advocates, police, etc, for a while; they gonna try to convince me to press charges, im gonna keep refusing - eventually they gonna give up, give me their business card, and let me go. the good part about it is that those advocates and social workers know the system, so they can tell me what exactly my options are, point me in the right direction, bring up things i didnt think of, etc. and its also a human connection, a phone number of someone i can call if things get worse and i change my mind and do want help - someone i know, spoke to before, they seemed nice, etc. invaluable for dv victims, truly the best thing anyone can offer, this business card. saves lives. so youre not really a whistle blower, all you do is get me to talk to the people who can help me make an educated choice about my situation, while its still up to me what to do. might wanna google how it works in your jurisdiction?

    second, helps to keep a clear perspective on whats happening. many victims of abuse dont want the police involved, cuz the system is imperfect and things get messed up sometimes, and i dont wanna get killed just cuz someone in the police screwed up. but the purpose of mandatory reporting is for my benefit. its not bureaucracy and its not for the benefit of the perpetrator or anyone else. its to protect me, thats the entire goal here. so youre not fighting against me, youre fighting for me, we're on the same team. helps if you frame it this way, just explain your position, that you cant just close your eyes and let me remain in a dangerous situation, same way you wouldnt apologize and close the door if you saw someone about to hang himself. makes it a lot more human if thats how you explain it. i mean, aside from abuse victims youre gonna be talking to all sorts of people - idk, those scared of having a surgery, refusing treatment with risk to life, etc. its same thing - its understandable that they are scared, but you arent fighting against them, youre fighting for them, you only have their best interest in mind, and at the end of the day its their decision to make, youre just trying to help.

    all these disclosures before anything is said sound too much like "anything you say can and will be used against you" - a really bad way to start a convo. just makes it sound like you're concerned with covering your butt more than with helping me; "im only doing my job, i hate reporting but i'll get fired if i dont, im basically just a coward here, etc". i mean, i came here cuz im injured, why not just focus on my injuries first and foremost. if i really dont want police involved - i googled mandatory reporting laws and/or asked you what your legal obligations are, before i say anything. if i dont ask - idk why would you wanna volunteer it.

    i would not like a doc telling me "im gonna have to call police if you say anything, so i dont wanna know, youre on your own here", and i would not like a doc telling me "i dont care how you feel, im obligated to report so report i will, my job pays my student loans, i aint risking my license over your stupid problem". but i would like a doc telling me "i cant let that jerk continue to hurt you, im sorry but im calling police/social services, talk to them, see what can be done about this, this isnt ok, i cant close my eyes on this cuz i care". even if i were livid about having to talk to the police - i would still like the latter doc far more than the first two. just cuz it shows someone cares.

    i cant speak for everyone, but i personally always wished someone would step in and save me somehow. if they did, i would resist, just cuz its scary and im not sure they know what they doing and that their involvement wont make things worse - but i always wished someone would help, despite my resistance. i figure im not the only one who felt this way. so its possible that some of the patients youd be talking to actually might want you to report it, just are too scared/worried/etc to say so openly. would object, protest, complain - but would feel relieved on some level too. and so by warning them about mandatory reporting immediately - youd just be giving a clear message that you dont want to report, dont want to hear, dont want to know, dont want to help, are suggesting them to keep it to themselves. which is a really bad message to give to a victim of a crime who wants and needs help, but is too scared to reach out.
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  4. #3
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    Thank you so much for your helpful perspective on this. I truly appreciate your viewpoints. It sounds like I do need to get to know the system within the state of CA, and get a better idea of what happens when I report an abused patient. I do wish the best for my patients, and I definitely want to fight for their safety even if it's not the easiest path.

  5. #4
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    First off, I think it's great that you're trying to be as up front as possible and helpful with patients. with much of what was already said. There isn't any point to bringing it up right off the bat, hopefully situations you have to report will be few in your career. On the other hand, my therapist and psychdoc both had the conversation with me about what things they are required to report. Those situations I am sharing a lot of personal stuff regularly, so I need to know ahead of time. My medical doctor I wouldn't expect to have that conversation right away.

    Where I live, charges can be pressed with or without my permission in some situations. Another thing is that most adults have a pretty good idea what mandated reporting is, and what kinds of professions usually have the requirement so it's not a surprise you are throwing at them.
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  7. #5
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    Thank you for starting this interesting coversation. Like Manya I have no legal qualifications and limited knowledge of the legislation in your counry. However I am happy to share what it was like to live with childhood abuse. How helpless I felt...how I wished some one would do something to help me. Unfortunately (admittedly in earlier less enlightened times) this never happened. Although I did have contact with professionals no one ever "joined the dots' or questioned the spurious explanations my parents gave to explain my "accidents"...that I had fallen astride a tree, accidently dropped fat on the back of my thigh, was clumsy and cut myself and bruised easily. I could go on...suffice to say I prayed that some one would see what was happening to and rescue me.

    May I wish you all the best with your studies. for treating this important aspect of your professional training with the seriousness it deserves.

    Although not completely on topic I thought you might find this article useful. It was written by one of our members about the negative impact that she experienced when well meaning people took ineffective action...failed to report through the correct channels. http://www.fortrefuge.com/Child-Abus...Gone-Wrong.php
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  9. #6
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    I remember going to the emergency room due to a concussion, from an abusive relationship. I told her I had a concussion, and how I got it. Then she asked me if I had notified police, and said that she is required to report it if I had not. My mom was with me, so she didn't bother to check my story, even though I HAD already told police at that point, days before.

    I honestly had a little problem with her not mentioning it upfront, because it DOES feel shady and it stings when someone almost lies to you, and then starts making choices on your behalf. Also, when people chose to ignore my wishes and take action on their own without my prior knowledge, it infuriated me, and made me cling tighter to my abuser. (think Stockholm Syndrome). I would have appreciated it so much more if people had said, "Hi, my name is ____. Everything you say to me is safe, but I want to be honest with you and tell you that if you are a victim of abuse, I am required by law to tell someone so that they can safely get you some help, and support you each step of the way whatever you choose in getting that help". My biggest problem with getting out of the abuse was that I didn't feel helped by ANYONE, not even police. I felt AMBUSHED, because no one was ever upfront with me, they just thought I didn't know anything and that I couldn't make my own decisions. It was awful, and it put me into a really big rage and depression.

    So I personally would have to say be upfront and honest. If you think something is going on that they aren't saying, and you will get 'that feeling', trust me, then it may be worth while to go ahead and say something like, "I just want you to know that abuse is never okay, and that if it IS happening to you, there's a better life than that, for both of you, and if it isn't happening, I'm glad." Maybe even call to schedule a follow up appointment and see how things are going/for a checkup/whatever, and reassess the situation if they didn't say yes, abuse is happening in my home.

    Please do your best to be upfront with them and be honest, because in the middle of abuse, the last thing I wanted was for people to trick me or withhold information to get what they wanted out of me, and then all of a sudden people were in my home and taking him away, and taking me to my parents, and chaos that I wasn't ready for, but that's what I got the first time it happened to me and I told someone.

    Thanks for posting. <3
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  11. #7
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    Hi just a quick experience I had with being a mandatory reporter...

    A women wanted to be part of a program with her children (under 18) and she knew her kids would be asked about DV at home etc and they were still being abused. I felt it only fair to disclose we were mandatory reporters so her children wouldn't be put into "the system". She was in the process of leaving and I felt the heads up would give her the chance to rethink joining the program at the risk of losing her kids to "the system" which sometimes is worse than the original DV.

    Don't know if it was right or wrong to this day...

    Just my two cents.

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  13. #8
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    I really think you should be completely honest up front. Yes, this can deter people from telling you everything. However, I think it might be almost traumatic for them to feel tricked into you having to report things.

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  15. #9
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    Thank you EFLP for giving this topic the respect it deserves, it is wonderful that there are people out there such as yourself willing to take extra time and energy to develop some compassion for this situation, understand its complexity and ask questions of survivors themselves.

    As a rule I would always put the child's needs first if there are any children involved; the younger the child (first 0-5yrs of life), the more vulnerable their development & future is.

    Some abusive parents, such as my mother, know the system well and disguise their parental abuse from the system, i.e. its professionals, in order to put their own needs first. But sometimes the system is an even worse environment that the home a kid was removed from. It's complex.

    Like Jane, as a little kid I had injuries and bruises that had been inflicted on me at home by my mother and her boyfriends but when professionals saw them they never did anything. They believed my mother's lies that I'd done them myself because I was a foolish or difficult child. No one reached out to me, asked me, considered my welfare, my safety, my future. It was like I was invisible. All I hoped and yearned for was that someone would see me, rescue me. But unfortunately all the many professionals involved focused entirely on my mother and her needs as she made such a convincing & voluble case. Me and my siblings needs went un-noticed & neglected, we were silent and ashamed.

    Maybe there isn't an exact formula for you to follow in every situation with every patient regarding mandated reporting. Maybe it is something that will develop further over time and with experience. If you put yourself in the child's shoes what would be best for them? That could be hard to imagine if you don't have an abusive parent who lies, don't know what it's like to be a kid to have no safe adult to turn to, haven't lived as a kid in the system & know how much worse it can be. Maybe its best to build rapport with the parent, so they are less defensive.

    It's complex, the system isn't perfect. But please don't underestimate the positive impact your kindness can have on patients, especially kids. A kind and reassuring bedside manner is a drastically under-rated quality in medical care.

    Above all, if as a doctor you have any time or interaction with a kid, please be kind to them. That could be the only positive interaction they have with an adult in a whole year, their only chance to feel safe & be seen. That child can only benefit if you act with warmth, reassurance & compassion towards them. Even if you say sincerely, "Good job," or "Well done," for how they stick out their tongue or sit on a chair for your examination, it could be a huge positive contribution to their future.

    I'm in my 40's and still avoid doctors because as a kid I found them cold and intimidating, interactions with them humiliating and I always felt like a fake, stupid and a liar even when I was very sick in ER. I have a lovely gp now and am so grateful for that.

    again for taking the time and energy to ask, that you care enough to ask survivors themselves asked suggests to me you'll be a wonderful doctor

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    Thanks for asking...

    Ok, so first, thanks for thinking of this. It shows the conscientiousness you have and how much you care about other people. The huge thing I have to add is this: There is a right time to disclose upfront and a right time to disclose after talking. I have a feeling you'll know. I've had something that happened to me when I was 10 at the top of my mind the last few days...I'm going to make this very general...

    When I was 10, I had an injury...hand through a window. When asked why, I had a nice little answer I'd concocted...no clue if I was coached...but I know I had to have a GOOD answer...otherwise they'd "take me away." No one questioned my answer, but had they, the up front approach would not have worked. I would have been even more reluctant to give the true details. However, had they asked gently, probed the inconsistencies in my answers, I might have been a bit more likely to let my guard slip. Same goes with something similar that happened when I was over 18...still at home, though. If I know you intend on "turning me in," because in the mind of many abuse victims, it isn't the abuser that did wrong, it's the abused, then I'm going to fight you every step of the way and withhold every ounce of info. But if you make me feel safe...not lie to me and say you won't "tell," but rather don't even bring up the subject until you have a reason to, then I might be a bit more forthcoming.

    I hope that makes sense.

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