Remember to remain objective during your assessment. Follow each lead; pin down every fact, gather each piece of data. Ask for clarification when you need to; but, whenever possible, allow the child to tell her story in her own words.”

That was the advice given to me by the pediatrician who taught me how to go about evaluating the child suspected of having been abused.

“Speak softly, modulate your voice. Above all, try not to show your own emotion—there will be time for that later, in private.”

His words percolated through my mind as I sat opposite an elderly woman in the confines of the small, sparsely furnished exam room. She had shown up with her three grandchildren that afternoon, asking if they could be seen by a doctor. When the triage nurse asked the reason for the visit, she would only say that they were sick. “Have a seat,” our nurse told her. “We'll see what we can do.”

Because I had a break in my afternoon schedule of patients, this family had fallen to me.

“I understand that you are concerned about your granddaughters,” I said. “What's wrong?”

The grey-haired woman shifted uncomfortably in her chair and pressed her fingers into the sides of the pocketbook in her lap. “I overheard them talkin' 'bout somethin' that made my blood run cold.”

“What was that?” I asked.

“They was talkin' about what seemed to me to be semen.”

The words dropped from her lips like a lead weight onto the floor. Somehow I had to pick them up.

“When was this?” I continued, conscious of the sudden dryness in my throat.

“Just this mornin'. I asked them, ‘Where'd you hear about somethin' like that?' and they told me what happened.”

Her words trailed off. Once again she shifted in the chair.

“It was our cousin,” the oldest girl piped up. “He did it—to my sisters and me, to all of us.”

“What's his name? How old is he?” I asked.

“His name's Jimmy,” the old woman said. “He's my daughter's boy, 15 years old.”

“Where is he now?” I asked.

“Gone,” the old woman said. “He took off when I told him I was goin' to bring the girls in to get checked.”

“Perhaps it might be best if I could have a word with each of your granddaughters alone. You can certainly stay in the room. I'd just like to hear what each one has to say by herself.”

The grandmother nodded her head. I opened the door and spoke to our nurse. She escorted the two younger girls out of the room. I settled back into my chair and addressed the oldest of the three sisters. “Now then,” I said, “why don't you tell me what happened.”

I made notes during our conversation and then interviewed the other girls. The stories were consistent.

“I'll need to collect a few samples to send to the lab,” I explained to the grandmother. “Don't worry,” I said to the girls. “It won't hurt.”

I gathered the additional demographic information necessary to complete the form for the state department of youth services, then picked up the telephone and called in the report.

“Where are the children now?” the intake worker asked.

“Here in clinic. The grandmother states that the perpetrator has left the home. After what happened, she won't let him back in.”

“We'll send someone out to the home today. Have you got cultures pending?”

“I should have something back from the lab within 48 hours,” I said.

Two days later a man in a white coat walked into the clinic and asked to speak to me. He introduced himself as one of the technicians who worked at the state laboratory on the second floor of our building.

“I wanted to give you the results of a set of cultures you sent down to us the day before yesterday. I guess I just needed to be sure of the source.”

I confirmed that I had indeed swabbed the girls' throats and inoculated the chocolate agar plates immediately afterwards.

Slowly he nodded his head. “That's what I thought. This morning they're all positive for Neisseria gonorrhoeae.”

In Osler's farewell address to his medical colleagues in the United States and Canada, “L'Envoi,” he enumerates his personal goals: to do the day's work well, to practice the Golden Rule, to cultivate a measure of equanimity that would enable him to bear success with humility.

Over the span of my 30-year career, I have seen several hundred children for suspected abuse. What do I accomplish in these cases? I properly evaluate those children entrusted to my care. I diagnose and treat their maladies and work to keep them from further harm. In short, I do what those in my profession are trained to do, and I do so to the best of my ability.

Yet as I reflect, I can't help but wonder why every time I evaluate a child for abuse, instead of Osler's measure of equanimity, I'm left with a hollow feeling deep inside. JAAPA

Brian T. Maurer, PA-C, practices pediatrics at Enfield Pediatric Associates, Enfield, Connecticut. He is the author of Patients Are a Virtue and a member of the JAAPA editorial board. Visit the author at http://briantmaurer.wordpress.com.