Doctors depend on parents' judgment But Bush case sends red flags

Now Bush is accused of inflicting eight years of chronic, debilitating illness on her daughter, Jennifer, and in the process, duping doctors on a list as long as a stethoscope.

Still, South Florida pediatricians say the alleged ruse will not topple their faith in parents. Parents, they say, often contribute the cornerstone of diagnosis.

``Mothers know the subtle details of their children. They can look at their child's eyes and know something is not right,'' Dania pediatrician Joseph Deleeuw said.

In medical schools worldwide, doctors learn that accurate diagnoses depend on medical histories. In pediatrics, that history comes from parents.

``You have to trust what parents say 100 percent until they're proven not to be reliable,'' Pembroke Pines pediatrician Scott Becker said.

Child abuse investigators and physicians believe Bush has Munchausen syndrome by proxy, a form of medical child abuse in which a parent, usually a mother, deliberately makes her child ill to get attention.

Her daughter, Jennifer Bush, 8, has been hospitalized more than 200 times. She has been separated from her mother since April 15 and is being evaluated at a Cincinnati hospital. So far, doctors there say she is healthy.

``I'm kind of surprised that someone didn't pick up on this sooner with 200 hospital stays and 40 surgeries,'' Becker said.

Nurses and administrators at Coral Springs Medical Center first suspected Munchausen in 1991. Nurses noted Jennifer became severely ill shortly after her mother visited. The hospital staff reported its suspicions to the Florida Department of Health and Rehabilitative Services.

Dr. John Wright, then medical director of the Child Protection Team, told HRS he saw a clear case of Munchausen. But HRS never took action to protect the child. HRS administrators decided they could not definitively say Jennifer's mother was abusing her.

``These are complex cases. Nobody leaves you a written confession,'' said Dr. Randell Alexander, a Munchausen expert from the University of Iowa Medical School.

The tip-off usually comes when the child's array of symptoms contradict one another, don't respond to regular treatment or appear only when the perpetrator is around, Alexander said.

``I keep a weathered eye out for symptom complexes that don't make sense,'' said pediatrician Robert McKey, a clinical professor at the University of Miami School of Medicine who has been practicing for more than 35 years. ``Usually, you can believe parents. Almost everybody loves their children.''

Becker learned to spot child abuse when he trained at Jackson Memorial Hospital. Red flags should fly for doctors when abnormal symptoms don't match clinical observation, he said.

``If you don't suspect it, you'll miss it. That's how subtle it can be,'' Becker said.

Bush, like others who have the rare syndrome, is accused of deceiving doctors in sly ways.

``When someone comes along with the intent to sabotage our diagnosis, that's when we get fooled,'' Alexander said. ``With Munchausen, the parent is actually lying to us.''

Parents can induce symptoms. For example, a parent can make a child vomit with a dose of syrup of ipecac, said Dr. Walter Lambert, a Miami pediatrician who heads the University of Miami Child Protection Team.

Often, the parent has worked in the medical field and can deliver a convincing medical history using medical terminology. Sometimes, they shop for doctors until they find one who will provide the medications or treatment they want. Bush, who worked as her pediatrician's office manager, has taken her daughter to dozens of specialists.

``We're supposed to believe our patients,'' Lambert said. ``The message here is that when people have strange and bizarre symptoms and don't respond to traditional therapies, we should start thinking about other things.''