Friday, April 21, 2017

The Consultant, plus a word on safety precautions

I've had a few conversations this week with new parents who just had their baby circumcised. They are in New York area - I was not the mohel.

They had questions about what had happened in their son's bris. Mind you - this is pretty atypical. Most people have a wonderful, surprise-free experience, and all goes well. But life is sometimes accompanied by surprises and unexpected turns.

While the photos that were sent to me can't be shared on this blog, I will tell you that there's a reason that I pride myself on the circumcision looking as nice as possible hours after bris. There is often swelling, and not much we can do about that. But aside from the natural swelling, to have the circumcision look palatable to any observer is really an important goal. I've had many parents squeamishly look only to discover, "Hey. That actually looks good!"

The natural redness that is exposed through the act of circumcision is not a frightening vision - you just need to know what to expect.

But when things don't go exactly as they should, you need to understand EVERYTHING that has happened in the circumcision and in what direction a proper healing process should go.

Anyway, these parents had questions. In general, when I get these kinds of calls, while in some cases they are in fact talking to their mohel, in other cases, they don't want to talk to him because they either do not want to hurt his feelings or feel they do not have a sympathetic ear for their concerns. This is why I do believe that parents who do not know the mohel they are hiring should at the very least have a phone conversation in advance of the birth, to be sure they are comfortable with their choice of mohel. 

Some previous blog posts addressing these issues are linked here:

And just FYI - I take many precautions to avoid the issues that I have been consulted to share information. I always tell parents that without actually having examined the baby, my opinion is only worth so much (a picture is good, but it isn't the same).

It's hard enough for some people to circumcise. Should the experience be anything other than as smooth as possible? I don't think so. Here are a few precautions every mohel should be taking. If they are not doing these, I honestly think every parent should look elsewhere.

Monday, March 13, 2017

Perceptions, Perceptions

I should probably learn how to do circumcisions on adults (Rephrase: I know how to do circumcisions on adults. I should learn how to administer local anesthetics and how to suture). What is it about adult men who want to get circumcised, and rather than going the medical route, they seek out a mohel? I've gotten 3 requests this month alone.

Which brings me to the irony of other conversations I've had in the last few weeks. I blogged about one here. And I received another email (from someone out of state who had been in touch with me - no local mohel options available in that town): "we are going to go with a local pediatrician to perform the brit."

And then there was the doctor from a northeastern state who called me today asking if I could advise him on where to train to hone his circumcision skills. Seems he recently watched a bris performed by a certain mohel (he did not identify the mohel) and felt, as a meticulous physician, he could do a better job. And yet, he is turning to mohels to seek that training.

Then there is this article from the Atlantic (goes back to 2015) entitled "Why Non-Jews Are Choosing Jewish Circumcision Ceremonies."

Bottom line: Who is better - a mohel or a physician? A silly question gets a silly answer.

Each mohel - whether medical doctor or simply mohel-specialist - must be judged as a practitioner on his own merit. Either he is good at what he does, or he is not as good as the other guy. Either he works well under pressure or he does not. Either he delivers a beautiful cosmetic result or he does not. Either he is the right person for your family or he is not. Your preference for one type over the other boils down to your perception, but should really boil down to your research.

Make no mistake. Mohels have been doing this for a very long time - much longer than it became "in vogue" for circumcision to be widespread and for doctors to get in to the "circ-service" industry.

Feel VERY comfortable trusting a specialist. Feel free to call me to have a conversation. The doctor I spoke with today was grateful, and I trust you'll find our conversation pleasant and informative as well.

Thursday, March 9, 2017

Metzitzah in the News - Again

Is it a witch hunt? More like "which" as in, "which mohel is responsible for being irresponsible?"

Seriously, this is beyond ridiculous. I have it on high authority that metzitzah is not even required today (Rabbi Herschel Schachter and his reporting on Rabbi Joseph B. Soloveitchik), let alone the permissibility of doing it without a barrier (Rabbi Moshe Dovid Tendler, who has told me it is forbidden to do metzitzah with direct oral contact - not that I was ever doing it that way anyway).

For those of us who are not abandoning the practice of Bris Milah, there is a very simple way to avoid these kinds of stories - completely sterile technique. No exceptions.

Thursday, March 2, 2017

Doing Research Properly

I got an email today from someone with whom I had been in contact for a little while about possibly doing her soon-to-be-born son's bris.

She apologized profusely, saying "my husband wants to try a doctor this time." This was followed by "Hope no hard feelings."

First of all - there are NEVER hard feelings when people are doing research and being open. You must do what you feel is best for your son and your family. And I support that.

However, you must also do RESEARCH and know what you are getting into, no matter who you hire for your son's bris.

This isn't a question of Dr. v. Mohel. A mohel, after all, is a specialist in this field. So being a Doctor doesn't make anyone better at circumcisions than a mohel.

What DOES matter, is how the circumcision is performed.

What METHOD is used

Whether the precaution of a marker is utilized

How much foreskin (see #5 there) and membrane is removed

And, of course, the follow up.

There are MANY fine mohels. There are MANY fine doctor-mohels. The questions every person must ask before hiring either one is, "Have I done my research? Do I know what I want for my son? Have I found the right mohel-specialist for the experience I want my son to have, and the experience I want to have?"

When the answer to all of these questions is YES, then proceed accordingly. Until that time, there is work to be done as a parent. Best of luck!!

Friday, February 10, 2017

Parental Vigilance

Dear Parents,
I can not emphasize this enough. (I've written about this before)

After the bris is over, and I am finished with MY job, YOUR job kicks in.

So let me explain to you what MY job is, so you understand what your job is and why your job is very important.

My job:
1. To get as even and aesthetically pleasing circumcision as possible. To achieve this I use a surgical marker to guide the incision
2. To make sure I take off the correct amount of foreskin, which actually has a small range of flexibility, and not to take off too much.
3. To make sure that beyond removal of foreskin there isn't an excessive amount of membrane left behind, which could give the baby the appearance of being uncircumcised.
4. To control the bleeding and make sure the baby is well on the road to healing and recovery post circumcision
5. To give you information about how things will look over the next few days and weeks
6. To give you instructions for after-care and what your job is over the next few days and weeks

Which leads us, most obviously to YOUR job
1. To follow the instructions for after-care (see 6 above)
2. To be in touch with ANY and ALL questions
3. To keep the diaper area as clean as you can during the healing process
4. Over the next few days, weeks, sometimes months, to avoid the Fusion Concern
5. To be aware of the Chubby Baby Syndrome

It boils down to this.
After circumcision, the body realigns the penis and restructures itself in the absence of the foreskin. Depending on how the circumcision goes, there may be a ring of leftover membrane between the incision spot and the glans, or there may be no membrane there at all. IN EITHER CASE, because the baby spends so much time on his back, and especially if he becomes chubby over time, the glans has a tendency to sink a little back into the membrane or the shaft and stay there, giving the baby a partially (as opposed to completely) circumcised look.

Which is where YOU come in.
Every time you change his diaper, every time you give him a bath, make sure that the glans is free and clear of anything that is below it. It really is a very simple massage every time his diaper is open, until time (could be weeks or even months) indicates that no intervention is required any more.

In simple terms - I met an adult recently whose parents did not take care of this when he was young. After a brief consultation I suggested he speak to a urologist, and he ended up having corrective surgery. This could have been avoided if his parents had been vigilant!

Tuesday, January 31, 2017

Being Prepared for Out of the Ordinary Circumstances

As much as possible, I try to meet the baby a couple of days before the bris. It gives me a chance to speak with his parents face to face, and it also helps prepare me in terms of what to expect with the technical side of the circumcision.

In other words, not all male anatomy develops in the same way.

In examining a baby recently, I noticed that the glans was extremely close to the body in its natural state, while when pushed on the two sides of the shaft to elongate the penis, the entire organ seemed to emerge. I have seen situations in which the entire penis was inside the body, requiring a reconstructive surgery to draw everything out - which I was later privileged to observe in the operating room, under the skilled hands of one of the finest surgeons I have ever seen in action. But this was not so extreme at all, as everything was external, it just seemed pulled by nature to be less prominent.

I explained to the parents what I needed to do - to be as precise as possible in marking the foreskin, to avoid this problem, and to see to it that everything looks right after the bris.

As luck would have it, the marking went perfectly, the incision was precise, and it looked like all was going to be smooth sailing. However, as sometimes happens, I noticed afterwards that there was extra membrane, necessitating this quick touch-up.

But it turned out to be so much more. What is often a tiny piece of membrane tissue turned out to be a significant amount of below the foreskin webbing. It kept emerging, causing me to realize what was pulling the glans almost into the belly itself. 

Thankfully, it seems this was it. When it was all removed, the baby looked like every other baby post-bris, and the internal issue he had that was pulling his penis, making everything so retracted, was resolved. 

As I told the father, if we hadn't taken care of this now, he may have developed phimosis or the inability to have a complete erection, with internal membranes pulling him away from being able to do what he'll need to do one day.

Baruch Hashem, a good ending and a happy story. It's a warning to mohels to be humble and to remember that not everything is "textbook" every time. It is also a reminder to parents that mohels must treat each case as if it is the most important thing he is doing now. I have seen cases similar to this one in which the circumciser erroneously removed ALL shaft skin because he thought that was what was required due to the unique anatomy.

Thankfully that wasn't the case here, wasn't the approach tried nor the results achieved (which were actually quite impressive)!

May we be blessed to deal positively with all new situations, and be guided to always fulfill the mitzvah of bris milah properly, including in non-textbook circumstancs. 

Friday, December 9, 2016

The Blessing We Don't Wish on Anyone

I got a call for a bris which included the question, "Our baby was sent to the NICU. Will this delay the bris?"

The proper answer to this question is "For what reason was he sent to the NICU?"

If the baby was brought there for observation and as a precaution because the doctors were concerned about something, then the next question follows, "Did they just observe and run tests? Or was any intervention required?" Because if he required antibiotics, then the bris date would likely be pushed off.

In this particular case, as the doctors did nothing but observe, they were just being cautious out of a concern, which was likely based on a need for the baby's system to mature ever so slightly, which is not a sign of illness, but just a simple sign of normal development.

So I told the mom, I think the bris will be taking place on time.

Her response: "So when will the bris be?"

If she called me Tuesday, and her baby had been born the previous day, I told her, "This coming Monday. In six days." To which she responded, "Oh boy..." indicating there is not enough time to prepare.

Of course, there is enough time, it's just overwhelming. But she is coming from a situation where her previous son (same mohel as this time!) had some issue which caused his bris to be delayed a week. Her most recent memory of bris preparation is having TWO WEEKS from birth until the bris.

Since the bris typically takes place on day-8 of life, from one perspective it is a blessing to have a little more time to prepare for the celebration.

On the other hand, that "blessing" usually means there is something wrong with the baby that is causing the bris to be delayed. And any kind of medical situation is not the kind of blessing we wish for a newborn.

Things happen. Hopefully the doctors are amazing at what they do. And all little boys should be able to have their brisses in a timely fashion.

Thursday, December 1, 2016

Blogging Mohel Lives Life as well!

I've noted before that sometimes life gets in the way of blogging. Thank God, between the Jewish holidays, moving, Thanksgiving, and just plain business as a mohel and a husband and father (and rabbi of a synagogue!), things have been good, and quite busy!

One day we'll begin exploring new topics here. In the meantime, please check out the Welcome Message and the All You Need to Know Blog Post.

I look forward to hearing from you! Best of luck with your pregnancy, birth, and with your baby!

Friday, October 7, 2016

Holiday Season

This time of year always brings with it frantic calls from people whose timing has them needing to schedule a bris on a holiday.

I got a couple of calls for Rosh Hashana bris.
I'm doing a bris on Erev Yom Kippur (YK Eve).

And I am sure that come this Monday and Tuesday I will get calls seeking my availability for the holiday of Sukkot.

Alas, unless you come to me for the holiday (and you are always welcome!) I serve as a pulpit rabbi and cannot leave for the holiday. :(

Wishing everyone well, Shana Tova, and a year of healthy babies!!

Sunday, September 4, 2016

The Bedside Manner Mohel

After my post-bris visit (which SHOULD BE a given with every mohel, but is not), I spent about 20 minutes talking to the baby's father, who gave me the whole history of how they found me. [a.k.a. "best kept secret in Florida" - flatterer]

There are a few mohels who have been in Florida for a very long time, such that "everyone" in certain circles uses them. In fact, before calling me, this couple called my friend Rabbi Howie Seif (the Knife), who was unable to serve because he was leaving town, but he gave them my name.

I do the same for him when I get calls when I am away.

But even Rabbi Seif wasn't the first mohel they lined up. All of their friends use a certain mohel, about whom they heard - from those very same friends - that his bedside manner is not what they need. Breaking the mold of just calling the guy everyone hires, they called around, got a few names, did their research and eventually got confirmation from a friend about me.

The phone calls: Baby's grandfather called. We spoke. Heavy focus on bedside manner being important.
Then the baby's father spoke. Again, assurances that the kind of bedside manner they'd be getting is what they are looking for.

And after the fact, after I spend 1/2 hour in their home the day before the bris, plenty of time at the bris (in minutes before and after) explaining what will happen, what did happen, and of course in caring for the baby, as well as another visit to their home to see the baby a few hours after the bris (to remove his bandage and make sure all was well), the father of the baby told me, "You were just what we needed."

I wish for all parents of a boy to have a similar experience as this one. Many mohels have a wonderful bedside manner, and give the time to the parents and explain everything, and address their concerns. 

Some, obviously, do not. Which is unfortunate. 

The bris is a holy act, a defining experience of the Jewish people for close to 4,000 years - in fact, the OLDEST TRADITION WE HAVE. Of course it should be joyous, of course it should be celebrated properly, and of course it is something we should be proud of and we should never need to defend it.

But for the parents of the baby, there is a natural tension and unease. Because the baby is, after all, undergoing surgery, and we want that to go well, and for the baby to be in a good place as far as his healing is going, as quickly as possible after the bris. And the parents sometimes need to be coddled through the experience, because as much as we want to do it, it doesn't make the experience an easy one.

Enter the Bedside Manner Mohel. And all will be OK!!