1. Resident Competency Assessment for Neonatal Circumcision John R. Brill, MD, MPH Brian Wallace, MD Aurora Family Medicine Residency Milwaukee

2. Outline  Introductions  Materials and Resources  Model Construction  Mini-Lecture/Demonstration  Practice/Use of Checklist/Watch videos  Wrap-Up

3. Goals  Participants will learn to construct an inexpensive neonatal genitalia model  Participants will practice performing and evaluating learner skills in circumcision using a competency checklist  Participants will help us eat the leftover cocktails weiners !

4. Materials and Resources  Circ Workshop Preparation  Competency Checklist  AAP Guide to Care of Uncircumsized Penis  On-Line Videos and Resources

5. Model Construction  Insert Dowel into Clay (pointy/angled end out)  Put weiner onto dowel  Optional—press small piece of sponge into clay at weiner/clay junction (for lidocaine)  Cut fingers off of surgical gloves; fold/roll distal end to form a point and cut to make 2-3 mm hole  Place glove finger onto weiner  (Optional) Put rubber band around glove  base of glans

6. Task Not competent Partially Competent Fully Competent Can state contraindications and describe risks, benefits, alternatives and procedure 15 Dorsal Penile Nerve Block 15 Selects and draws appropriate anesthetic, typically 1% lidocaine without epinephrine 15 Injects.5 ml at the 2 and 10 o'clock positions at the base of the penis with slight medial angulation and approximately 0.5 cm beneath the skin surface 15 Gomco Clamp Makes Dorsal crush and slit. 15 Breaks Adhesions 15 Inserts bell over the glans 15 Grasps the edges of the dorsal slit and inserts the arms of the bell through the hole of the plate. 2*13 Pulls the foreskin upwards and adjusts the bell and base 2*13 Assembles and tightens clamp 15 Excises the foreskin 15 Removes clamp, inspects, applies gauze 15 Can state how to manage bleeding and other complications 15

22. Our Results  Pretest2-11/11 items correct, mean 7.8  Competency checklist  12 competent in all 15 items  2 competent in 14/15  1 competent in 13/15  Steps of grasping the foreskin around the bell and passing the bell through the base plate and adjusting most difficult  Significant improvement in perceived knowledge and comfort of performing the dorsal penile nerve block and in using the Gomco clamp.

23. References  Circumcision: Position Paper on Neonatal Circumcision (AAFP) http://www.aafp.org/online/en/home/clinical/clinicalrecs/circumcision.html Retrieved 11/26/06. http://www.aafp.org/online/en/home/clinical/clinicalrecs/circumcision.html  "National Center for Health Statistics." Trends in circumcisions. 4th Oct 2006. Centers for Disease Control. Retrieved 23 Oct 2006 http://www.cdc.gov/nchs/products/pubs/pubd/hestats/circumcisions/circumcisions.h tm. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/circumcisions/circumcisions.h tm  Recommended Curriculum Guidelines for Family Medicine Residents—Men’s Health. AAFP Reprint No. 257, Accessed from http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/ menshealth.Par.0001.File.tmp/menshealth.pdf 10/24/06 http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/ menshealth.Par.0001.File.tmp/menshealth.pdf  Erickson, SS. A model for teaching newborn circumcision Obstetrics & Gynecology 1999;93:783-784  Peleg D, Steiner A. The Gomco circumcision: common problems and solutions. Am Fam Physician 1998;58:891-8.  Care of the Uncircumcised Penis, Elk Grove Village, IL: American Academy of Pediatrics, 1999