Objective. We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure.
Methods. Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%).
Results. Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02–0.08] or obstetrical (OR, 0.14; 95% CI, 0.08–0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3–110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4–306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7–7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7–4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties.
Conclusions. Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.
- AAP =
- American Academy of Pediatrics •
- ACOG =
- American College of Obstetricians and Gynecologists •
- AAFP =
- American Academy of Family Physicians •
- DPNB =
- dorsal penile nerve block •
- OR =
- odds ratio •
- CI =
- confidence interval •
- EMLA =
- eutectic mixture of local anesthetics
Although the benefits and risks of neonatal circumcision continue to be debated, it remains a commonly performed surgical procedure in the United States. In 1995, the National Center for Health Statistics estimated that approximately 64% of male neonates underwent circumcision (personal communication, National Center for Health Statistics, August 1997).
Increasingly, the pain of unanesthetized circumcision is being recognized as a significant complication resulting in short-term physiologic changes and short- and possibly long-term behavioral changes.1-9 The American Academy of Pediatrics (AAP) Section on Anesthesiology recognizes the importance of anesthesia and analgesia for infants undergoing painful procedures stating that “the decision to withhold such medication should be based on the same criteria used for older children.”10 Published before new efficacy and safety studies on pain relief in circumcision, both the 1989 AAP Task Force on Circumcision statement and the 1992 American College of Obstetricians and Gynecologists (ACOG)/AAP Guidelines For Perinatal Care acknowledge the usefulness of local anesthesia for pain control during neonatal circumcision, but state that further safety data is needed before its routine use is recommended.11 12 Conversely, the American Academy of Family Physicians (AAFP), in its 1996 statement about circumcision, clearly acknowledges that the procedure is painful and that dorsal penile nerve block (DPNB) alleviates the associated pain and carries minimal additional risks to the infant.1
To date, no published studies have addressed rates of anesthesia or analgesia with neonatal circumcision by a national sample of US physicians. One unpublished survey of US obstetricians, family practitioners, and pediatricians suggests that rates of use are low; only 46% of those surveyed reported the use of analgesia/anesthesia for circumcision.13 Anecdotal accounts and two studies, one of family physicians in Oregon and another of pediatricians and family practitioners in Ontario additionally suggest that most neonates undergo circumcision without anesthesia or analgesia.14 15
Training practices with regard to neonatal circumcision and pain relief in US residency programs are largely unknown, with published reports limited to small studies of individual programs.16 In the United States, pediatricians, obstetrician-gynecologists, and family practitioners are most likely to perform neonatal circumcision. Current Residency Review Committee recommendations for pediatrics state that residents should be exposed to neonatal circumcision.17Residency guidelines from the Ambulatory Pediatric Association recommend proficiency in neonatal circumcision and in penile nerve block.18 Neither the “Program Requirements for Residency Education in Family Practice” as written in the 1996–1997 Graduate Medical Education Directory nor the “Recommended Core Educational Guidelines for Family Practice Residents” presented by the American Academy of Family Practitioners have specific recommendations regarding the training of family practice residents in circumcision or anesthesia for the procedure.19 20 The Council on Residency Education for Obstetrics and Gynecology makes only a rudimentary statement in its guidelines that circumcision should be performed according to the wishes of the parents, and the Residency Review Committee requirements for obstetrics and gynecology do not address circumcision or anesthesia for the procedure.21 22
Recognizing that the curriculum content of residency programs is likely to predict future US medical practice, we surveyed residency directors of accredited pediatric, family practice, and obstetrics and gynecology programs to assess current training practices with regard to neonatal circumcision and pain relief for the procedure.
A list of pediatric, family practice, and obstetrics and gynecology residencies was compiled from the 1994–1995 Graduate Medical Education Directory of the American Medical Association. This listing is recognized as the official list of residency training programs accredited by the Accreditation Council for Graduate Medical Education. A survey was mailed to directors of all accredited United States programs in pediatrics, family practice, and obstetrics and gynecology. Those programs failing to respond to the first mailing received a duplicate mailing approximately 2 months after the initial contact. The forced choice and short answer survey was designed to gather information about curriculum, teaching methods, and residents' experiences in the newborn nursery. Directors were asked to seek information from other faculty as needed in completing the survey. The data in this report represent a portion of the data collected in a larger survey of residents' newborn nursery experiences.
Pediatric and family practice surveys were mailed in July of 1995 with a follow-up mailing in September of 1995. Surveys mailed to pediatric and family practice training programs were identical. An obstetrical version of the survey was developed with an initial mailing to residencies in November of 1995 and a second mailing in January of 1996. The written survey consisted of forced choice, categorical response, and short answer questions and required approximately 15 to 20 minutes to complete. Questions regarding circumcision and pain relief were identical in both versions of the survey. Surveys for all three residencies were completed during and are applicable to the 1995 to 1996 academic year.
Data were entered and analyzed using SPSS for Windows23 and Epi Info version 6.24 For purposes of some analyses, multiple response answers were collapsed to reflect the direction of the response or reduce the number of categories (eg, use of local anesthesia, topical anesthesia, oral analgesia, or comfort measures were reduced to use of any method of pain relief). Programs were categorized by region of the country using the same schema used by the National Center for Health Statistics.25 Residencies in Puerto Rico are not included in geographic analyses because of the small numbers of such programs.
Univariate analysis was used to describe the study sample. Bivariate analysis was used to evaluate potential associations between program/community characteristics, and residency training practices and curriculum content with regard to neonatal circumcision and pain relief for the procedure. Statistical tests used for analyses included: Student's t test for normally distributed continuous data, the Wilcoxon two-sample test for nonnormally distributed data, χ2 tests to evaluate differences in proportions,26 and Mantel-Haenszel χ2 test for proportional differences in stratified analyses.27
Response rates were similar among the program types with 83% (186/223) of pediatric, 72% (295/411) of family practice, and 71% (199/280) of obstetrical directors responding to the survey. Response rates did not vary significantly within or across medical specialties with regard to geographic location. The overall response rate was 74% (680/914). The respondents to this survey represent programs in 480 out of 615 different teaching institutions to which surveys were mailed.
Pediatric residents were less likely than family practice (OR, 0.04; 95% CI, 0.02–0.08) or obstetrical (OR, 0.14; 95% CI, 0.08–0.23) residents to be taught circumcision. Only 43% (80/186) of pediatric programs versus 95% (279/295) of family practice and 84% (168/199) of obstetric programs taught circumcision.
Given the nonspecific training recommendations for pediatric, family practice, and obstetrical residents regarding circumcision, we asked directors to rate the influence of a variety of factors in determining which specialties perform neonatal circumcision in their institution. Physician training was most frequently cited as an important determinate in this process (82%), followed by local tradition (ie, custom) (67%), quality of care (53%), convenience (43%), and reimbursement (20%).
Community practices with regard to circumcision were associated with teaching practices in local pediatric and obstetrical residency programs. In communities where pediatricians perform some proportion of circumcisions, pediatric residents were more likely (OR, 39.0; 95% CI, 14.3–110.6) and obstetrical residents were less likely (OR, 0.10; 95% CI, 0.03–0.28) to be taught circumcision in comparison to pediatric and obstetrical residents in programs in which community pediatricians do not perform circumcision. Similarly, obstetrical residents were more likely to be taught circumcision (OR, 79.0; 95% CI, 22.4–306.4) if obstetricians in the community perform circumcision. Training of family practice residents, however, did not seem to be associated with community practices.
There also were significant regional differences in circumcision training for pediatric and obstetric residents. Compared with pediatric residency programs in the northeast, where 28% of pediatric programs train residents to perform neonatal circumcision, significantly more pediatric programs in the southern (55%; OR, 3.3; 95% CI, 1.4–7.9) and western (68%; OR, 5.9; 95% CI, 2.0–18.2) United States teach circumcision. Conversely, obstetrical residents in the western United States were significantly less likely (59%; OR, 0.1; 95% CI, 0.02–0.4) than northeastern obstetrical residents (93%) to receive training in neonatal circumcision. Training practices for pediatric residents in the midwestern United States and for obstetrical residents in the midwestern and southern United States did not significantly vary from patterns in the northeast. Regional training differences were not evident in family practice programs.
Residents in each specialty were predominately instructed by faculty from their own specialty (Table 1). The Gomco clamp method of circumcision was the most frequently taught, followed by the plastibell and the Mogen clamp for pediatric, family practice, and obstetrical residency programs.
In programs teaching neonatal circumcision, the topic was addressed in the formal curriculum by 68% (54/80) of pediatric programs and 60% (167/279) of family practice programs. Analgesia/anesthesia for circumcision was addressed by 58% (46/80) of pediatric programs and 43% (119/279) of family practice programs. We do not have data for obstetrical programs regarding written curriculum content with regard to circumcision or pain relief.
In an attempt to characterize the clinical experiences of residents with regard to neonatal circumcision and pain relief for the procedure, we asked residency directors to estimate rates of neonatal circumcision and rates of use (use by any practitioner performing procedures) of various analgesia and anesthesia techniques in their institutions. Reported rates of circumcision from pediatric (68%), family practice (74%), and obstetrical (68%) programs were slightly higher than current national rates of approximately 64% percent (personal communication, National Center for Health Statistics, August 1997). (It should be noted that rates from the National Center for Health Statistics are based on hospital discharge data that may result in falsely low rates.)
Of the 680 programs surveyed, 59% reported some use (use by any practitioner) of local anesthesia (DPNB or local infiltration of the prepuce), 22% some use of topical anesthesia [eutectic mixture of local anesthetics (EMLA, Astra USA, Inc, Westborough, MA) or lidocaine cream], 6% reported some use of oral analgesia (acetaminophen or concentrated sucrose solution), and 31% reported some use of comfort measures (swaddling, pacifiers, or sucrose-soaked pacifiers). It is important to note that these percentages indicate only that the method in question was used for some proportion of neonatal circumcisions in the reporting institution.
Regional variations in resident education about analgesia and anesthesia techniques were evident with regard to instruction in: 1) any method of pain relief; and 2) specifically for DPNB/local anesthetic use. Significant regional variations were noted for all programs combined and within individual specialties (Table2). With regard to instruction in the use of topical anesthetics, oral analgesia, or the use of comfort measures, no such differences were noted.
Similar to instruction rates for circumcision, pediatric residents were significantly less likely than obstetrical residents or family practice residents to receive instruction in anesthesia and analgesia methods for use with neonatal circumcision (P < .01). Only 35% of pediatric programs (66/186) as opposed to 49% of obstetrical (98/199) and 75% of family practice programs (220/295) provided instruction about analgesia/anesthesia methods. If, however, only those programs that teach residents to perform circumcision are considered, pediatric programs (84%; OR, 3.4; 95% CI, 1.7–7.1) and family practice programs (80%; OR, 2.7; 95% CI, 1.7–4.2) were significantly more likely than obstetrical programs (60%) to instruct residents about pain relief methods.
Forty percent of residency programs that provided instruction in neonatal circumcision taught more than one method of anesthesia or analgesia. Disturbingly, 26% of programs teaching circumcision did not teach the use of any pain relief technique. Local anesthetic techniques and topical anesthetics have been shown to be effective pain relief methods for neonatal circumcision.16 28-37 Although concentrated oral sucrose is known to alleviate pain during invasive procedures, we consider oral sucrose, acetaminophen, and comfort measures to be ineffective sole methods of providing pain relief for the intraoperative pain of circumcision.6 38-41 If such methods of analgesia are excluded, 71% of programs provided instruction in effective methods of pain relief (local or topical anesthetics).
Instruction in specific anesthesia and analgesia techniques varied significantly between program types. In programs teaching circumcision, comparison between specialties was made for each method of pain relief. Pediatric and family practice training programs were more likely than obstetrical programs to teach local anesthesia, oral analgesia, and comfort measures. Family practice programs, however, were less likely than obstetrical programs to teach the use of topical anesthesia. There were few differences between pediatric and family practice programs with regard to pain relief instruction, although pediatric programs were approximately twice as likely to teach comfort measures (Table3).
This is the first study to provide national data about pediatric, family practice, and obstetrics and gynecology residency training regarding neonatal circumcision and pain relief. Significant variations in resident training are evident regionally as well as within and across medical specialties. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States.
This study has several limitations. Information about rates of circumcision and usage of anesthesia and analgesia was obtained as estimates by residency directors. No empirical data were used to verify these rates and they should be viewed as estimates. The response rate obtained in this survey makes it unlikely that the data were influenced by reporting bias. The authors of this study, however, were surprised that the rates of anesthesia/analgesia use were as high as reported and acknowledge the small but real chance that our results are subject to such bias. Results of this survey are supported by an as yet unpublished national survey of practicing pediatricians, obstetricians, and family practitioners by Stang et al.13 Although that study is limited by a 51% response rate, it demonstrates findings with regard to specialty responsibility for circumcision and specialty use of anesthesia/analgesia that reflect this survey's data regarding resident training.
Additionally, these data provide information about training and clinical practices at teaching institutions and are not necessarily representative of community practices. Although we assume that curriculum content for residencies will predict future clinical practice, we have no empirical data to verify this assumption. We as faculty in various specialties, however, design and implement curriculum changes based on this very assumption. Despite these limitations there are several important findings about current resident training regarding neonatal circumcision and anesthesia and analgesia.
Circumcision remains a commonly performed and taught surgical procedure in US family practice and obstetrical residency training programs. Although there are significant regional variations in training within obstetrical and pediatric programs, fewer pediatric programs (80/186) teach neonatal circumcision than do family practice (279/295) or obstetrical programs (168/199).
Many residency directors reported that physician training (82%) and local custom (67%) exert significant influences on which medical specialty performs circumcision in their community. These observations are supported by other findings in this survey including the association of community practices (eg, which specialties perform circumcision) with training practices of local residency programs and the observed differences in curriculum between programs located in different regions of the country. Because the majority of graduates begin practice in the same region in which they train, and in light of the current nonspecific training recommendations with regard to neonatal circumcision, the trend for local custom to dictate medical responsibility for the procedure is likely to continue.42
Interestingly, pediatricians and obstetricians seem to split responsibility for neonatal circumcision and this relationship is often reflected in local residency training practices. It is perhaps because the role of the family practitioner encompasses both pediatric and obstetrical responsibilities that the vast majority of family practice programs train residents to perform neonatal circumcision.
Instruction in analgesia and anesthesia for neonatal circumcision was distressingly low with only 71% of residency programs that teach circumcision reporting instruction in effective pain relief methods and 26% fail to provide instruction in any method of pain relief. A number of research studies have evaluated analgesia and anesthesia in neonatal circumcision5 6 28 33-38 40 43-45 with DPNB being the most frequently studied method.5 30 32 34-38 43 It has been demonstrated to be both effective and safe for use in neonates.1 16 30 Other methods of analgesia, such as EMLA, although less well studied have been demonstrated to be effective and safe.28 29 33 Orally administered concentrated sucrose may help to alleviate procedural pain and acetaminophen can be used to alleviate postoperative pain.6 39 40 Comfort measures such as sucrose-flavored pacifiers, swaddling, and the use of special physiologic restraints, while not substitutes for effective pain relief, make infants more comfortable intraoperatively.38 40 44
Given the overwhelming evidence that the procedure is painful1 5-7 33 34 36-38 40 43 45-48 and the existence of safe and effective methods of pain relief,1 28 30 32 the continued performance of circumcision without analgesia or anesthesia is especially disconcerting. Although the practice of routine circumcision of male infants is certainly debatable, efficacy and safety data currently available support the use of local anesthesia, concentrated sucrose solutions, and comfort measures.1 10 28 30 32 38 39 Faculty overseeing the performance of residents, regardless of specialty, should insist that adequate pain relief be provided for infants undergoing the procedure and ensure that residents be instructed in the proper and safe use of such techniques.
Although rates of instruction in analgesia and anesthesia for pediatric and family practice programs could be improved, rates of instruction in obstetrical programs were very low. One might argue that the last encounter of an obstetrician-gynecologist with an infant, for whom they perform no further primary care, should not be circumcision. Whereas obstetrics and gynecology is a surgical specialty, the procedure is not technically difficult and is easily mastered by physicians at all levels of training.
It is perhaps because of the cautionary statement by ACOG and because the Residency Review Committee of Obstetrics and Gynecology has failed to address circumcision in its guidelines that rates of training in anesthesia/analgesia for circumcision are so low for obstetrical residents.11 22 With regard to pediatric and family practice residents, either the parent professional organization (AAFP) or training recommendations (Ambulatory Pediatric Association) support resident instruction in local anesthesia, and rates of instruction are substantially higher.1 18
It is important that residency training requirements specify that training regarding neonatal circumcision include effective pain relief methods; specifically training in DPNB and possibly EMLA cream if future studies verify its effectiveness and safety. To date, few research studies have addressed the most effective method or combination of methods for relieving intraoperative and postoperative circumcision pain.38 49 50 Until such research can be completed, simple comfort measures such as swaddling, the use of physiologic restraints, sucrose dipped pacifiers, and postoperative oral analgesics should not be neglected. If all three specialties are to continue to perform this procedure, training requirements in all three specialties should include neonatal circumcision and anesthesia and analgesia for the procedure.
There is a growing consensus that routine or commonly performed procedures should have national standards, not only for their performance, but also for their teaching and supervision.51 52 It is unlikely that a national standard of practice will be achieved with regard to neonatal circumcision and pain relief if current regional and specialty related variations in training are not remedied.
Given the training practices reported in this survey, we predict expanded use of pain relief techniques with circumcision in the future. We must, however, be cognizant of the substantial number of teaching hospitals that do not teach effective pain relief for circumcision. Thus a significant number of infants are likely to continue to undergo this painful procedure without the benefit of pain relief. Although work remains to be done to define the best method or combination of methods for pain relief during neonatal circumcision, we believe an updated statement endorsed by ACOG, AAP, and AAFP supporting the use of some type of anesthesia/analgesia is warranted and would speed this much needed change in neonatal care. Given the frequency of neonatal circumcision national training standards should be developed.
This study was supported by a grant from the Kidd Fund of Rochester General Hospital, Rochester, NY.
- Received March 26, 1997.
- Accepted August 26, 1997.
Reprint requests to (C.R.H.) Department of Pediatrics, Rochester General Hospital, 1425 Portland Ave, Rochester, NY 14621.
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- Copyright © 1998 American Academy of Pediatrics