1. Ambulatory Neonatal Circumcision Clinic in a Family Medicine Residency
Kyle Fletke MD
Cone Health Family Medicine Residency
Introduction
Equipment
Resident Survey
Discussion cont.
Circumcision, the surgical removal of the foreskin from the human penis, is one of the most common neonatal procedures performed worldwide. According to the American College of Pediatrics, the current evidence indicates that the benefits associated with neonatal circumcision outweigh the potential risks.1 Benefits include the prevention of urinary tract infections, penile cancer, and decreased transmission of STIs including HIV. In light of these findings the AAP supports neonatal circumcision for families that are interested in the procedure due to religious, cultural, or personal preference.
Medicaid currently does not cover the cost of circumcision in the state of North Carolina. Therefore, many families are unable to afford this procedure at the time of birth, often costing upwards of $500 in the hospital setting. In an effort to improve patient care we have implemented an ambulatory circumcision clinic at the Cone Health Family Practice Residency in Greensboro, NC. In this setting we are able to offer neonatal circumcision at a fraction of the cost.
Resident physicians are exposed to neonatal circumcision during medical school and residency across a variety of settings. However they often do not gain enough exposure to competently perform this procedure after residency. In an effort to improve education, resident physicians are actively involved in performing neonatal circumcision in our clinic.
The following presentation will focus on the required equipment, initial costs, and clinic scheduling used to implement the circumcision clinic in our residency program.
In May 2015, the twenty four residents of the Moses Cone Family Medicine Residency completed a survey to evaluate their previous experience with neonatal circumcision and interest in learning the procedure. The results of the survey are summarized in Table 1. Note that the circumcision clinic in our office was started in March 2015.
The residents felt mildly comfortable discussing the risk/benefits and managing the after care of neonatal circumcision with an average score of 3.75 and 3.2 respectively, based on a 5 point Likert scale. However, in the ambulatory setting they are directly involved in counseling the parents about the procedure and discussing home care at the time of discharge. Furthermore, they are encouraged to follow up with the patient in 5-7 days. Over time this would likely improve their comfort with obtaining consent and counseling parents on the post-procedural care of neonatal circumcision.
The neonatal circumcision clinic also represents an opportunity to provide a medical service to a disadvantaged medical population. As stated in the introduction, Medicaid does not cover the cost of neonatal circumcision in the state of North Carolina. As such many patients choose to forego a procedure that has direct ties to their ethnic and cultural heritage. The Cone Health Family Medicine Residency exists to train well rounded family medicine residents, therefore we are able to provide neonatal circumcision at a fraction of the cost compared to the hospital setting. The procedure is offered to our patient population as well as the local health department and private practices. As the clinic expands we hope to provide neonatal circumcision to a lager patient population.
Discussion
The neonatal circumcision clinic at the Cone Health Family Medicine Residency represents an opportunity to expand the procedural skillset of resident physicians. At the time of the survey in May 2015, eighteen of twenty two residents (only 22 of the 24 responded to this question) planned to care for neonates in their future practice. Out of all twenty four residents only 11 planned to perform neonatal circumcision in their future practice, however this number increased to 16 if they would have/will receive adequate training in the procedure during their residency training. Based on the survey results it appears that there is a substantial interest in learning the procedure. Furthermore, the average number of completed/observed neonatal circumcisions across all levels of training was less than ten. There is not a set number of completed procedures that defines competence in completing neonatal circumcision, however less than 10 completed procedures likely represents an inadequate number to achieve competency. The survey data supports this conclusion as the average level of comfort with completing a neonatal circumcision, based on a 5 point Likert scale, was only 2.7 across all levels of training. Based on this data is can be concluded that a circumcision clinic in the ambulatory setting would help to improve competence and comfort in this procedure. Additionally, the majority of residents have only completed the procedure in the hospital setting. As such the resident oftentimes is not directly involved in discussing the risks/benefits or the post-procedural care of the procedure.
Resident Comments
“I think if the circumcision clinic had been available when I was an intern and I had established a greater comfort level during that year, I would have been more likely to develop the skill and do it in clinic.” PGY-3
“I would like to offer that surface. I am much more comfortable with them now that I have worked with Dr. Fletke in clinic and performed 3 on my own.” PGY-3
“Absolutely would if I had more training. They are a relatively easy procedure to perform that pays decently well.” PGY-2
“Depending on the future practice, I think it is a good procedure to be skilled at performing for already established or even new patients that present just for the procedure.” PGY-1
“Still deciding ultimately, but would like to be able to offer my patients the option of not having to go to someone just for that procedure” PGY-1
Clinic Template
Time is allotted at the start of clinic for resident teaching. Topics discussed at this time include: indications for the procedure, risks of the procedure, how to perform a dorsal penile nerve block, how to perform a neonatal circumcision with a Gomco clamp, and aftercare. The infant remains in office for 45 minutes following the procedure to ensure adequate hemostasis. During this time home care instructions are discussed with the parents/guardians.
References
1. Pediatrics Vol. 130 No. 3 September 2012 pp