Letter to my pediatrician - Page 4

[Pirogi]

No, the guidelines I have referenced in any communication on the matter are from the AAP and the AAFP.  The text of their recommendations is in the hospital letter I haven't sent yet.

Here is more of the text from the DOC FAQ they will send when you request help from them.  This is only part of the FAQ.  I have been given permission by DOC to share all materials they provide to me.

 YOUR NARRATIVE— we will need a comprehensive and detailed story of exactly what occurred. 

Include “when, where, what occurred, by whom, to whom, and what happened as a result” details.  Your 

story should include the following, at a minimum:

• full name of your child, 

• his place of birth and birth date;

• your full names and addresses as parents, 

• the reason you took him to the doctor (well-baby check, immunization, suspected infection, 

puzzling fever, earache, urinary problem, etc.);• name of the doctor, nurse or other medical professional;

• name and address of the clinic;

• the date (and if possible, the time) of the occurrence;

• whether you warned the med professional not to retract your son and were ignored;

• whether he or she wore surgical gloves;

• whether you observed him or her washing his or her hands;

• how aggressively the doctor retracted your child*;

• how far was you son retracted? All the way to the corona? (the widest part of the penis)

• your child’ reaction at that moment of retraction;

• your child’s condition the next few days or weeks;

• whether your child bled, had swelling, discharge, or showed other signs of trauma or infection

• any efforts you made to relieve your child’s distress

• your own distress and worry

• whether you were obliged to take your son to another medical professional or an ER;

• names of ALL of the offending professional’s clinic partners;

• the advice (good or bad) you were given about male genital hygiene and bathing techniques for 

boys, and by whom.

(*Note: some knowledgeable docs will gently and carefully retract the child’s foreskin to the boundary 

where the balano-preputial lamina attachment occurs. This is permissible in the (washed and gloved) 

hands of a professional who otherwise knows this anatomy, a rare person in our experience. Assuming 

that is all that occurred, this is no cause for a formal complaint unless the retraction is more aggressive 

and there is pain, bleeding, and swelling and/or you saw the child’s glans appear in whole or part. Even 

this exam technique is unnecessary –the need to see the urinary meatus in a healthy child is imaginary--

but it is also not harmful enough to warrant a formal complaint.

So they specifically mention "surgical gloves" not "sterile gloves," but surgical gloves are sterile I believe, no?

[Sarahfeena]

Originally Posted by PuppyFluffer 

My son was not retracted ONLY because I was educated AND prevented it from happening physically.  The OP's son was not retracted because she did not physically allow it.  If neither of us was educated AND proactive, our sons would have been retracted, thus tearing their genital tissue and causing them harm and pain.  Her informative letters are not about whether her son was harmed but about the fact that her son would have been harmed had she not prevented it.  It stands to reason that both of the medical care individuals we both saw were accustomed to retracting on a normal basis.  The issue isn't about whether her son was harmed (he wasn't) but about bringing a health care professional's knowledge and practice up to speed on accurate information and procedure.  In the case of the OP, the doctor doesn't seem interested in changing her care.  The OP's actions are for the benefit of other boys that will be in her care.  The chances are that many of the peds retract and that most of the nursing staff may not know proper intact care.

In todays world, most people wouldn't bother taking any action if it didn't directly impact themselves personally.  The OP is acting for the benefit of others and I support that!

I don't think it's true at all that the doctor ONLY didn't retract because the OP didn't allow her.  According to the OP's own words, "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."  THE DOCTOR SAID SHE WASN'T DOING THAT.  And when she said it doesn't sink in right away," she meant that it didn't sink in what the OP was asking her not to do BECAUSE SHE WASN'T DOING IT. 

I think she owes this doctor a huge apology. 

[WildKingdom]

No, surgical gloves are just latex or vinyl exam gloves.

[Pirogi]

Originally Posted by Sarahfeena 

I don't think it's true at all that the doctor ONLY didn't retract because the OP didn't allow her.  According to the OP's own words, "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."  THE DOCTOR SAID SHE WASN'T DOING THAT.  And when she said it doesn't sink in right away," she meant that it didn't sink in what the OP was asking her not to do BECAUSE SHE WASN'T DOING IT. 

I think she owes this doctor a huge apology. 

No, what she meant was NOT that she wasn't intending to retract.  She clearly was, and did pull the foreskin back along the shaft.  She did not mean, "Oh!  I wasn't even going to do that, OK."  What she meant was, "Oh, You don't even want me to do that, OK."

[Pirogi]

Ah, k, I thought surgical gloves were always sterile.  The doctor did wash her hands but did not wear any gloves at all, sterile or no.

[PeterJ]

I think WildKingdom has a valid point.  It's fine to be guided by a group that you align with, in terms of what you see as appropriate care for your child.  But DOC is not a regulatory body and for want of a better word, is by its very nature and objective "biased" on this situation regarding retraction.  Most of us are aware of a senior member of the AAP being quoted recently in an MDC article about "gently tugging on the foreskin to check for retractability" (paraphrased).  It's very clear that there is a difference of opinion as to what constitutes an acceptable examination and I personally, though undoubtedly in the minority here at least, believe it runs further than doctors being simply uneducated about intact anatomy.  Our own ex-Pediatrician trained in England (very low circ rate country) and practiced there for decades before moving to the states, yet he still forcibly retracted my son at 3 months.  With this kind of difference of opinion within the medical community, I'm not sure how much success you will have quoting from a group that is 100% anti-circ and consequently 100% 'leave it alone at all times', when this position is at odds with some members of the AAP itself.  I should add that I am absolutely against circumcision and forced retraction, believing it unnecessary.

However, if you feel that the doctor should be reported for attempting to disregard your wishes, then you may have a case.  In any event, I'm glad to see that you are using appropriate caution and thinking through your options before acting.

Peter

[Sarahfeena]

Originally Posted by Pirogi 

No, what she meant was NOT that she wasn't intending to retract.  She clearly was, and did pull the foreskin back along the shaft.  She did not mean, "Oh!  I wasn't even going to do that, OK."  What she meant was, "Oh, You don't even want me to do that, OK."

So when she said "we're not doing that," you know for a FACT that she meant "I would have done this if you hadn't stopped me," vs "I wasn't planning to do that."  For a FACT?  Or this was your interpretation because you already feared it?

Your story has contradicted itself, by the way.  You said that she DID retract him, enough to see the urinary meatus, and that this was her purpose.  Then you said if you hadn't stopped her, she would have continued retracting him, which you have no reason to believe if the first part is true.  And if the act of pulling the foreskin enough to see the meatus is enough to cause injury, wouldn't the baby have cried?  Oh, wait, I just remembered that you mentioned I think on page 3 of this thread that he was crying, but never thought to mention it in any of the letters that you wrote about this event.  Color me confused.

[tennisdude23]

Chiefmir, maybe your husband could post on this board what the AAP and AAFP really mean by retraction.  I think that there is some confusion on here that makes it seem that retraction includes touching the foreskin, which it does not.  After all, little kids touch and manipulate their penises all the time.  It does not cause them any harm.  So, if a doctor looks at the penis and touches the foreskin to visualize the urethra, it is not retraction.  Retraction would be pulling against the membrane between the foreskin and the glans, which causes pain and discomfort.  

Pirogi, it does not seem that the doctor was attempting to do this at all.  Even if she was, she covered herself by telling you that you could refuse any part of the exam.  You say that the original purpose of your letters was to educate, but you clearly got the opposite effect because you don't seem to realize that your letters are patronizing and off-putting.  I don't think there is anything professional about the way you are dealing with this situation.  If you had concerns, you should have just brought those up at the next office visit or if you really wanted to write a letter, briefly summarize them and send the necessary links.  Instead, you, the patient, were telling the doctor that she was uneducated about patient care and dictating that she should also educate her colleagues.  You just don't do that.  I think that it's great that you want to educate.  Again, the idea of an inservice is something that I would have brought up at the next office visit, depending on how open the doctor was to the information in question.  But your style made it seem that you were looking for a problem were there was none.  So, don't be surprised she dropped you.  

In any case, I agree with the general sentiment on here.  My advice would be to tear up the letter you plan to send to the hospital and forget this entire situation.  That letter is completely inappropriate.  As someone else said, you are taking a situation that on the scale of awful was at the most a 2 and turning it into an 11.  You are making a very serious accusation that your doctor provides "dangerous care" without any factual basis, simply basing everything from assumptions linked to a two second incident.  Words like that have serious meaning and I would not be surprised if something like this does finally result in a legal matter if you keep pursuing the situation in this manner.  

[Pirogi]

Originally Posted by PeterJ 

I think WildKingdom has a valid point.  It's fine to be guided by a group that you align with, in terms of what you see as appropriate care for your child.  But DOC is not a regulatory body and for want of a better word, is by its very nature and objective "biased" on this situation regarding retraction.  Most of us are aware of a senior member of the AAP being quoted recently in an MDC article about "gently tugging on the foreskin to check for retractability" (paraphrased).  It's very clear that there is a difference of opinion as to what constitutes an acceptable examination and I personally, though undoubtedly in the minority here at least, believe it runs further than doctors being simply uneducated about intact anatomy.  Our own ex-Pediatrician trained in England (very low circ rate country) and practiced there for decades before moving to the states, yet he still forcibly retracted my son at 3 months.  With this kind of difference of opinion within the medical community, I'm not sure how much success you will have quoting from a group that is 100% anti-circ and consequently 100% 'leave it alone at all times', when this position is at odds with some members of the AAP itself.  I should add that I am absolutely against circumcision and forced retraction, believing it unnecessary.

However, if you feel that the doctor should be reported for attempting to disregard your wishes, then you may have a case.  In any event, I'm glad to see that you are using appropriate caution and thinking through your options before acting.

Peter

I haven't seen the MDC article.  Can someone link it?

[Pirogi]

Originally Posted by Pirogi 

I don't know what you mean, that I admitted the struggle was really a non-struggle?  There was definitely some physical maneuvering going on.  When the diaper came off, I immediately put my hand on my son's penis and held it upward toward his torso.  She felt for and pulled down on my sons's testicles, which caused him to cry, and I momentarily looked at his face and tried to comfort him.  Then she reached for his penis.  I believe that she thought I was holding it up just to keep it out of the way of the testicular exam, and she was physically taking it to perform the urinary meatus check.  She was intentionally trying to remove my hand from his penis/worm her fingers under my hand so that she could pull back the foreskin.  And she did pull it backwards a little, although because my son has ample foreskin, I did not see the glans.  He continued to cry pretty loudly until she took her hands off of him and I picked him up and held him against my chest.  He didn't calm completely down (whimpering) until she left the room.  It was one continuous attempt on her part, continually pulling the foreskin back while I held the penis.  I said, "No-retraction-no-retraction-no-retraction" quickly.  Does that clear it up?

Originally Posted by Sarahfeena 

So when she said "we're not doing that," you know for a FACT that she meant "I would have done this if you hadn't stopped me," vs "I wasn't planning to do that."  For a FACT?  Or this was your interpretation because you already feared it?

Your story has contradicted itself, by the way.  You said that she DID retract him, enough to see the urinary meatus, and that this was her purpose.  Then you said if you hadn't stopped her, she would have continued retracting him, which you have no reason to believe if the first part is true.  And if the act of pulling the foreskin enough to see the meatus is enough to cause injury, wouldn't the baby have cried?  Oh, wait, I just remembered that you mentioned I think on page 3 of this thread that he was crying, but never thought to mention it in any of the letters that you wrote about this event.  Color me confused.

The people who were in the room were me, my son, the doctor, my daughter, and the person I brought to care for my daughter during the visit.  You were not there.  I have given my interpretation of the events.  I'm not sure why you are attacking my interpretation as incorrect?

Where did I say that she did retract him enough to see the urinary meatus?  Good grief, this is getting out of control!  She tugged backward on his foreskin, despite my physical attempts to block her from doing so and my verbal instruction not to retract.  *I* did not see any part of the glans, including the urinary meatus.  It became clear during the visit with the office manager that the reason she did this was to check for hypospadias, and she believes that this is a valid reason to do so.  Yes, he did cry during the exam, beginning from the moment she pulled downward on his testicles and continuing until she left the room.  I didn't mention it in the letters because infants sometimes cry during exams, and that doesn't automatically mean that the care provider did anything to harm them.  Would it have mattered if I had mentioned that my son cried?

[Pirogi]

Originally Posted by tennisdude23 

Chiefmir, maybe your husband could post on this board what the AAP and AAFP really mean by retraction.  I think that there is some confusion on here that makes it seem that retraction includes touching the foreskin, which it does not.  After all, little kids touch and manipulate their penises all the time.  It does not cause them any harm.  So, if a doctor looks at the penis and touches the foreskin to visualize the urethra, it is not retraction.  Retraction would be pulling against the membrane between the foreskin and the glans, which causes pain and discomfort.  

Pirogi, it does not seem that the doctor was attempting to do this at all.  Even if she was, she covered herself by telling you that you could refuse any part of the exam.  You say that the original purpose of your letters was to educate, but you clearly got the opposite effect because you don't seem to realize that your letters are patronizing and off-putting.  I don't think there is anything professional about the way you are dealing with this situation.  If you had concerns, you should have just brought those up at the next office visit or if you really wanted to write a letter, briefly summarize them and send the necessary links.  Instead, you, the patient, were telling the doctor that she was uneducated about patient care and dictating that she should also educate her colleagues.  You just don't do that.  I think that it's great that you want to educate.  Again, the idea of an inservice is something that I would have brought up at the next office visit, depending on how open the doctor was to the information in question.  But your style made it seem that you were looking for a problem were there was none.  So, don't be surprised she dropped you.  

In any case, I agree with the general sentiment on here.  My advice would be to tear up the letter you plan to send to the hospital and forget this entire situation.  That letter is completely inappropriate.  As someone else said, you are taking a situation that on the scale of awful was at the most a 2 and turning it into an 11.  You are making a very serious accusation that your doctor provides "dangerous care" without any factual basis, simply basing everything from assumptions linked to a two second incident.  Words like that have serious meaning and I would not be surprised if something like this does finally result in a legal matter if you keep pursuing the situation in this manner.  

I agree that the definition of "retraction" needs to be clarified.  I do not believe that *touching* the foreskin is retraction.  Does tugging the foreskin backward toward the torso constitute retraction? If not, at what point does it become retraction?  Yes, little kids touch their penises all the time, but it's THEIR penis.  Hasn't the general consensus always been that the first person to retract a boy's penis should be the boy himself?  The doctor doesn't have the benefit of nerve impulses connecting their actions with an adhered penis to pain receptors.  How would they know when they've pulled too far?    

I don't know how many ways I can say this.  I was there.  I know what happened.  The doctor DID attempt to pull my son's foreskin backward toward his torso.  She told me later in the week, when we met with the office manager, that I could refuse any part of an exam in the future.  She did NOT say this before the genital check, and she did not say this after the genital check during the visit.  And for all the mud-slinging going on here about my intentions, no one has specified what exactly it was in the letter I sent that was off-putting or patronizing.  Please, show me.

It takes less than two seconds to completely retract a non-retractable boy.  Should that two-second incident also be disregarded?  My son's foreskin was tugged backward.  This despite my vigilance.  I should just stay quiet about that and allow this to continue for other boys who visit this doctor?

[tennisdude23]

Kids tug on their foreskins all the time.  It's no big deal.  So, don't be surprised the doctor might have gently done the same to simply visualize the urethral opening.  If you don't want that to happen, opt-out of that part of the exam.  The more I think about this, the more obvious it becomes that writing letters and making such a fuss about what you admit is simply your two second interpretation of an event is absolutely ridiculous.  

To address your points above.  First, what's patronizing is your tone, your wordage, your litany of what should and should not happen, making it sound that you are the know it all and the doctor is clueless, you telling her to educate her colleagues, etc.  A perfect example of patronizing is your entire first paragraph after you mentioned that your son is intact and an aspect of the visit concerned you.  I would have simply taken that first sentence and the last dealing with creating an evidence-based plan for your son and thrown out the rest.

Second, the point when it becomes retraction is when it starts to tear at the membrane and your child would probably scream pretty loudly at that moment.  I also believe that the foreskin does not need to be touched, but if it happens it's not going to fall off.  Seriously, my concern with this board sometimes is that if a parent who knows nothing about circumcision sees posts like this, they may very well come to the conclusion that having a foreskin is a big deal because my god if you touch it micro-tears will form, the foreskin will become infected, etc, etc.  

Third, you are right, none of us were there.  So, it's your word against the doctors, not exactly much evidence to suggest she provides "dangerous care" to her other patients.  

Edited by tennisdude23 - 8/14/11 at 1:36pm

[TCMoulton]

Originally Posted by Pirogi 

I don't know what you mean, that I admitted the struggle was really a non-struggle?  There was definitely some physical maneuvering going on.  When the diaper came off, I immediately put my hand on my son's penis and held it upward toward his torso.  She felt for and pulled down on my sons's testicles, which caused him to cry, and I momentarily looked at his face and tried to comfort him.  Then she reached for his penis.  I believe that she thought I was holding it up just to keep it out of the way of the testicular exam, and she was physically taking it to perform the urinary meatus check.  She was intentionally trying to remove my hand from his penis/worm her fingers under my hand so that she could pull back the foreskin.  And she did pull it backwards a little, although because my son has ample foreskin, I did not see the glans.  He continued to cry pretty loudly until she took her hands off of him and I picked him up and held him against my chest.  He didn't calm completely down (whimpering) until she left the room.  It was one continuous attempt on her part, continually pulling the foreskin back while I held the penis.  I said, "No-retraction-no-retraction-no-retraction" quickly.  Does that clear it up?

Just curious - how did all of that take place in just 2-3 seconds. Seems like an awful lot of action for such a brief moment in time.

[Pirogi]

I am completely floored that this is the response I am getting in this forum.  I won't be recommending it to friends anymore.

Yes, tennisdude23, it was my interpretation of events.  You know, just like everything we experience in life is an interpretation of events.  Cogito ergo sum and all that.

TCMoulton - how am I supposed to answer that?  Are you implying that I have intentionally misrepresented what happened?

I'm going to take a break from this thread.  Thank you all for your responses.

[MCatLvrMom2A&X]

The definition of retraction is "Any movement at all back toward the body" Some retraction is more than others obviously but if the foreskin goes back toward the glans where you can see the inner foreskin or the gland that IS retraction and it is in no way needed there is nothing under there to see period.

[MsFortune]

Originally Posted by tennisdude23

Seriously, my concern with this board sometimes is that if a parent who knows nothing about circumcision sees posts like this, they may very well come to the conclusion that having a foreskin is a big deal because my god if you touch it micro-tears will form, the foreskin will become infected, etc, etc.   

Yep.  I didn't circ my son but I didn't really think much about the aftercare aspect of it.  I started reading this thread and started to worry about penis care, and infections, and felt my head start to explode.  I thought, jeez, maybe I should have just circed.  I didn't know it was this big of a deal.  

I think I'm calmed down now, but DS is at an age where he is doing a lot of tugging and now I'm going to worry all the time that he is pulling and micro-tearing, and getting infected.  I don't want to stop him from playing with it (at home, in private) but now I am worried and it will be hard to relax.

Also, I thought my ped was pretty savvy, and listened to his advice on how to manage the foreskin and cleaning.  Now I am wondering if he is really undermining me.  
 

[tennisdude23]

And where does this definition come from?  Because by just touching the penis, you can slightly move the foreskin back toward the body and visualize the inner foreskin.  That in my opinion should not constitute the definition of retraction and most doctors don't consider this retraction either, rightfully so.  I agree that there is nothing to see there period, but by the orthodoxy presented here, doctors should not touch the penis at all or so it seems.  

Originally Posted by MCatLvrMom2A&X 

The definition of retraction is "Any movement at all back toward the body" Some retraction is more than others obviously but if the foreskin goes back toward the glans where you can see the inner foreskin or the gland that IS retraction and it is in no way needed there is nothing under there to see period.

[tennisdude23]

Well, I am guy, and FWIW, I never had any issues.  Nobody ever gave the foreskin two thoughts, including my numerous health care providers.  The foreskin is a non-maintenance appendage if you will.  By its very design, it can be tugged and manipulated in very intricate ways without anything happening to it.  So, don't worry about it.  The chances are basically 0 of your son doing anything that would cause him any harm.  By the time he is 11, 12, 13, he will figure out a lot of fun things about his body and the cleaning aspect will come naturally.  It's not something that you have stand over him and teach him how to do.  Once those hormones kick in, the foreskin usually completely retracts.  So, it's really a total non-issue, which I would just forget about, anyway that's my two cents, hope it helps.  

Originally Posted by MsFortune 

Yep.  I didn't circ my son but I didn't really think much about the aftercare aspect of it.  I started reading this thread and started to worry about penis care, and infections, and felt my head start to explode.  I thought, jeez, maybe I should have just circed.  I didn't know it was this big of a deal.  

I think I'm calmed down now, but DS is at an age where he is doing a lot of tugging and now I'm going to worry all the time that he is pulling and micro-tearing, and getting infected.  I don't want to stop him from playing with it (at home, in private) but now I am worried and it will be hard to relax.

Also, I thought my ped was pretty savvy, and listened to his advice on how to manage the foreskin and cleaning.  Now I am wondering if he is really undermining me.  
 

[MCatLvrMom2A&X]

The definition comes from the dictionary

(retract) draw in: pull inward or towards a center
(retract) Latin re = back, and tractum = pulled; hence, to pull something back, and retraction - the act of retracting.

Well since there is no way to know exactly what the Dr. is going to do it is safer to not allow them to touch it. If you know for a fact that your Dr. will be super gentle and not try to force anything than it isnt a problem. But since I dont have a Chrystal ball and I am not able to read minds I dont think the risk is worth it. We have had so many posters come in that I have lost count talking about their Dr. tearing their ds's foreskin and making it bleed and dealing with major irritation after wards, it just makes more sense to have a hands off policy.

I had to institute that policy with my ds's ped's practice because he was hurt once and nearly hurt again after me asking them not to retract him.

I do not think all Dr's are out to hurt little kids at all but I do think that the level of ignorance among them on this topic is scary.

[BananaBreadGirl]

Originally Posted by tennisdude23 

Second, the point when it becomes retraction is when it starts to tear at the membrane and your child would probably scream pretty loudly at that moment.  I also believe that the foreskin does not need to be touched, but if it happens it's not going to fall off.  Seriously, my concern with this board sometimes is that if a parent who knows nothing about circumcision sees posts like this, they may very well come to the conclusion that having a foreskin is a big deal because my god if you touch it micro-tears will form, the foreskin will become infected, etc, etc.  

My child had his foreskin retracted prematurely by a doctor (glans fully visible), and he didn't make a peep at the time. He did scream like crazy every time he peed for the next 2-3 days though, and red "cracks" were visible around the tip of the foreskin. So, just because the child doesn't cry or bleed at the time doesn't mean they aren't hurt (which is what the doctor tried to tell me...basically, if there's no bleeding, he doesn't consider it a forced retraction...yikes).

His next doctor started pulling the foreskin towards the body and I yelled "no, no, don't touch", and he stopped. He said of course he was not going to fully retract it, just checking...something...maybe the meatus? There seems to be differing opinions in the medical community on whether any pulling backwards is OK, I think it's not necessary to be manipulating it and will be telling any healthcare providers who ever open my son's diaper again exactly what I am allowing them and not allowing them to do. I'm not sure I would call any pulling of the foreskin towards the body as "dangerous", although I guess it is hard to know when to stop or when injury is occurring, since, as I said earlier, the child doesn't not necessarily scream at the point of injury, and by that time, it's too late, isn't it.