title: Are physicians performing neonatal circumcisions well-trained?
abstract: BACKGROUND
  Notwithstanding the recommendations from the Canadian Pediatric Association and the American Academy of Pediatrics on the indications for neonatal circumcision, this procedure is still common in North America and throughout the world. Our purpose is not to argue whether this procedure should be done, but rather to examine who is doing it, their training, how it is performed and how can we prevent unsatisfactory results and complications. The objective is to identify what fields of knowledge require improvement and then design a teaching module to improve the outcomes of neonatal circumcision.
  
  
  METHODS
  A 19-question cross-sectional survey, including a visual identification item, was submitted to 87 physicians who perform neonatal circumcisions in Southwestern Ontario, Canada. To improve our response rate, study subjects were contacted in a variety of ways, including mail and fax and telephone. Once the survey was completed, we produced a surgical technique training video on using the Gomco clamp and the Plastibell techiques. A knowledge dissemination workshop was held with survey participants to discuss contraindications and the use of anesthesia and management of complications of neonatal circumcision and to evaluate the surgical technique training video. A 6-month follow-up questionnaire was completed to determine the impact of the teaching course on participants' daily practice.
  
  
  RESULTS
  In total, we received 54 responses (62% response rate). From these, 46 (85%) were family doctors and pediatricians, while the remaining 8 (15%) were pediatric general surgeons and urologists. The circumcisions were carried out with the Gomco clamp 35 (63%) and the Plastibell 21 (37%). No respondent admitted to learning the procedure through a structured training course. Of the non-surgeons, 19 (43%) learned to perform a circumcision from a non-surgeon colleague. A little over a third of the participants (17, 31%) were happy to perform a circumcision in a child born with a concealed penis, where circumcision is contraindicated. With respect to the early complications post-circumcision, 8 (100%) surgeons versus 29 (63%) non-surgeons felt comfortable dealing with bleeding (p = 0.046). In total, 7 (88%) surgeons versus 16 (35%) non-surgeons were comfortable dealing with urinary retention (p = 0.01). Also, 8 (100%) surgeons versus 24 (52%) non-surgeons were comfortable dealing with a wound dehiscence (p = 0.02). Moreover, 6 (75%) surgeons and 5 (10%) non-surgeons were comfortable managing meatal stenosis (p < 0.01). Five (63%) surgeons versus 15 (33%) non-surgeons were confident in dealing with a trapped penis post-circumcision (p = 0.24).
  
  
  CONCLUSIONS
  Our survey findings indicate that most physicians performing neonatal circumcisions in our community have received informal and unstructured training. This lack of formal instruction may explain the complications and unsatisfactory results witnessed in our pediatric urology practice. Many practitioners are not aware of the contraindications to neonatal circumcision and most non-surgeons perform the procedure without being able to handle common post-surgical complications. Based on our survey findings, we planned and carried out a formal training course to address these issues.
authors.affiliation: Division of Urology, Department of Surgery, McMaster Children's Hospital, Hamilton, ON; ; Department of Surgery, McMaster University, Hamilon, ON.
authors.forename: Jorge
authors.initials: J
authors.lastname: Demaria
authors.forename: Alym
authors.initials: A
authors.lastname: Abdulla
authors.forename: Julia
authors.initials: J
authors.lastname: Pemberton
authors.forename: Ayman
authors.initials: A
authors.lastname: Raees
authors.forename: Luis H
authors.initials: LH
authors.lastname: Braga
references.citation: Pediatrics. 2012 Sep;130(3):585-6
references.pmid: 22926180
references.citation: Fam Med. 2007 Apr;39(4):241-3
references.pmid: 17401765
references.citation: Int Braz J Urol. 2006 Jul-Aug;32(4):454-8
references.pmid: 16953915
references.citation: J Urol. 2010 Oct;184(4 Suppl):1754-7
references.pmid: 20728165
references.citation: J Pediatr Urol. 2007 Feb;3(1):32-5
references.pmid: 18947695
references.citation: Br J Surg. 1993 Oct;80(10):1231-6
references.pmid: 8242285
references.citation: CMAJ. 1996 Mar 15;154(6):769-80
references.pmid: 8634956
references.citation: Sex Transm Infect. 2003 Dec;79(6):499-500
references.pmid: 14663134
references.citation: Pediatrics. 2000 Jan;105(1 Pt 3):246-9
references.pmid: 10617731
references.citation: Sex Transm Infect. 1998 Oct;74(5):368-73
references.pmid: 10195035
references.citation: Pediatr Clin North Am. 2001 Dec;48(6):1539-57
references.pmid: 11732129
references.citation: Pediatrics. 1999 Mar;103(3):686-93
references.pmid: 10049981
references.citation: J Pediatr Surg. 2002 Sep;37(9):1343-6
references.pmid: 12194129