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Mandatory reporting laws
Correspondence
Mandatory Reporting Laws
Joel Geiderman, MD Reply
Debra E. Haury, MD, MPH Kim M. Feldhaus, MD
Jean Abbott, MD EMRA's 25 Years
Jeffrey C. Bates, MD Generalized Seizures Associated With Low-Calorie Dieting
Mark A. Marinella, MD Copyright © 2000 by the American College oj Emergency Physicians. 0196-0644/2000/$12.00 + 0
Mandatory Reporting Laws To the Editor: The study reported by Houry et ail (article #100379) in the September 1999 issue of Anna/smight mislead readers in several significant ways. Although all wou Id agree that it is a highly desirable goal to protect members of society from domestic violence (DVI. it is important that issues surrounding mandatory reporting laws (MRLs) be presented in a balanced way. The article's initial statement, "As of March 1994,45 states had laws that, to varying extents, required health practitioners to report cases of domestic violence," is misleading. The majority of states require reporting only when the assault involves the use of a firearm or other weapon, or is the result of an illegal act. According to the cited reference, only 5 states had laws that separately addressed domestic violence. 2
The selection bias inherent in the study's design renders it unable to be general ized to the entire population ofthe United States. Non-English-speaking patients were excluded from the study. This ignores cultural differences, a fact that has been taken into account in other more rigorously designed studies that looked atthis same issue. 3 Also, in many regions ofthe country, particularly the Southwest, non-English speakers stand a reasonable likelihood of being undocumented residents. The fear of deportation of oneself or a family member might certainly be a powerful deterrent to seeking care for non-life-threatening conditions. (An inclusion criterion ofthe study was "non-critically ill patients," although this term was not specifically defined.) The study also does not break down the responses as to race or ethnicity. Fear and skepticism of the legal system is known to be more prevalent in minorities, and without knowing their representation in this study, it is hard to generalize its conclusions to the entire population. We are also
Guidelines for Letters Annals welcomes correspondence, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor will not be accepted if they exceed 500 words and 5 references. Two double-spaced copies must be submitted; a computer disk is required. Letters should not contain abbreviations. They must be signed and include a postscript granting permission to publish. Financial associations or other possible conflicts of interest should always be disclosed. Letters discussing an Annals article must be received within 6 weeks of the article's publication. Annals acknowledges receipt of letters with a postcard or e-mail message, and correspondents are notified by postcard when a decision is made. Published letters will be edited and may be shortened. Unpublished letters will not be returned. Authors of articles for which we receive comments will be given the opportunity to reply. The reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers. Acceptance of an advertisment for placement in Annals in no way represents endorsement of a particular product or service by Annals of Emergency Medicine, the American College of Emergency Physicians, or the Publisher.
APRIL 2000
35:4
ANNALS OF EMERGENCY MEDICINE
403
CORRESPONDENCE not told what percentage of patients who were approached refused to be interviewed atal!. orwhatthe ethnic makeup was of those who refused. A further selection bias occurred as a result of interviewing women who had already chosen to return to a battered women's clinic, a group "with more experience with DVand presumably with the MRL. ", Women who had already encountered the MRL and who were not comfortable with it in the first place might have chosen to stay away from these clinics. The inclusion of so many men in the study may also have skewed the results; in fact, interview results were not reported by gender. Potential male victims of DV may feel less vulnerable and threatened than female counterparts. Even with these selection biases, the reported conclusions may not be totally justified. The question posed to this group of patients was iftheywould be "less likely" to seek care because of mandatory reporting. The conclusion that was reached was that MRLs donotdeterthe large majority of patients from seeking care.' The definitive term "do not" is a semantic leap from the former "less likely" proposition that was offered in the survey. Further, the characterization of 12% of patients who would be deterred by the MRLas "rarely" affecting a patient's decision to seek medical care is a liberal use of the word rare. Other policies that deterred 12% of patients who needed care from coming to an ED would surely raise ethical questions regarding their usefulness. Finally, reporting laws of any kind raise a host of ethical concerns. Permissive reporting laws have the potential for discrimination because individuals who can pick and choose whom to report may be more likely to choose those in a different socioeconomic group than themselves. Even mandatory laws may be subjectto such concerns since only "suspicions" must be reported and individuals may also be biased as to of whom they are suspicious. 2 Other concerns are that reporting against an individual's wishes violates both their autonomy and their confidentiality. Finally, the historical record in the 20th century of physicians serving as agents of the state has been a troubling one, and all such arrangements should be viewed with healthy skepticism.
404
Joel Geiderman. MD Department of Emergency Medicine Cedars-Sinai Medical Center Los Angeles, CA 47!B1105595 doi:10.1067/mem.2000.105595 1. Houry D, Feldhaus K, Thorson AC, et al. Mandatory reporting laws do not deter patients from seeking medical care. Ann Emerg Med. 1999;34:336-341. 2. Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence. JAMA. 1995;273:1781-1787. 3. Rodriguez MA, Craig AM, Mooney DR, et al. Patient attitudes about mandatory reporting of domestic violence. Implications for health care professionals. West J Med. 1998;169:337-341.
In reply: We appreciate Dr. Geiderman's response to our article about domestic violence (DV) mandatory reporting laws. It provides another chance to continue an important social and ethical dialogue concerning the scope of emergency physician responsibilities and how best to serve our patients. We acknowledged the very reallimitations in our study. The questions were hypothetical for the majority ofthe respondents. We studied only English-speaking patients, the study was performed in Denver, and at only municipal health care sites (ratherthan private emergency departments). The most important limitation was that the first 2 patient groups in the study were patients who had already presented to a health care facility(the ED) for treatment. thus indicating an inclination toward health care-seeking behavior. Dr. Geiderman is indeed correct aboutthis. Forthis reason, we added a 60woman focus group of people outside the health care setting who were in DV support groups; this focus group was additionally surveyed regarding their interactions with the police. As both this article and the JAMA article that we referenced noted,' the strength and focus of the laws in 45 states which mandate police reporting for assault. or more specifically DV, varies. Interesting gender differences in response were noted in our article. as were the 2% of patients who refused or were missed. Clearly, more rigorous and extensive work in the area of patient preferences needs to be done. The study cited by Dr. Geiderman involved nonrandomized, nonquantitated
interviews. Our study, which used more stringent methodology, missed the personal issues that an interview method uncovers. We look forward to more research in this important area, and continued debate about how best to treat our patients with respect while assisting them in making their lives safe.
Debra E. Haury, MD, MPH Kim M. Feldhaus, MD Department of Emergency Medicine Denver Health Medical Center Denver, CO Jean Abbott. MD Division of Emergency Medicine University of Colorado Health Sciences Center Denver, CO 47/B/105596 dodO. 1067/mem.2000. 105596 1. Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence. JAMA. 1995;273:1781-1787.
EMRA's 25 Years To the Editor: I was delighted to find "Twenty-five Years of Resident Representation From the Emergency Medical Residents' Association" (article #1 01382) in your October 1999 issue.' I applaud the Editors of Annals of Emergency Medicine for recognizing the merits of such an article. Some ofthe important contributions of the Emergency Medical Residents' Association (EMRA) were nicely summarized but as impressive as they seem, they are even farther-reaching than the authors present. Although the contribution to emergency medicine residents and to emergency medicine in general are well described. whatthe authors failed to mention are the broad-reaching effects on residents of other specialties. In 1967, the American Board of Pediatrics and the American Board of Internal Medicine, seeing a need for a broadly trained primary care physician, established a means for residencytraining leading to board certification in both fields. As such. Combined Internal Medicine & Pediatrics, or MedPeds as it is commonly called, was born. A few years later family practice and even emergency medicine were established as unique entities and saw rapid growth.
ANNALS OF EMERGENCY MEDICINE
35:4 APRIL 2000
Mandatory Reporting Laws
Joel Geiderman, MD Reply
Debra E. Haury, MD, MPH Kim M. Feldhaus, MD
Jean Abbott, MD EMRA's 25 Years
Jeffrey C. Bates, MD Generalized Seizures Associated With Low-Calorie Dieting
Mark A. Marinella, MD Copyright © 2000 by the American College oj Emergency Physicians. 0196-0644/2000/$12.00 + 0
Mandatory Reporting Laws To the Editor: The study reported by Houry et ail (article #100379) in the September 1999 issue of Anna/smight mislead readers in several significant ways. Although all wou Id agree that it is a highly desirable goal to protect members of society from domestic violence (DVI. it is important that issues surrounding mandatory reporting laws (MRLs) be presented in a balanced way. The article's initial statement, "As of March 1994,45 states had laws that, to varying extents, required health practitioners to report cases of domestic violence," is misleading. The majority of states require reporting only when the assault involves the use of a firearm or other weapon, or is the result of an illegal act. According to the cited reference, only 5 states had laws that separately addressed domestic violence. 2
The selection bias inherent in the study's design renders it unable to be general ized to the entire population ofthe United States. Non-English-speaking patients were excluded from the study. This ignores cultural differences, a fact that has been taken into account in other more rigorously designed studies that looked atthis same issue. 3 Also, in many regions ofthe country, particularly the Southwest, non-English speakers stand a reasonable likelihood of being undocumented residents. The fear of deportation of oneself or a family member might certainly be a powerful deterrent to seeking care for non-life-threatening conditions. (An inclusion criterion ofthe study was "non-critically ill patients," although this term was not specifically defined.) The study also does not break down the responses as to race or ethnicity. Fear and skepticism of the legal system is known to be more prevalent in minorities, and without knowing their representation in this study, it is hard to generalize its conclusions to the entire population. We are also
Guidelines for Letters Annals welcomes correspondence, including observations, opinions, corrections, very brief reports, and comments on published articles. Letters to the editor will not be accepted if they exceed 500 words and 5 references. Two double-spaced copies must be submitted; a computer disk is required. Letters should not contain abbreviations. They must be signed and include a postscript granting permission to publish. Financial associations or other possible conflicts of interest should always be disclosed. Letters discussing an Annals article must be received within 6 weeks of the article's publication. Annals acknowledges receipt of letters with a postcard or e-mail message, and correspondents are notified by postcard when a decision is made. Published letters will be edited and may be shortened. Unpublished letters will not be returned. Authors of articles for which we receive comments will be given the opportunity to reply. The reply will not be shared with the author of the letter before publication. Neither Annals of Emergency Medicine nor the Publisher accepts responsibility for statements made by contributors or advertisers. Acceptance of an advertisment for placement in Annals in no way represents endorsement of a particular product or service by Annals of Emergency Medicine, the American College of Emergency Physicians, or the Publisher.
APRIL 2000
35:4
ANNALS OF EMERGENCY MEDICINE
403
CORRESPONDENCE not told what percentage of patients who were approached refused to be interviewed atal!. orwhatthe ethnic makeup was of those who refused. A further selection bias occurred as a result of interviewing women who had already chosen to return to a battered women's clinic, a group "with more experience with DVand presumably with the MRL. ", Women who had already encountered the MRL and who were not comfortable with it in the first place might have chosen to stay away from these clinics. The inclusion of so many men in the study may also have skewed the results; in fact, interview results were not reported by gender. Potential male victims of DV may feel less vulnerable and threatened than female counterparts. Even with these selection biases, the reported conclusions may not be totally justified. The question posed to this group of patients was iftheywould be "less likely" to seek care because of mandatory reporting. The conclusion that was reached was that MRLs donotdeterthe large majority of patients from seeking care.' The definitive term "do not" is a semantic leap from the former "less likely" proposition that was offered in the survey. Further, the characterization of 12% of patients who would be deterred by the MRLas "rarely" affecting a patient's decision to seek medical care is a liberal use of the word rare. Other policies that deterred 12% of patients who needed care from coming to an ED would surely raise ethical questions regarding their usefulness. Finally, reporting laws of any kind raise a host of ethical concerns. Permissive reporting laws have the potential for discrimination because individuals who can pick and choose whom to report may be more likely to choose those in a different socioeconomic group than themselves. Even mandatory laws may be subjectto such concerns since only "suspicions" must be reported and individuals may also be biased as to of whom they are suspicious. 2 Other concerns are that reporting against an individual's wishes violates both their autonomy and their confidentiality. Finally, the historical record in the 20th century of physicians serving as agents of the state has been a troubling one, and all such arrangements should be viewed with healthy skepticism.
404
Joel Geiderman. MD Department of Emergency Medicine Cedars-Sinai Medical Center Los Angeles, CA 47!B1105595 doi:10.1067/mem.2000.105595 1. Houry D, Feldhaus K, Thorson AC, et al. Mandatory reporting laws do not deter patients from seeking medical care. Ann Emerg Med. 1999;34:336-341. 2. Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence. JAMA. 1995;273:1781-1787. 3. Rodriguez MA, Craig AM, Mooney DR, et al. Patient attitudes about mandatory reporting of domestic violence. Implications for health care professionals. West J Med. 1998;169:337-341.
In reply: We appreciate Dr. Geiderman's response to our article about domestic violence (DV) mandatory reporting laws. It provides another chance to continue an important social and ethical dialogue concerning the scope of emergency physician responsibilities and how best to serve our patients. We acknowledged the very reallimitations in our study. The questions were hypothetical for the majority ofthe respondents. We studied only English-speaking patients, the study was performed in Denver, and at only municipal health care sites (ratherthan private emergency departments). The most important limitation was that the first 2 patient groups in the study were patients who had already presented to a health care facility(the ED) for treatment. thus indicating an inclination toward health care-seeking behavior. Dr. Geiderman is indeed correct aboutthis. Forthis reason, we added a 60woman focus group of people outside the health care setting who were in DV support groups; this focus group was additionally surveyed regarding their interactions with the police. As both this article and the JAMA article that we referenced noted,' the strength and focus of the laws in 45 states which mandate police reporting for assault. or more specifically DV, varies. Interesting gender differences in response were noted in our article. as were the 2% of patients who refused or were missed. Clearly, more rigorous and extensive work in the area of patient preferences needs to be done. The study cited by Dr. Geiderman involved nonrandomized, nonquantitated
interviews. Our study, which used more stringent methodology, missed the personal issues that an interview method uncovers. We look forward to more research in this important area, and continued debate about how best to treat our patients with respect while assisting them in making their lives safe.
Debra E. Haury, MD, MPH Kim M. Feldhaus, MD Department of Emergency Medicine Denver Health Medical Center Denver, CO Jean Abbott. MD Division of Emergency Medicine University of Colorado Health Sciences Center Denver, CO 47/B/105596 dodO. 1067/mem.2000. 105596 1. Hyman A, Schillinger D, Lo B. Laws mandating reporting of domestic violence. JAMA. 1995;273:1781-1787.
EMRA's 25 Years To the Editor: I was delighted to find "Twenty-five Years of Resident Representation From the Emergency Medical Residents' Association" (article #1 01382) in your October 1999 issue.' I applaud the Editors of Annals of Emergency Medicine for recognizing the merits of such an article. Some ofthe important contributions of the Emergency Medical Residents' Association (EMRA) were nicely summarized but as impressive as they seem, they are even farther-reaching than the authors present. Although the contribution to emergency medicine residents and to emergency medicine in general are well described. whatthe authors failed to mention are the broad-reaching effects on residents of other specialties. In 1967, the American Board of Pediatrics and the American Board of Internal Medicine, seeing a need for a broadly trained primary care physician, established a means for residencytraining leading to board certification in both fields. As such. Combined Internal Medicine & Pediatrics, or MedPeds as it is commonly called, was born. A few years later family practice and even emergency medicine were established as unique entities and saw rapid growth.
ANNALS OF EMERGENCY MEDICINE
35:4 APRIL 2000