Fast help, Dr's and education

[Eman'smom]

I am looking at this as a small window of opportunity rather than more upsetness for me.

My sister actually said something about circing. Ok now I need help.

She told me she isn't going to believe me and what I read on the internet, but to her ped : A person she spoke to once, and that person told her something about pain relief : She won't tell me what this person said, but she did say that he/she went to medical school and I didn't so they know more than me. Heck at least I know not to cut penis' off.

So how much education to dr's get on pain relief for circing? I know they get basically zero on BFing.

I'm hoping if I can get her to see that they don't have all the answers, maybe this will be a crack in the window.

[Quirky]

Doctors essentially learn what they need to know beyond the basics of anatomy, physiology, and how the body works by apprenticing. The first 2 years of med school are classes, the last 2 are rotations through various disciplines in a hospital setting (or maybe it's 3 years/1 year, I don't know for sure).

The point is, doctors don't learn how to circ or give pain relief in med school; there's no curriculum for that. They learn how to do circs and anesthesia through on-the-job training. And circs are fairly simple, so the saying goes "see one, do one, teach one" - in other words, those who are teaching circs are not going to be pediatric urologists with many years of slicing and dicing to their credit () but whoever is tasked with teaching the residents circ on that particular day. It would probably be a second-, third-, or fourth-year resident showing the med students or first-year residents how to do circs.

(And since ob-gyns do 75% of all circs, it's likely it would be an ob-gyn resident/attending demonstrating circs.)

On pain relief, the student would learn whatever the practice is of his or her teacher. Some of those teaching are going to be more up on modern recommendations than others.

And then of course once doctors graduate and start their own practices or join another practice, whether they stay current on the literature is another question altogether - tons and tons of research comes out all the time and between seeing patients all day and running practices (admin work takes tons of time for doctors), whether they can stay current on all the research and recommendations in their field is a huge question. There is so much out there you really have to sacrifice all hope at a personal life to stay current.

The point being, there is no uniformity of practice which is why the AAP has done a study that shows that the vast majority of doctors are not following the pain relief recommendations that the AAP has made.

We can link you to those studies! I have a screaming baby so I have to stop for the moment but I will come back and post them if someone doesn't beat me to it.

Both the pain study and the pain recommendations are online - although it is the Internet they are AAP publicatiosn!

[mamakay]

Well, a lot of docs don't use any pain meds. If your sister disbelieves this, suggest that she make a few calls to local hospitals.
Everything you've told us about your sister makes me feel a little just imagining trying to communicate with her.
My gut response would be "Well, maybe those docs are right. Maybe babies don't feel pain. Maybe the docs that do think babies can feel pain are the ones to ignore."...just to see what she'd say.
(I understand how rediculous this sounds...it might put her in a position of having to think just a little, though).

[Quirky]

Link to AAP policy statement

ANALGESIA

There is considerable evidence that newborns who are circumcised without analgesia experience pain and physiologic stress. Neonatal physiologic responses to circumcision include changes in heart rate, blood pressure, oxygen saturation, and cortisol levels.36-39 One report has noted that circumcised infants exhibit a stronger pain response to subsequent routine immunization than do uncircumcised infants.40 Several methods to provide analgesia for circumcision have been evaluated.

.....

In summary, analgesia is safe and effective in reducing the procedural pain associated with circumcision, and, therefore, adequate analgesia should be provided if neonatal circumcision is performed. EMLA cream, DPNB, and a subcutaneous ring block are options, although the subcutaneous ring block may provide the most effective analgesia.

[Quirky]

Still looking for the recent survey showing that docs most often don't use pain relief...but here are some recent studies published in medical journals:

http://tinyurl.com/bwm2n

Pediatr Nurs. 2004 Sep-Oct;30(5):414-7, 427.
Pain management for newborn circumcision.

Razmus IS, Dalton ME, Wilson D.

Children's Hospital at Saint Francis, Tulsa, OK, USA.

PURPOSE: To describe current newborn circumcision pain interventions and to identify which forms of analgesia were most effective. METHOD: Each male newborn was assessed for pain during the circumcision procedure and at 15-minute intervals after the procedure using the FLACC pain scale. The type and combination of analgesia was also recorded on the pain assessment record. RESULTS: Pain scores were highest for newborns receiving no analgesia during circumcision. Newborns circumcised with the dorsal block and the ring block in combination with the concentrated oral sucrose had the lowest pain scores. The sucrose alone did not provide sufficient analgesia; however, it did reduce the FLACC score somewhat when used in conjunction with other analgesics/anesthesia. CONCLUSIONS: Information obtained from this project facilitated a change in policy wherein newborn circumcision is performed only with the use of analgesia and not concentrated oral sucrose alone.

Ok, here's the Cochrane Review, this is the gold standard of evidence-based medicine. How a Cochrane Review works is they review all studies done and make conclusions - a meta-analysis.

http://tinyurl.com/dsm6l

Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004217. Related Articles, Links
Click here to read
Pain relief for neonatal circumcision.

Brady-Fryer B, Wiebe N, Lander JA.

Child Health - Critical Care, Capital Health, Royal Alexandra Hospital, 10240 Kingsway, Room 5027-10 DTC, Edmonton, Alberta, Canada, T5H 3V9. [e-mail]

BACKGROUND: Circumcision is a painful procedure that many newborn males undergo in the first few days after birth. Interventions are available to reduce pain at circumcision; however, many newborns are circumcised without pain management. OBJECTIVES: The objective of this review was to assess the effectiveness and safety of interventions for reducing pain at neonatal circumcision. ....

SELECTION CRITERIA: Randomised controlled trials comparing pain interventions with placebo or no treatment or comparing two active pain interventions in male term or preterm infants undergoing circumcision.

.....

MAIN RESULTS: Thirty-five trials involving 1,984 newborns were included. Thirty-three trials enrolled healthy, full term neonates, and two enrolled infants born preterm.Fourteen trials involving 592 newborns compared dorsal penile nerve block (DPNB) with placebo or no treatment.

....

REVIEWERS' CONCLUSIONS: DPNB was the most frequently studied intervention and was the most effective for circumcision pain. Compared to placebo, EMLA was also effective, but was not as effective as DPNB. Both interventions appear to be safe for use in newborns. None of the studied interventions completely eliminated the pain response to circumcision.

[Quirky]

Here's a study that shows that there is currently no formal training regimen for residents learning to do circumcisions (i.e. that's why this study was done, to study what a training regiment might accomplish):

http://tinyurl.com/dmf7y

Ambul Pediatr. 2002 Nov-Dec;2(6):470-4.
Neonatal circumcisions performed by pediatric residents: implementation of a training program.

Chandran L, Latorre P.

Department of Pediatrics, Health Sciences Center, SUNY at Stony Brook, 11794-8111, USA. [e-mail]

OBJECTIVE: To implement a pilot training program on neonatal circumcisions for pediatric residents in a residency training program, and to evaluate the effectiveness of the program in improving knowledge and skills in performing circumcisions. DESIGN: Educational curriculum. SETTING: The mother-baby unit of a tertiary care university medical center. PARTICIPANTS: Nineteen pediatric residents in training. INTERVENTION: A 1-month circumcision-training program. OUTCOME MEASURES: Successful completion of the training program, change in mean knowledge scores, and change in attitudes regarding circumcision. RESULTS: All 19 residents successfully completed the pilot program. Residents were enthusiastic about the opportunity to train in performing circumcisions. The mean test scores on the content items increased significantly from 5.0 (SD, 1.8) before training to 8.3 (SD, 1.0) after training (P <.003). After training, there were significant changes in residents' attitudes regarding giving anesthesia for the procedure and the medical indications for performing routine circumcisions. CONCLUSIONS: Given a structured curriculum, pediatric residents can be taught to safely and successfully perform neonatal circumcisions with adequate technical competency and pain relief skills. Training results in increased knowledge and increased level of comfort in performing this routine procedure.

What the bolded sentence in results says to me is:

1) before this training the residents probably thought pain relief was unnecessary

2) the training convinced them even more that circ is necessary.

[Eman'smom]

Thanks I'm hoping if I can get in just a little bit, maybe the flood gates will open, doubtful, but I have to hope right?

[Quirky]

Maybe the AAP statement followed up by the Cochrane Review with the conclusion sentence about nothing being totally effective for pain relief?

Good for you for continuing to try! If you can at least get this poor baby boy some pain relief that will be a major victory.

[calngavinsmom]

Here is some info for ya!
Pain
http://www.circumcision.org/response.htm
http://www.infocirc.org/babypain.htm
http://pediatrics.aappublications.o.../full/100/4/626

%Of Pain Control Actually Used
http://pediatrics.aappublications.o.../full/101/3/423
http://pediatrics.aappublications.o...t/full/101/6/e5
http://pediatrics.aappublications.or...ode=pediatrics

Pain Relief that SHOULD Be Used
http://www3.us.elsevierhealth.com/WOW/op043.html

Hope there is something that gets through......

Take care,
Tara

[Quirky]

Tara, two out of three of your links under pain control actually used are dead.

[Frankly Speaking]

From what I have been told, med students get about 10 minutes of discussion about circumcision and less than a half page in a single text book their entire student career.

I have also been told that in large hospitals, it is often interns (doctors in training) that do the circumcisions paid by insurance or Medicare, so their experience is minimal.

I also was given a link to a doctor's discussion board where circumcision was being discussed. The distressing thing was that the vast majority of the doctors in the discussion did not use any pain relief. The reason most often given was that "it takes too much time." There were a few doctors on the board that wanted to try analgesia for the procedure and the other doctors were giving them instructions on how it is done on the board.

Probably the most distressing thing to me is that there were three doctors on the board from my neighborhood. My neighborhood is one of the most affluent neighborhoods in the Atlanta area and doctors who practice there are at the top of their game. They went to the best medical schools and interned at the best hospitals and they practice in the best neighborhoods. Most of them are practicing at the number one baby hospital in the nation, Atlanta's Northside Hospital that delivers more than 2,000 babies a year. The lack of knowledge was appalling! I can only imagine what it would be at lesser hospitals and in less affluent neighborhoods.



Frank

[Pandora114]

There's a BBS out there of OB/GYNs and they discuss a myriad of things like mutilations to the mom during childbirth *aka Routine Episiotomies* RIC, and all that

http://www.obgyn.net I think is the url for the forums. Just have a bucket handy when you read the site. Print out their discussons re: circ. They are drs and you can blatantly tell from the terminology they use

[liseux]

I just want to add that due to the misfortune of having had all my boys spend time in the NICU, I`ve seen several circs. First, they always used only EMLA cream if anything and I was in 3 hospitals. The nurses told me it takes up to 45 min to take effect and the dr`s don`t have that kind of time so they often do the surgery before it works. The next thing I noticed is that in teaching hospitals it is usually the med students and if a mom requests that her OB does it, the OB`s rarely use any anesthesia at all because they feel its so quick, why waste time on drugs. This is so depressing but thats been my experience.