DDr. Carole Jenny has had to be both tough and tender during her career as a pediatrician. She has made tough choices all along the way—for starters, entering medical school at a time when it was an uncommon path for women; then leaving medicine for several years to raise her two daughters at a time when that was frowned upon by the profession; and ultimately choosing the discipline of child abuse—a field that didn't exist when she began her training and that doctors still aren't flocking to enter because of the emotional challenge of working with severely abused children.

But while surmounting those and other hurdles, plus winning national and international acclaim for her work, she has managed to sustain a tender spirit. There's a lilt in her voice and a sparkle in her eye that belie the heartrending nature of her work.

She needed to hone a tough exterior early on. "Back then," she remembers, "men would come up to us [women] in our senior year in college and say, 'I didn't get into medical school. You took my place.' " At DMS, where she was one of just four women in her class, there were further indignities. For example, she was dismayed that the women in the class didn't get a chance to learn how to examine the male genitalia. She also recalls a visiting professor who looked down on the four women sitting in the front row and warned them that the next year, "one of you will not be here."

But complaining about the insults seemed out of the question. "We were very meek and not at all liberated," Jenny recalls. "You can't imagine how we worked to make sure we didn't make waves."

Yet her sense of justice was aroused again a few years later, when she arrived in Philadelphia for her residency. She was shocked at the state of primary care for children there. "It occurred to me at that point that maybe how health care is delivered affects children's health," she recalls. So, hoping it would help her address the health of the medical system and not just of individual patients, she earned an M.B.A. at Penn's Wharton School. Today, joint M.D.-M.B.A. programs are common (Dartmouth has had one since 1992). But Jenny was once again in the vanguard in acquiring both degrees in the 1970s.

Soon thereafter, she and her husband, Dr. Thomas Roesler, a child psychiatrist, moved to Seattle. There, Jenny took up a faculty post, practicing pediatrics and doing health-care research at the University of Washington. The academic career she had planned on was right on track—or so it seemed.

Her decision to quit 18 months later, "to stay home with my babies," almost sabotaged her hope for a life in academe. Back then, women in medicine were still cause for comment, and "if you did drop out, that was considered a betrayal," says Jenny. "It was a cop-out." Characterizing herself as someone who tends "to do things in a big way," Jenny says that the "big way" for her at that time was to stay home with her two daughters.

When she was ready to return to work seven years later, she was scared that she wouldn't be able to get back into academic medicine. But thanks to persistence and serendipity—and a job no one else wanted—a new career path opened up. After her younger daughter started kindergarten, Jenny applied for several jobs. She didn't even get as far as an interview for any of them. She did some locum tenens work—filling in temporarily for doctors who were on vacation—but began to feel very discouraged.

Then I got a call from the University of Washington," she says. "Someone had written a grant for child abuse. He said that no one wanted the job so I could have it. I said, 'Who would want to work in child abuse? That's so depressing. I don't know anything about child abuse.' He said, 'That's okay. No one else does either.'

"He was right," Jenny continues. "It was a field that had no academic basis for what it did. My husband, the psychiatrist, said, 'Get your foot in the door, do a great job, then do a lateral move.' I've been doing child abuse ever since. It turned out to be a very exciting field because it was all brand new. There were tremendous amounts of things we had to learn and figure out."

She recalls an incident from her first week on the job, when she was called to court to testify in a sexual abuse case. The doctor who had examined the child in question observed that she had no hymen—implying that it had been broken during the sexual assault. But a defense attorney picked up on that comment and challenged Jenny, asking, "Isn't it true that some newborn females do not have hymens?"

"I said, 'I don't know,' " relates Jenny, "so I went back and organized a study with a nurse. . . . No one really knew what normal genitals were." She and her collaborator examined 1,131 female newborns, and she described their findings—that every single one of them had been born with a hymen—in a paper published in the journal Pediatrics.

Jenny also started Seattle's first hospital-based child protection program, then went on to run a similar program six years later in Denver and another one six more years later in Providence, R.I. The move to Providence came when she was offered the country's first endowed chair in child abuse pediatrics, at Hasbro Children's Hospital, and a faculty post at Brown's medical school.

Such child protection programs now exist at many—though still not all—hospitals. Recently, Jenny worked with the National Association of Children's Hospitals to write standards for child protection programs. And, she adds, the organization is recommending that every hospital have one. Over the years, Jenny has trained and supervised 22 fellows in forensic pediatrics, many of whom are now running child protection programs themselves. In fact, one of them is Dr. Kent Hymel, the medical director of the Child Advocacy and Protection Program at Dartmouth-Hitchcock Medical Center.

"It's just amazing," Jenny says of the advances in her field. For example, she explains, "we've devised ways to diagnose physical abuse," by showing how its effects are different from those of accidental injuries. One way is a skeletal survey of children under one year old. Instead of depending on visible, evident injuries, such a survey will reveal skeletal injuries that a child that young cannot describe or even indicate. "That was very powerful," she says.

"We've learned so much about infant trauma, head trauma, the presentation of head trauma," Jenny continues. She herself has worked with a Japanese company, Aprica Childcare Institute, to develop biomechanical research models that led to a better understanding of shaken baby syndrome and other pediatric head injuries.

Shaking a baby generates very unusual patterns of retinal hemorrhage. And shaking also leaves injuries in the brain that look very different from those received in car accidents, for example. Victims of car accidents will show injury in one part of their brain, while "babies who have abusive injuries come in with these horrible injuries—what we call 'big black brain,' " Jenny explains.

"If they survive," Jenny says of babies who have been subjected to such abuse, "they are seriously handicapped. There's probably a very different regulation of cerebral circulation in infants, and it's probably very vulnerable to periods of prolonged hypotension in the brain after an episode of rotation force being applied."

The term "big black brain," Jenny adds, was first used by Dr. Ann-Christine Duhaime, director of pediatric neurosurgery at DHMC.

In her many court appearances—several every month, many of them in other countries—Jenny has heard all the reasons for shaking and injuring young children. Abusers will often say they just couldn't stand a child's crying. Abuse also correlates with mental illness or anger at a spouse. Risk factors for child abuse include poverty, drug and alcohol abuse, and domestic stress. "With sexual abuse, we find much higher rates with children who live with people who are not their biological or adoptive parents," Jenny says.

Research into child abuse is critically important, she explains, because mistaken diagnoses—either way—can be disastrous. "If you send a child home who has been abused, the chance is they're going to come back with other injuries or even death," she says. On the other hand, "if you make the wrong call and say it's abuse and it turns out not to be, you've destroyed a family."

How has a pediatrician who is a mother herself dealt for so many years with the horrific cases that she sees every day? Jenny says the hardest time was when her own children were young—the same age as many victims. She learned then how to cope. "I have my work-life and my life-life," she says. "Now, in my life-life, I have my English garden and my grandchild, and my nice family and husband. I read English novels where the most exciting thing is that the spinster in the congregation falls in love with the vicar. I don't read novels where people are raped or killed or blown up. I never go to violent movies."

She also enjoys the travel that comes with her work-life. Frequently invited to lecture all around the world, she is often joined on trips by her husband—especially if the destination offers a chance of sighting an exotic bird. "My husband is an avid birder. I enjoy seeing a nice, colorful bird, but I don't obsess about it," says Jenny. But she does love the lecturing and the traveling. "The rest of the world is starting to realize child abuse hurts kids, and if they want to see their country progress and life be better for the next generation, they're going to have to pay attention to it."

Jenny has addressed pediatric professionals all over the U.S. and in 18 countries—including Cambodia, Japan, Germany, England, Ireland, Bolivia, Poland, Mexico, and Canada. She has also lectured extensively for the U.S. military (for whom she also testifies in court-martial cases), the FBI, and Interpol, as well as local police forces.

In fact, the variety of her work is one of the things she likes best about it. "One day," she says, "I'll be tracking down the epidemiology of some STD [sexually transmitted disease] and how some five-year-old came up with [it]. The next day I'll be going to a forensic autopsy. The next day I'll be diagnosing a major head injury of a seven-month-old. The next day I'll be going down to the statehouse to lobby for changes in the law to protect kids. Right before Christmas, I was at a Congressional briefing on the Hill about the long-term ramifications of abuse on the population."

All that variety means child abuse pediatrics is a great field for someone with a short attention span, she jokes.

But it's clear that for Carole Jenny, the attraction of the field is the opportunity to do everything humanly possible—"in a big way"—for mistreated children. And that's not a job she'll ever quit.