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being the foster child of one’s doctor
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sethg_prime wrote in little_details
Setting: Boston (Massachusetts, US-ish) area, contemporary

I’m trying to plot a novel in which Our Heroine, a pregnant teenager, unwittingly crosses into an alternate universe, gets hit by a car, and is taken to the hospital with a head injury. When she regains consciousness and at least part of her memory, she can’t answer some of the questions on the mental-status exam, because, for example, she doesn’t know the name of the country she’s in; as a result, she is transferred to a psychiatric ward for evaluation. Because of the pregnancy, the psychiatrist is leery of giving her antipsychotics, but aside from that, she goes through whatever system they have for assessing a possibly-mentally-ill teenager. Eventually, the staff decides that aside from the weirdness with her memory, Our Heroine has no symptoms of psychosis, and certainly isn’t far gone enough to need inpatient care, so they give her a tentative diagnosis of “fugue” and discharge her... but nobody in this universe is claiming her as a relative, so they have to discharge her into foster care.

It would be very convenient for the plot if one of the doctors responsible for her care—either in the emergency room where she was first treated, or the psychiatric ward where she was evaluated—could step up and volunteer to take her in. (Technically, since in this universe people live with their extended families, it would be his mother who volunteers.) However, I’m not sure if professional ethics would permit that kind of thing.

I looked at the Web pages that Massachusetts has for information about foster parents, and it looks like the main requirements they impose are that you have to take a class, pass a background check, and have your home inspected. I also looked at the AMA code of medical ethics, and while they have something there about how physicians shouldn’t treat members of their own family, if the physician-patient relationship was terminated before the foster-family relationship began, that rule wouldn’t apply... technically.

So could a doctor get away with this kind of thing, or do I have to find a more elaborate way of introducing her to a foster family?

The thing about the foster system is that it's extremely overloaded: while it might not be ideal for a former treating doctor to foster the teenage girl, there's not going to be foster parents knocking down the door to take her. It would be better if the doctor is from the emergency room rather than the psych ward (so there has already been a termination of the physician-patient relationship when the paperwork begins) but again, not impossible either way.

Just another detail - if your doctor lives in an extended family, all the adults have to be police checked for a foster child to live there, and any adult who would be responsible for her care must do the foster parent training. Unless doctors' working hours are very different in your universe, I would expect at least one other person to have done that training.

Disclaimer: this is how it would work in one state, in the US.

In some cases, at the first court hearing, which would be when the facts get presented to a judge on whether there's grounds for her to be brought into agency custody, an adult who has formed some kind of relationship with the teen could present themselves (to the agency first, or to the judge) as an option for emergency foster care.

The judge would probably ask the agency to do a fast background check and home inspection, but would have the authority to sanction the doctor as an emergency placement.

Without being licensed, with the classes, the fire inspection, the TB test, and all the other parts of being a "real" foster parent, the doctor couldn't get paid the foster parent stipend, but if they were willing to waive that, they could be a court-sanctioned placement without going through the full process.

The background check and home inspection would be a must, though, and the judge would want to know why the doctor and the teen wanted this.


You are in an alternative universe. You can make up your own rules.

While this is true, I think it makes sense to take existing rules as a jumping off point. And I'd be fascinated to see how such rules accommodated the extended family thing.

But such rules are so rooted in ideas about the family that there is no reason at all to base them on "here".

An example: in the 1890s US fostering was disapproved of because it brought in foreign blood to the family (children were distributed across the west in the orphan trains as semi-servants, not true family members). This attitude was maintained by the Catholic Church in Ireland until the 1970s.

Through the 19th century single women were seen as better choices for girls than married women because of the fear of immorality with in situ boys.

And a ps: the Shakers collapsed precisely because of a change of attitude to fostering. They had been seen as the best possible choice and took in thousands of orphans. Then suddenly they were seen as "unnatural".

Interesting... I knew the Shakers did fostering, but I didn’t know that was why it stopped.

The AU family structure is matriarchal; children are typically raised by their mothers and maternal uncles in family units of about 15, and the leaders of each unit tend to be grandmothers. There is some shuffling around to maintain balance (e.g. a mother with lots of children may move out of her mother's house and join cousins who want a larger family), and it is not unheard of for a wealthy family to adopt a child who is promising but destitute.

Sounds fascinating. So the doc could argue "family balance", and "assets" and thus be approved, particularly if the doc is female.

The doctor is male*, but an aunt that he lives with is a semi-retired teacher. I can just put in the backstory that the family used to be on the list of foster parents back when everyone was younger and spryer, so they’ve already passed all the relevant background checks.

*He’s just as good as his female colleagues, really. :-/

think of me when you want a beta reader :-)

I'd also be pretty interested in how the industrial revolution and subsequent changes in work environments accommodated the extended family. How much do people move to follow work? Do wealthier families have more options to have larger families whereas poorer families are more likely to be forced to split? Or are poorer families likely to hang together all the more tightly to insure each other against the vagaries of the market? (Whereas wealthier families, whatever the ideal might have the resources to move somewhere else so they don't have to see that sister that drives them absolutely nuts every morning. I mean, sure, spending more of their time in the family house up in Maine is technically still living with the family, but...)

And then, where do the men fit into things? "Walking marriages" a la the Mosuo?

Last question first: yes, this is inspired by the Mosuo.

Job opportunities and not getting along with the current family are both socially acceptable reasons for someone to migrate to the family of a more distant cousin. (Poor immigrants without broad in-country kinship networks are obviously at a disadvantage here.) A certain amount of genteel haggling among the grandmothers would accompany this transfer, and the terms of the deal would depend on how much the sending family saw the migrant as a future income stream they were giving up, and how much they saw her/him as a malcontent that they would be happy to get rid of. Also, as with corporate spinoffs/mergers, large families can split, and small or impoverished families can merge with their better-off kin.

If a discontented daughter can’t avail herself of any of these options, she typically consoles herself by making a long list of what she will do differently once she finally inherits the mantle of authority. A discontented son typically consoles himself by looking for a job that requires a lot of travel.

It might make sense to have the rules being almost the opposite - that it would be highly unusual to give children to foster parents that they didn't know well, and the question would be if there was *enough* of a relationship with a doctor to qualify?

Would it be possible for the doctor's family to already be part of the fostering system? That way the background checks, etc., would already be done and the process could go more quickly.

Unless the doctor is already a licensed foster parent, nope. The class is about 30 hours, then there's the paperwork and monthly trainings and some other things you have to do to maintain your license.

If you want to use artistic license you could have a social worker in the hospital recommend an 'emergency placement' which basically speeds the licensing process up and in the meantime keep the teen in group care or a respite home (the latter of which are basically short term foster homes designed specifically for this kind of situation). It would still be at least a few days (I could easily see a week going by) before she could move in, but it's still light years ahead of what it is normally.

What kind of stuff is she saying to warrant a transfer to the psych unit? Not knowing what country you're in following a brain injury would suggest a "simpler" neurological problem, not a psych issue.

People with brain injuries do frequently eventually end up in the mental health system, but this is right after she got injured!

^This. I failed the "What year is it?" question during an atypical migraine once, and the response was "Okay, into the radiology department with you for a CT scan and MRI" not "Okay, into the psych ward with you for possible psychosis".

She reported detailed memories of being from a country that does not exist, a school that does not exist, and parents whose names are not in any government record, and so forth. All of this seemed out of proportion to the amount of trauma, and persisted after most other signs of concussion had faded. This led the ER staff to say, “hmm, sounds like she’s delusional“, and transfer her to psych—not because they had definitely diagnosed her with a psychiatric problem, but because they had ruled out other possibilities and wanted to kick the question over to experts in that field.

Wouldn't she stop telling them those details once she realized that they didn't believe anything she's saying? While psych providers don't aim to directly confront psychotic beliefs (especially in a patient they don't know well), they're not supposed to encourage an in depth discussion of them either.

That said, I guess it would be possible for her to end up at a psych facility once the team treating her runs out of ideas (with the understanding that it's nonetheless probably due to the head injury*, with a slight possibility that this could her first psychotic break).

The "emergency placement" trick may be your best bet unless one of the providers has been a foster parent.


*even if it doesn't show up on an MRI

She could stop telling them those details, but she couldn’t come up with a good cover story to replace them. “So, what are your favorite TV shows?” ”Umm....”

If it’s more reasonable for her to go directly from the ER into foster care, the stopover in the psych ward is not an absolute requirement of the plot.

About what age would she be? Any thoughts on what the age of majority would be where she currently is? You could conceivably bypass foster care and have her be taken in by the sympathetic doctor or become his ward otherwise.

She’s 15 or 16, so definitely a minor.

You can make up whatever rules you'd like in your AU, but in the real world, a member of a patient's medical team stepping up and volunteering to foster or adopt a kid would raise more than a few eyebrows about whether or not professional distance and objectivity had been maintained. At a minimum, the hospital would likely try to assign the patient's care to another provider - one about whom there aren't any such questions, especially if we're talking about psychiatric care.

And even if the professional relationship's terminated prior to the personal one beginning - especially with psych care, that puts ellipsis after his name, as in "Dr. X? Oh, you know, he's the one who...' People would be wondering about what sort of 'treatment' he'd been giving - even if there are no blemishes on his record or his name prior.

Codes of ethics are one thing - people talking is another. Even giving an appearance of doing something which may be a little shady ethically can be enough to have a hospital ethics committee start digging into every record of every patient you've ever treated looking for any more evidence of unethical behavior.

So it might be strictly permissible, but it'd likely create difficulties - in this world, anyway.

Hmm. Of course, I might be able to work with that. “Kid, you should be grateful that Dr. X stuck his neck out the way he did...”

If Dr. X had learned about Our Heroine during a case conference, rather than being directly involved in her care, would that make his behavior less weird, or more weird?