(The New York Times News Service) -- Pediatricians and other primary care providers are good at identifying physical injuries in their young patients that might be the result of child abuse, but they are not as good at judging when to report those cases to child protective services, a new study found.

A group of researchers led by Dr. Robert Sege of Boston Medical Center compared how primary care providers responded in 92 child injury cases with evaluations by child abuse specialists.

They found that reporting was warranted in 13 of the 63 cases doctors chose not to report to authorities. Most of those cases involved leg fractures or bruises to the face or ear, and in six cases the physicians themselves had identified a high likelihood of abuse.

Sege, professor of pediatrics at Boston University School of Medicine and medical director of the child protection team at Boston Medical Center, said most primary care providers are trained in how to identify child abuse injuries.

"We need to go the next step and talk to them about why they need to report, how they report, what information they need to provide," he said.

Massachusetts is among states that require physicians to report suspected child abuse. But deciding when to report a case is tricky, the authors noted. Delayed reporting leaves a child at risk, while unnecessary reporting can cause family disruption.

Reporting can be a psychological challenge, said Dr. Benjamin Siegel, a pediatric primary care physician at Boston Medical Center who serves on a committee of the American Academy of Pediatrics that looks at psychosocial factors in child health.

Doctors may question their own judgment of whether an injury is enough to meet the standard of reasonable suspicion for abuse, the threshold for reporting in Massachusetts, Siegel said. Or they may worry that a parent will become angry.

Some of that can be overcome with training and a better understanding among physicians of how the process works once a case is reported to the state, Siegel said. More upfront coordination between pediatricians, social workers, and psychosocial services is important too, he said.

Some doctors interviewed for the study said officials in their state's child protective office discounted the injuries they were trying to report because they were not very severe or because the suspected abuser did not have custody of the child. Both responses are in contrast to state laws or best practices around abuse reporting, the study noted. On the other hand, Sege said, he thinks doctors often underestimate the state's ability to conduct an investigation.

How to improve commuication between doctors and the state "is a really big question," said Dr. Kimberly Schwartz, a physician with the child protection program at UMass Memorial Children's Medical Center.

Massachusetts lawmakers mandated in 2008 that the same training be given to all state-licensed professionals -- including social workers, doctors, and teachers -- who are required by law to report suspected child abuse to the state. That program was never funded.

Sege's study, released Tuesday by the journal Academic Pediatrics, provides a "sense of urgency around correcting both the training issues and restoring confidence" in the reporting system, said Nancy Allen Scannell, spokeswoman at the Massachusetts Society for the Prevention of Cruelty to Children.

The researchers used data from a large national study conducted between 2002 and 2005, which asked hundreds of health care providers to each collect information about 40 children seen consecutively in their practice for injuries and record whether they suspected child abuse and reported the cases to child protective services. That study found that 27 percent of doctors did not report injuries they had deemed to be likely or very likely caused by abuse.

From that data, Sege and colleagues affiliated with the American Academy of Pediatrics and the National Medical Association's Pediatric Resource Network selected a smaller group of physicians who were interviewed about their familiarity with the family in particular cases, factors that influenced their decisionmaking, and follow-up care.  

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