Paradise J E, Winter M R, Finkel M A, Berenson A B, Beiser A S
Department of Pediatrics, Boston Medical Center and Boston University School of Medicine, Boston Massachusetts, USA.
Pediatrics. 1999 May;103(5 Pt 1):980-6. doi: 10.1542/peds.103.5.980.
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.
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.
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.
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.
由于在疑似性虐待的儿童病例中，医生通常在检查前获取病史，且由此得出的诊断意见会影响重要的社会和法律决策，我们调查了临床病史是否会影响医生对女童生殖器检查结果的解读。
通过邮寄问卷，邀请1387名随机抽取的美国儿科学会会员以及四个关注儿童虐待或儿科妇科的专业团体的全部802名成员解读七个模拟病例。在4个月后邮寄的单独问卷中，要求受访者再解读另外七个病例。两组病例均涉及相同的七张女童外生殖器照片。然而，在七组病例对中的六组里，两份问卷中的病史在提示性虐待的程度上有所不同。在其余（对照）病例对中，两份问卷呈现相同的病史。
2189名医生中，1114名（50.9%）做出了回应。604名医生（54.2%）的回复符合分析条件。总体而言，经验最丰富的医生对生殖器检查结果的解读最为一致，经验最少的医生解读最不一致。对于一张照片，其解读因相关病史从“无虐待迹象”变为“可能存在虐待”（或反之）而发生反向变化的医生比例，经验丰富的医生为0至5.6%；中等经验的医生为1.6%至19.8%；经验不足的医生为3.6%至27.2%。在四组病例对中，经验组之间的这种差异具有统计学意义。当病史发生变化时，经验丰富的医生在两组病例对中生殖器检查结果的平均解读得分有显著变化，中等经验的医生在五组病例对中有显著变化，经验不足的医生在所有六组病例对中均有显著变化。
在某些情况下，尤其是对于经验较少的医生，诊断预期似乎可能会影响医生对女童生殖器检查结果的解读。医生应警惕诊断预期偏差的可能性及其潜在的严重社会和法律后果。
