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#1 of 115 Old 07-19-2011, 11:23 AM - Thread Starter
 
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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.

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#2 of 115 Old 07-19-2011, 11:28 AM
 
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Way to go, mama!


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#3 of 115 Old 07-19-2011, 12:21 PM
 
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wow, that was an amazing letter!  a true empowered mom.

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#4 of 115 Old 07-19-2011, 12:28 PM - Thread Starter
 
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Thanks!  I just hope it doesn't piss anyone off.  I don't want to get kicked out of the practice.  Is it respectful?

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#5 of 115 Old 07-19-2011, 12:36 PM
 
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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!

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#6 of 115 Old 07-19-2011, 01:44 PM
 
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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.

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#7 of 115 Old 07-19-2011, 04:27 PM - Thread Starter
 
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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.

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#8 of 115 Old 07-19-2011, 05:05 PM
 
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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.  

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#9 of 115 Old 07-19-2011, 05:46 PM
 
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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.

 
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#10 of 115 Old 07-19-2011, 06:33 PM
 
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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!

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#11 of 115 Old 07-19-2011, 06:47 PM - Thread Starter
 
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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?

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#12 of 115 Old 07-19-2011, 09:10 PM
 
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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.

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#13 of 115 Old 07-20-2011, 06:46 AM - Thread Starter
 
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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)

 

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#14 of 115 Old 07-20-2011, 02:53 PM
 
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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.

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#15 of 115 Old 07-20-2011, 03:10 PM
 
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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. 

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#16 of 115 Old 07-20-2011, 08:18 PM
 
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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!

 

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#17 of 115 Old 07-21-2011, 02:13 PM - Thread Starter
 
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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.

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#18 of 115 Old 07-21-2011, 02:58 PM
 
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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.

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#19 of 115 Old 07-21-2011, 03:24 PM
 
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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! 
 

 

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#20 of 115 Old 07-22-2011, 06:22 AM - Thread Starter
 
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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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#21 of 115 Old 08-10-2011, 11:15 AM - Thread Starter
 
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So I got fired.  Here's the letter:

 

Quote:

August 3, 2011

 

RE: Pirogi's son and Pirogi's daughter

 

Dear Pirogi

 

I find it necessary to inform you that I will no longer be able to provide medical care to your children.  After careful consideration I feel it best if you find another physician to go along with your philosophy.  If you desire, I will be available for emergency care and already scheduled appointments for 30 days.

This should give ample time to select a physician of your choice from the many competent practitioners in this area.  With your written authorization, we will make a copy of your medical records available to your new physician.

 

Very truly yours,

D. W., M.D.

 

 

 

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#22 of 115 Old 08-10-2011, 11:21 AM
 
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Well at least you know she/he wasnt willing to learn, which is beyond sad because no doubt other little boys will be hurt because of that unwillingness.

 
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#23 of 115 Old 08-10-2011, 11:25 AM
 
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Quote:
Originally Posted by Pirogi View Post

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.


Looks like she wasn't the type to let a parent make these decisions (unless you think the other doctors in the practice made the call to fire you?) Good luck finding another practice that will respect you & your children! 

 


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#24 of 115 Old 08-10-2011, 11:34 AM - Thread Starter
 
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Yeah that's the weird thing.  When I met with her (referenced in the above quote), she actually said that it was fine with her for a parent to decline anything they weren't comfortable with.  Apparently she changed her mind?  The way the letter is written, it's a bit vague as to whether I am fired from the practice or just from her.  Is it common for a practice to blacklist someone and require that no one in the practice see them?

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#25 of 115 Old 08-10-2011, 11:58 AM
 
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That is seriously outrageous.  Personally I would want to know what research she could provide you with to back up the assumption that she should be retracting little boys.  Also, there are some websites that allow you to rate doctors.  You might want to consider that.  Job well done on doing what you could, OP.  The fact that she is unwilling to accept responsibility and learn from her mistakes is really awful but you did as much as anyone can. 

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#26 of 115 Old 08-10-2011, 12:30 PM
 
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#27 of 115 Old 08-10-2011, 01:44 PM
 
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Here's what would be awesome to be able to do: Interview every pediatrician in the area until you find one who actually understands that "retraction" means ANY manipulation of the foreskin back toward the shaft. Then, write your ex-doctor a letter explaining that, happily, you have found a physician whose training and education and cooperative, evidence-based approach suit yours and your children's needs to a "T." Explain that, although you are happy with your new doctor, you still worry about the potential for harm to other intact males in her practice, due to her mistaken notion that it somehow isn't "retraction" if it is only a "little bit." Therefore, you are asking the DOC to send her their standard letter in order to emphasize the seriousness of manipulating non-retractile boys' foreskins (and it IS serious; even though the likelihood of harm from the tiny amount of manipulation she does during a visit a couple times a year may indeed be very low, for parents to see her pulling back and messing with the foreskin could very well give them the idea they can and/or should do the same, whether to "check on things" or to clean), in the hopes that she will discuss this further with some of the outstanding, helpful, and knowledgeable physicians in that group.

 

I hope you really CAN find a doctor who understands that no retraction means NO RETRACTION! All the best to you.

 

You can take being dismissed from her practice as a badge of honor!

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#28 of 115 Old 08-12-2011, 10:51 AM
 
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Does this doctor have hospital privileges?  If so, I would contact the hospital (pediatric unit, risk management, patient advocate office) and inform them of your experience - the way you addressed it (the info you printed and the content of the talk in person) and the discharge letter you got. 

I would also contact Doctors Opposing Circumcision and have them send their usual stuff.

 

Thank you so much for following up!

 


"To err is human, to forgive, canine." - Unknown
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#29 of 115 Old 08-12-2011, 11:47 AM - Thread Starter
 
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Yes, she has privileges.  I had already contacted DOC but was going to try to meet with the doctor and discuss the situation with her face-to-face first, because I didn't want to get fired from the practice.  LOL!  I will contact the hospitals' Executive Officer, Risk Manager, Pediatric Department Clinical Director, and Patient Relations Coordinator.  I will also contact DOC again and ask them to move forward with the information they send.

 

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#30 of 115 Old 08-12-2011, 01:29 PM - Thread Starter
 
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Here's the letter:

" 

Dear Mr. M:

I am writing to inform you of an incident that occurred regarding one of the pediatric physicians who has privileges at ABC Hospital. The doctor is W, and she is in practice at ABC Pediatrics.

The incident in question occurred du...ring a regular 6-month well-child exam on 18 July 2011. My son is intact, and during the check of his genital area, Dr. W attempted to manipulate his foreskin backwards along 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. Dr. W and I 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. However, the interaction I have had with her since then is most concerning to me as a parent.

On 21 July 2011 I visited XYZ Pediatrics with the intent to drop off a letter with information as to the correct care of the intact penis, as well as current practice recommendations of the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP). The letter is attached herein. I was pleased that the office manager of the practice, Ms. E, offered to see me and discuss the information. Ms. E then offered to ask Dr. W to join us for the discussion. Dr. W listened to the information I presented her. However, she claimed that manipulating the foreskin backward along the shaft was not harmful and was in fact necessary to check for hypospadias. Despite the fact that the foreskin is adhered tightly to the glans penis via the balano-preputial membrane, Dr. W believes that she is able to retract only enough to visualize the urethral meatus, and that by doing so she is not harming children. Dr. W also ignored information I supplied her that forced retraction can damage the sphincter of the preputial orifice, increasing the risk of phimosis and paraphimosis later in life. Dr. W’s beliefs and practices are in direct contradiction to current care guidelines by the AAP and the AAFP. AAP recommends: “Foreskin retraction should never be forced. Until the foreskin fully separates, do not try to pull it back. Forcing the foreskin to retract before it is ready can cause severe pain, bleeding, and tears in the skin.” AAFP recommends: “Don't try to force the foreskin to retract, because this can damage the penis and cause problems.” Dr. W informed me she would read through the materials I left with her and provide them to the other doctors in the practice. I thanked Dr. W and Ms. E for their time and attention, and we parted ways amicably.

On 10 August 2011 I received a letter from XYZ Pediatrics dismissing me from the practice. The letter cited no reason other than this statement: “After careful consideration I feel it best if you find another physician to go along with your philosophy.” I feel that this dismissal is in direct retaliation for my efforts to provide her with correct care information for the intact penis. I am concerned that Dr. W continues to provide dangerous, contraindicated care to the intact boys of Small Town, USA.

I would be happy to discuss this with you further. I can be reached on my cell at ##. Thank you for looking into this situation.

Sincerely,

Pirogi

Encl: 1. Letter to Dr. W
2. “Care of the Uncircumcised Penis” from AAP; http://www.growingchildped​iatrics.com/pdf/Uncircumci​sedPenis.pdf
2. “Circumcision” from FamilyDoctor.org, AAFP; http://familydoctor.org/on​line/famdocen/home/men/rep​roductive/042.printerview.​html
3. “The Development of Retractile Foreskin in the Child and Adolescent” from Doctors Opposing Circumcision; http://www.doctorsopposing​circumcision.org/pdf/2008-​03retractileforeskinleafle​t.pdf
4. “Short Warnings About Forcible Foreskin Retraction” from Doctors Opposing Circumcision
5. “Only Clean What Is Seen” from Kindred, Aug 2008; http://www.kindredcommunit​y.com/articles/only-clean-​what-is-seen-reversing-the​-epidemic-of-forcible-fore​skin-retractions/p/1253

cc: C, Pediatric Department Clinical Director
E, Risk Manager
K, Patient Relations Coordinator"
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