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Letter to my pediatrician

post #1 of 115
Thread Starter 

Just wanted to post this for others if they ever need to send a similar letter.

 

 

 

Quote:

"Dear Dr. W:

 

On 18 July 2011 you provided care for my son’s 6-month well child visit.  I found you to be warm, caring, and helpful, and I want to thank you for the professionalism you showed during the visit.

 

There was one aspect of the visit that concerns me.  My son is intact, and during the check of his genital area, you attempted to manipulate his foreskin backwards towards the shaft while asking, “Are there any adhesions?”  This was despite my holding my son’s penis with my fingers and repeating, “No retraction!” three times or more.  We had already discussed the fact that my son’s urine stream flows straight and freely prior to the genital exam.  I am concerned that even with this level of vigilance from his mother, my son was still in danger of forcible retraction or manipulation at the hands of his doctor.  I can only assume that other intact boys have their foreskins retracted or manipulated during well-child visits.

 

In virtually all intact male infants, the foreskin is adhered to the glans by way of synechiae, which are the normal physiological attach points of the foreskin to the glans in the infant.   This attachment is similar to the way that the fingernail is adhered to the nail bed, or the way a kitten’s eyes are fused shut at birth.  In virtually all males, the synechiae will naturally desquamate over time, and the foreskin will naturally separate from the glans.  There is no specific age by which desquamation should or must occur, and wide variation exists from toddlerhood to the teenage years.  In a very small percentage of adults, the foreskin never becomes retractable; if this occurs and if the adult male would prefer a retractable foreskin, non-surgical alternatives exist to loosen the synechiae and induce retraction.  However, because virtually all males will become retractable by adulthood, the risks of routine premature retraction or manipulation of the fused foreskin of all boys outweigh any possible benefit to the very small percentage of males who would not have otherwise become retractable on their own with time and who would prefer to be. 

 

Premature retraction or manipulation of any kind of the fused foreskin backward toward the shaft of the penis can cause tearing of the synechiae.  This tearing apart of the tissues causes pain, opens a wound, can introduce pathological bacteria into the delicate area between the foreskin and the glans, and can cause the development of scar tissue and true adhesions.  Adhesions are a pathological consequence of forced or premature retraction or manipulation of the fused foreskin, when scar tissue adheres the foreskin to the glans at the site of tissue damage from the forced retraction or manipulation.  The infant foreskin that has not been manipulated or retracted does not have adhesions, only synechiae, and there is no reason for anyone, including a medical provider, to check for their presence.  Similarly, there is no medical reason for a boy’s foreskin to be retracted for “cleaning.”  Like the vagina, the intact penis is a self-cleaning organ.  The first person to retract a boy’s foreskin should be the boy himself, never a care provider.  After a boy has become retractable, it is sufficient for him to retract himself during bathing and rinse with water or wash, if desired, with mild soap and water.

 

I have enclosed a copy of current guidelines for proper care of the intact penis from the American Academy of Pediatrics and the American Academy of Family Physicians.  I have also included several educational brochures for your education and possible dissemination to parents of your intact patients.  I have included digital links for some of these brochures below, so that they can be printed with high-quality materials for dissemination; for the rest I can provide a digital file if you desire.  I would appreciate if this topic could be reviewed and shared with all doctors and practitioners at XYZ pediatrics. 

 

I would be happy to discuss this topic with you if you have any questions or concerns.  I can be reached on my cell at ###.  Thank you again for the care you continue to provide to my children.

 

Sincerely,

 

 

 

Pirogi

 

 

Encl:       1. “Care of the Uncircumcised Penis” from AAP; http://www.growingchildpediatrics.com/pdf/UncircumcisedPenis.pdf

                2. “Circumcision” from FamilyDoctor.org, AAFP; http://familydoctor.org/online/famdocen/home/men/reproductive/042.printerview.html

3. “The Development of Retractile Foreskin in the Child and Adolescent” from Doctors Opposing Circumcision; http://www.doctorsopposingcircumcision.org/pdf/2008-03retractileforeskinleaflet.pdf

 

4.

5.

6.

7.

8."

 

 

 

I'd be happy to hear any suggestions for improvement!

 

ETA: I posted the final letter a few posts down.  It wasn't shorter, but I tried to use more neutral/supportive language.  I figure that if the doctor is interested in learning, she'll read it.


Edited by Pirogi - 7/20/11 at 6:48am
post #2 of 115

Way to go, mama!

post #3 of 115

wow, that was an amazing letter!  a true empowered mom.

post #4 of 115
Thread Starter 

Thanks!  I just hope it doesn't piss anyone off.  I don't want to get kicked out of the practice.  Is it respectful?

post #5 of 115

No, I think it just shows that this is a mom who does her homework!  These days, I don't even go to a doctor without having done my own research.  Yes, some of them might feel threatened by that, but  it's getting more common.  Go with your intuition, it is working for you!  The good thing is that it could start some discussions at the dr. office and you might even change some of their practices!  Yay!

post #6 of 115

It is way too long.  Doctors are very busy. Also, it is very patronizing in tone in tone and then you are suggesting that the doctor goes around educating his colleagues.

 

If you got a letter like that about your job, you would not  like it.  In general, letters that are 1/2 long and have shorter paragrpath produce more impact.

 

 

I would shorten it and just include links and APA brochure.

 

What is the goal of this letter? To share and get along or to........?

 

It is oftne not what is said but how it is said.

post #7 of 115
Thread Starter 

Thanks for your input, Alenushka.  Can you elaborate on what specifically makes the tone seem patronizing to you?  I will look into trimming the letter down.  Brevity is not my forte.

 

The intent is to educate and hopefully to change the policy of the pediatric practice on retraction or manipulation of the fused foreskin.  

 

If I got a letter like that, I would likely look at the information provided and decide if I believed what was being presented first of all.  If not, I would dismiss it or perhaps write a reply explaining my position.  If I found the information to be credible I would determine if my actions were in line with the new information I had received.  If they weren't, I would change my actions.  And if I felt that my actions were harmful to someone else, I would definitely feel compelled to share the information with others who did the same wrong things.

 

I will be cc'ing the letter, whatever final form it takes, to the office manager also.  My understanding is that she would be the right person to talk to about disseminating information to the other doctors in the practice?

 

I have re-read the letter and seriously don't see anywhere that could be construed as condescending or patronizing.  It is factual and even a bit dry/detached, specifically void of emotion.  Just the facts, ma'am.  

 

And really, when you think about it, I think that this letter is quite mild, considering the actions the doctor (and the others in the practice?) seem to be routinely performing on intact boys.  Retraction is harmful and should be addressed.  The practice should make sure all their practitioners are up to date on knowledge of the foreskin and what is appropriate and inappropriate with regards to exams.  What if one of the doctors routinely "checked" little girls' vaginas with a finger because they wrongly believed it was needed?  Do you think that a mildly-worded educational letter is all they would receive for that?  Why is this any different?  This doctor needs to be educated, and the practice needs to create awareness and a policy for genital exams of intact boys.  Better to do it this way than with a licensing complaint by a disgruntled parent who wasn't able to successfully stave off a practitioner's inappropriate actions.  Or even worse, a lawsuit.  I think it's also relevant to mention that DOC (search this forum for "Geisheker") will send a 10-page referenced letter to practitioners who have prematurely retracted a boy.  That's a lot more than my letter.

post #8 of 115

I also agree that it's a little long and patronizing (e.g.: level of vigilance, etc).  Your tone makes it sound as if you are the know it all expert and he/she is clueless about patient care.  For a busy doctor with lots of patients, it does not come off well.  I would just say (based from what i read here, here, and here) and from there summarize your concerns briefly and attach the links.  If his/her response is negative, then send him the DOC letter, which coming from a physician's association carries more weight and can be much more detailed and longer.  

post #9 of 115
I dont see patronizing and I think that all the information you provided is critical in getting your point across since obviously this Dr. is woefully behind on proper intact care. Just saying it can cause damage is not enough having the why it can cause damage is important and shows you are not just talking.

I would actually be a lot more verbal in my upset about him repeatedly trying to retract while you said no. That was beyond disrespectful on his part and he needs to understand that in no uncertain terms.
post #10 of 115

PERFECT!  You were deliberate and factual.  He is in the wrong and regardless of his true intentions, risking your son a feeling of being wronged in a horrible way and he needs to be told where to stand. Will he be defensive? Quite possibly but not a thing you said was unnecessary or deliberately insulting. I'd like to flyer the entire pediatrics community with this letter!

post #11 of 115
Thread Starter 

In her defense, I really do think the pediatrician wasn't willfully trying to do something in defiance of my protests.  The whole "struggle" with his penis lasted probably two or three seconds total.  After which she said, "Oh!  We aren't even doing that, OK.  Sorry, it just doesn't always sink in right away."  She didn't continue with any reasons as to why she thought it was necessary, or that I should be doing it, etc.  She just went on with the exam.  

 

So, I don't think it was willful, but it still does indicate that this was part of her "autopilot" exam for intact boys.  Which is the whole point of trying to provide her with education.

 

And sorry, but I am kind of an expert on this.  I have correct, research-based, professional organization-endorsed information that I have spent hours compiling and checking sources, etc.  She is much more broad and general in her knowledge.  I am offering my knowledge to her.  I don't see that there is anything wrong with that.  I think the issue that some people are having is that this is a doctor, and doctors are revered in our society.  I think it feels to some like some kind of subversive maneuver for a non-medically trained person to educate a medically-trained person.  Why should that be so?

post #12 of 115

Kudos to you for following up!! I had that same experience at a well child visit once and never followed up with a letter, regretfully. I think your tone is remarkably even and unemotional, almost too so! :) My only suggestion is to try and consolidate the third and fourth paragraphs and penis development and care. Maybe you could print off and include this type of info from the AAP or something instead of getting highly detailed in this letter? 

 

Even if you send it as is, I think it's wonderful and I *really* hope it has a meaningful impact. Let us know if you get a response.

post #13 of 115
Thread Starter 

The final letter I will be sending:

 

 

Quote:

Dear Dr. W:

 

On 18 July 2011 you provided care during the 6-month well child visit for my son, Little Pirogi.  I found you to be warm, caring, and helpful, and I want to thank you for the professionalism you showed during the visit.

 

There was one aspect of the visit that concerns me.  My son is intact, and during the check of his genital area, you attempted to manipulate his foreskin backwards towards the shaft while asking, “Are there any adhesions?”  This was despite my holding my son’s penis with my fingers and repeating, “No retraction!” three times or more.  We had already discussed the fact that my son’s urine stream flows straight and freely prior to the genital exam.  It was distressing to me to realize that if I had not been so attentive, my son could have suffered unintentional pain and harm from his doctor.  I am writing to share information that may be used to ensure the best quality care for all intact male patients of XYZ Pediatrics.  I look forward to developing a mutually supportive, evidence-based care plan for my son.

 

In virtually all intact male infants, the foreskin is adhered to the glans by way of synechiae, which are the normal physiological attach points of the foreskin to the glans in the infant.   This attachment is similar to the way that the fingernail is adhered to the nail bed, or the way a kitten’s eyes are fused shut at birth.  In virtually all males, the synechiae will naturally desquamate over time, and the foreskin will naturally separate from the glans.  There is no specific age by which desquamation should or must occur, and wide variation exists from toddlerhood to the teenage years.  In a very small percentage of adults, the foreskin never becomes retractable; if this occurs and if the adult male would prefer a retractable foreskin, non-surgical alternatives exist to loosen the synechiae and induce retraction.  However, because virtually all males will become retractable by adulthood, the risks of routine premature retraction or manipulation of the fused foreskin of all boys outweigh any possible benefit to the very small percentage of males who would not have otherwise become retractable on their own with time and who would prefer to be. 

 

Premature retraction or manipulation of any kind of the fused foreskin backward toward the shaft of the penis can cause tearing of the synechiae.  This tearing apart of the tissues causes pain, opens a wound, can introduce pathological bacteria into the delicate area between the foreskin and the glans, and can cause the development of scar tissue and true adhesions.  Adhesions are a pathological consequence of forced premature retraction or manipulation of the fused foreskin, when scar tissue adheres the foreskin to the glans at the site of tissue damage.  The infant foreskin that has not been manipulated or retracted does not have adhesions, only synechiae, and there is no reason for anyone, including a medical provider, to check for their presence.

 

Virtually all intact male infants also exhibit physiologic phimosis, where the preputial orifice acts as a tightly closed sphincter at all times except during urination.  This is a normal, protective mechanism of the foreskin.  As the child matures, the preputial orifice will gradually stretch to accommodate retraction.  Forced premature foreskin retraction or manipulation can create small tears at the preputial orifice.  These tears can create scar tissue and lead to true pathological phimosis later.

 

I have enclosed a copy of current guidelines for proper care of the intact penis from the American Academy of Pediatrics and the American Academy of Family Physicians.  I have also included several educational documents.  I would appreciate if this topic could be reviewed and shared with all doctors and practitioners at XYZ Pediatrics. 

 

I would be happy to discuss this topic with you.  I can be reached on my cell at ###.  Thank you again for the care you continue to provide to my children.

 

Sincerely,

 

 

 

Pirogi

 

 

Encl:       1. “Care of the Uncircumcised Penis” from AAP; http://www.growingchildpediatrics.com/pdf/UncircumcisedPenis.pdf

2. “Circumcision” from FamilyDoctor.org, AAFP; http://familydoctor.org/online/famdocen/home/men/reproductive/042.printerview.html

3. “The Development of Retractile Foreskin in the Child and Adolescent” from Doctors Opposing Circumcision;  http://www.doctorsopposingcircumcision.org/pdf/2008-03retractileforeskinleaflet.pdf

4. “Short Warnings About Forcible Foreskin Retraction” from Doctors Opposing Circumcision

5. “Only Clean What Is Seen” from Kindred, Aug 2008; http://www.kindredcommunity.com/articles/only-clean-what-is-seen-reversing-the-epidemic-of-forcible-foreskin-retractions/p/1253

 

 

cc:          (Office Manager)

 


Edited by Pirogi - 7/22/11 at 6:25am
post #14 of 115

I think it is great the way it is.  Besides you are not the "professional", the dr. is and why should you be avoiding putting not only your shared information and links to facts in your letter, but adding a mother's emotions would be quite appropriate!  As a parent, it is not our "job" to schmooooze the professionals..... it's our job to be the care takers of our children and protect them in whatever way a parent feels appropriate.  I would not listen to those who are "experts" in the field, I would encourage you to be just what you are, the most important advocate in the world for your child!  I support you, even if it is emotional.

post #15 of 115

That is a good letter.  I think there is a solid chance that it will tick off your pediatrician, and while I doubt you'd be kicked out of the practice, I can see her being offended and maybe not so kind to you next time you are there.  One thing I have learned over time is that people don't like to be challenged on stuff like this, especially when they are the "professional."  That said, I think it NEEDS to be said.  You will be educating this pediatrician and saving a lot of other babies from retraction.  She will probably be embarrassed by her lack of knowledge, but hopefully will educate herself more fully and be a better doctor because of it.  I would definitely send it, and if she is rude to you later on, switch doctors and make it clear with the new one why you are switching so the same thing doesn't happen twice. 

post #16 of 115

I think it is a fantastic letter and completely appropriate to send to your pediatrician.  If it makes her so angry that she cannot read it, then obviously there are other issues there.  The reality is that it is an extremely informative piece, which offers her facts that she obviously is unaware of.  I wish that ALL parents who had similar trouble with their doctor would write this clear of a letter.  We need to be educating them; not running off in search of a new ped.  I personally would follow up with a phone call to the doctor, to ask her if she received the letter - I wouldn't want to risk the chance that the admin person opened it, read it, and filed it somewhere.  You are smart and clear about what you are saying, and it is important that your doctor hears your message, along with your desire to remain in the practice and agree on a plan for care for your son in the future.  Let us know what happens!

 

post #17 of 115
Thread Starter 

So I went by the practice and dropped my letter and materials off today. The office manager agreed to see me, and after about a minute of explaining why I was there, she offered to go get the doctor also. So the doctor came in, and she listened to me explain the intact male anatomy, and why retraction is harmful, and the AAP's/AAFP's recommendations on the matter. She was polite, but she was a brick wall. She believes that what she does isn't retraction, and that it's ok to pull the foreskin back "just a little bit" to visualize the urethral meatus and check for hypospadias. I said, "But wouldn't hypospadias result in abnormal urination?" She said, "Not necessarily." This isn't what I have read, but anyway. I was a bit nervous, so I forgot to counter her argument that she would be able to carefully retract just to the point where the synechiae are still intact, with the fact that any manipulation can cause small tears in the preputial orifice and increase the risk of phimosis and paraphimosis later.  I also offered to provide an in-service if that is the type of thing they do at that practice.

So the good news is that she is the type of doctor that is fine with a parent asserting their right to refuse any part of an exam. The bad news is that I doubt it will affect any real change for other intact boys in the practice. 

It was a little disheartening, but I guess I did everything I could have done. Maybe she will read everything I sent over. She did say that she would photocopy the materials and provide them to the other doctors.


Edited by Pirogi - 7/22/11 at 6:24am
post #18 of 115

I will say, if she is only visualizing the urethral opening, its pretty unlikely that she's causing serious harm (no flames please - this is how a catheter was given to my ds so that we could test for a UTI when he was hospitalized about a year ago) - so I would let it go at this point.  If she is providing the materials to the other physicians, thats a good sign that she will read them herself as well.

post #19 of 115
Quote:
Originally Posted by Pirogi View Post

The bad news is that I doubt it will affect any real change for other intact boys in the practice. 

It was a little disheartening, but I guess I did everything I could have done. Maybe she will read everything I sent over. She did say that she would photocopy the materials and provide them to the other doctors.


Good for you!  That took quite a bit of courage, I'm sure.  I wouldn't be so sure it won't affect real change.  Of course she isn't going to admit to wrong doing to you for a host of reasons, including her own pride, but it doesn't mean it won't have a huge impact and cause her to examine her practices.  She probably just needs some time to digest that one of her patients just corrected her on something she should know.  Well done, Mama! 
 

 

post #20 of 115
Thread Starter 

Yes, unlikely, but not 100% sure not to cause harm.  It still shouldn't be done, especially if she isn't wearing sterile gloves.  The medical organizations recommend NO RETRACTION for any reason.  A catheter can be placed without retraction by threading it through the preputial orifice and "feeling" for the urethral meatus.

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