Circumcision-Pain Tips to Residents Spurned by Attendings

ROCHESTER, N.Y., July 20 -- Those pointers that residents get about avoiding the pain of infant circumcision aren't always taken to heart by the attendings who do the teaching.

Nearly all family practice, ob-gyn, and pediatrics residency programs in the United States that teach trainees how to perform circumcision also teach circumcision anesthesia methods, researchers here have found. But that's only 84% of the story.

But when it comes to giving anesthesia to newborns about to go under the circumcision knife, the attendings who teach the residents don't always practice what they preach, according to pediatrician Daniel Yawman, M.D., M.P.H., of the Rochester (N.Y.) General Hospital, and colleagues, in the July-August issue of Ambulatory Pediatrics.

They surveyed residency programs throughout the United States about whether they taught circumcision, and if so what pain relief techniques they also practiced.

Eighty-two percent of all programs surveyed taught circumcision (family practice: 95%, ob-gyn: 89%, and pediatrics: 49%). They found that 97% of all the responding programs that taught circumcision also taught administration of topical or local anesthetics, but only 84% of these programs said that the anesthesia were always or frequently used for circumcision cases.

Still, pain-relief circumcision practices have improved. In 1995 and 1996, only 84% of all pediatric residency programs surveyed taught any form of pain relief for use with circumcision, and a survey of attending physicians conducted during the same period found that only 45% of attending physicians used any form of analgesia or anesthesia for circumcision.

"This is a large leap ahead in how physicians are trained to perform circumcisions, which at one million annually, is the most common surgical procedure," Dr. Yawman said. "There is no reason a newborn should have to endure the pain of circumcision without a local or topical anesthetic."

He and his colleagues sent a 9-item questionnaire to the program directors (or their appointed surrogates) of all U.S. resident programs in family practice, ob-gyn, and pediatrics.

The questionnaire asked whether residents were taught how to perform circumcision, whether they used anesthesia, and if so, which of the following forms of anesthesia, if any, they used:

• Local anesthesia using ring block
• Local anesthesia using dorsal penile nerve block
• Topical anesthesia such as EMLA (eutetic mixture of local anesthesia) or lidocaine cream
• Pacifier or gloved finger to suck on
• Oral doses of sugar solution
• Inviting parents to comfort infants
• Physiologic restraints or swaddling
• Other

A total of 86% of all programs returned the survey, and of these 82% said they taught circumcision. Of these programs, 95% said they taught the use of the Gomco clamp, 38% taught the Mogen clamp, and 37% taught the use of the Plastibell circumcision device (some programs taught the use of multiple devices).

Although there is evidence to suggest that the Mogen clamp technique may be less painful than either the Gomco clamp or Plastibell, the Gomco clamp was the most widely taught method, the investigators noted.

Of the 669 programs that taught circumcision, 97% (648/669) said they taught the administration of either a local or topical anesthetic, compared with 71% of such programs reporting the use of anesthetics in 1998 (P<0.001).

"However, of these same programs that taught circumcision, the anesthetic techniques were used frequently or always in only 84%," the authors wrote.

This was despite the fact that since 1999, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics have called for the universal use of local or topical anesthetics to provide pain relief for neonatal circumcision, the authors noted.

In searching for an explanation as to why nearly all residents who learned to perform circumcision were taught anesthesia techniques but a significant number of attendings who did the teaching don't follow through themselves, the authors said.

"These physicians may recognize that their role as instructors includes teaching recommended effective analgesic technique, but may not have changed their own practice habits," the investigators wrote. "Previous research documented that the lack of familiarity with the use of analgesics in newborns, and with the dorsal penile block in particular, were the most common reasons cited for lack of analgesic use for circumcision by attending physicians."

The authors noted several limitations to the study.

• "The most important of these is that surveys rely on accurate reporting by respondents. Respondents may be aware of the current recommendations that effective analgesia for circumcision should be used, and therefore overestimate how frequently proper techniques are taught in their programs. Furthermore, the responses are based upon one person's opinion regarding the practices of an entire department.
• "These data provide information about the practices at teaching hospitals and may not accurately reflect practices in community settings."