Child Abuse: Are Pediatricians Biased?

Source: Laskey AL, Stump TE, Perkins SM, et al. Influence of race and socioeconomic status on the diagnosis of child abuse: a randomized study. J Pediatr. 2012; 160(6):1003-1008; doi:10.1016/j.jpeds.2011.11.042.  See AAP Grand Rounds commentary by Dr. Christopher Greeley (subscription required). 

PICO
Question: Among a national sample of pediatricians, do race and/or socioeconomic status of the family influence the diagnosis of child physical abuse?
Question type: Diagnosis
Study design: Randomized survey

Racial and socioeconomic bias in medicine certainly are serious issues, and whenever I see a new article on the subject I'm reminded of an older study that made the news because of overstatements of conclusions in the article followed by misinterpretations by the lay press.  I've used it for years in my evidence-based medicine classes.

Fortunately, the current study by Laskey and colleagues doesn't repeat the mistakes of its predecessors.  It was a mail survey study of pediatricians who commented on various scenarios surrounding an 18 month-old child with an unwitnessed oblique femur fracture, and ranked their likelihood of considering the situation as representing abuse.  Race of the child in the vignette did not affect this likelihood, but children portrayed as lower socioeconomic status were slightly more likely to be considered victims of abuse (48 vs 43%).  The main drawback to the study, beyond just the limits of a study with hypothetical scenarios, is the low response rate to the survey (48%).  So, while the 5% absolute difference in "risk" for reporting as child abuse was statistically significant, its not clear that this is a clinically significant problem. 

The older study (NEJM 1999; 340:618-26) is a classic example of misuse of odds ratios and subgroup analysis.  The lay press compounded this by misrepresenting the study's findings, reporting a much greater degree of bias than the study actually showed.  The authors and journal editors seemed to do little initially to correct these misrepresentations. 

Whether clinically significant or not, the pediatrician study serves as a reminder to all of us to try to guard against our subconscious personal biases in our daily interactions with patients and families.  They deserve our objectivity.