July 9, 2022

1400H - 1500H
Empowerment Via Zoom

Health Issue objective - for

Course– laypeople to have an
Low-value understanding of the
Medical Care: issues of
CIRCUMCISION CIRCUMCISION as a
Low-value
Operation.
 Empowerment ROJoson PEP Talk

Health Issue objective - for I have a Patient

Course– laypeople to have an Empowerment
Low-value understanding of the Program in which I
Medical Care: importance of Low- like to empower the
CIRCUMCISION value Operation: lay people or
CIRCUMCISION. patients to take
control in the
management of
their health.
 There are 3 courses
in the PEP Talk.
I completed the Core
Course on October 9,
2021.
 From October 23,
2021 onwards, I have
been tackling Health
Disorder and Health
Issue Courses. This
may take 3 years or
longer.
 My PEP TALK today
is entitled: Low-
Empowerment value Operation:
Health Issue objective - for CIRCUMCISION.
Course– laypeople to have an
Low-value understanding of the This is part of the
Medical Care: issues of Health Issue Course.
CIRCUMCISION CIRCUMCISION as a
Low-value
Operation.
 Contents of PEP TALK on Low-value Medical Care:
Health Issue CIRCUMCISION
Course– • What is a circumcision?
Low-value • What are the different types of circumcision?
Medical Care: • What is a low-value medical care? low-value
operation?
CIRCUMCISION • Why is male circumcision considered as a low-
value operation?
• What are tips on avoiding or reducing
circumcision as a low-value or unnecessary
operation?
 • What is a circumcision? What are the different
Health Issue types?
Course–
Low-value
Medical Care:
CIRCUMCISION
 • What is a circumcision? What are the different
Health Issue For this PEP Talk, I
types?
will focus on MALE
Course– CIRCUMCISIONS.
Low-value
Medical Care: First of all, strictly speaking, there are two types However, allow me
of circumcision based on the sexual organs –
CIRCUMCISION MALE and FEMALE circumcisions. to give you first a
brief idea on
FEMALE
Male circumcisions are far more frequently done
CIRCUMCISIONS.
than female circumcisions.
 • What is a circumcision? What are the different
Health Issue types?
Course–
FEMALE circumcisions
Low-value
Medical Care: • Female genital cutting
CIRCUMCISION • Female genital mutilation (FGM) – WHO

• Prevalence:
• affects over 200 million women worldwide
in 30 countries, with an additional three
million women and children at risk annually
(WHO, 2018)
 • What is a circumcision? What are the different
Health Issue types?
Course–
Low-value
Medical Care: FEMALE circumcisions – FEMALE GENITAL
CIRCUMCISION MUTILATIONS (FGM)
• any procedure that intentionally alters or
causes injury to the female genital organs for
non-medical reasons.

• carried out from as early as infancy until age

15, although in some areas it is delayed until
just prior to marriage.
 • What is a circumcision? What are the different
Health Issue types?
Course–
FEMALE circumcisions – FEMALE GENITAL
Low-value MUTILATIONS (FGM)
Medical Care: 4 types of circumcision described by the WHO.
• Type 1 involves excision of the prepuce, with or without
CIRCUMCISION excision of part or all of the clitoris.
• Type 2 involves the partial or total removal of the clitoris and
the labia minora.
• Type 3, also called infibulation, includes removing part or all of
the external genitalia and approximation of the remnant labia
majora. This can result in a small neointroitus and the creation
of a covering seal over the urethra and/ or vaginal opening.
• Type 4 includes all other harmful procedures to the genitalia,
including scratching, pricking, and others not specified in the
first three types.
 • What is a circumcision? What are the different
Health Issue types?
Course– FEMALE circumcisions – FEMALE GENITAL
Low-value MUTILATIONS (FGM)
CHRONIC
Medical Care: ACUTE COMPLICATIONS COMPLICATIONS
CIRCUMCISION • Hemorrhage • Urinary tract
• Pain infections
• Septic shock • Vaginal infections
• Genital edema • Difficult
• Infections, abscesses labor/delivery
• Urinary retention • Dyspareunia
• Broken bones • Decreased sexual
• Death satisfaction
 • What is a circumcision? What are the different Personally, I don’t
Health Issue types? know if female
Course– circumcision is being
Low-value FEMALE circumcisions – FEMALE GENITAL practiced in the
Philippines.
Medical Care: MUTILATIONS (FGM)
Hopefully NOT.
CIRCUMCISION • FGM is a cultural practice performed
predominantly in Africa, the Middle East, and
Asia.  If being done, it is a
• Many in the Western World consider FGM to low-value operation
be a human rights violation and there have (HARMS with no
been international efforts to eliminate the medical benefit;
practice.   unnecessary cost;
waste limited
healthcare resources.
 • What is a circumcision? What are the different
Health Issue types?
Course–
Low-value
Medical Care: MALE circumcisions – TULE or TULI
CIRCUMCISION
• Frequently done in the Philippines
• Frequently done for cultural and religious
reasons more than medical reasons
• For Muslims and Jews – religious reason
• For Christians (St. Paul already said
circumcision is not needed for salvation) –
more of cultural reason and peer-pressure
 • What is a circumcision? What are the different
Health Issue types?
Course–
MALE circumcisions – TULE or TULI
Low-value
Medical Care: • a surgical procedure to cut or remove partially
CIRCUMCISION or totally the foreskin of the penis. Excision, total using GOMCO,
Dorsal slit Excision, partial or total in newborns
 • What is a low-value medical care? low-value
Health Issue operation?
Course–
Low-value
Medical Care:
CIRCUMCISION
 • What is a low-value medical care?
Health Issue
Course– Low-value medical care is defined as medical
care or services that provide little or no benefit
Low-value to patients, have potential to cause harm, incur
Medical Care: unnecessary cost to patients, or waste limited
CIRCUMCISION healthcare resources.
 • What is a low-value medical care? NO or LITTLE
Health Issue BENEFIT is in terms
Course– Low-value medical care is defined as medical of effectiveness,
care or services that provide little or no benefit thus, NOT effective
Low-value to patients, have potential to cause harm, incur
Medical Care: in the goal of the
unnecessary cost to patients, or waste limited medical service
CIRCUMCISION healthcare resources. rendered.
 • What is a low-value medical care? POTENTIAL TO
Health Issue CAUSE HARM is in
Course– Low-value medical care is defined as medical terms of RISKS for
care or services that provide little or no benefit UNWANTED side
Low-value to patients, have potential to cause harm, incur
Medical Care: effects or adverse
unnecessary cost to patients, or waste limited effects,
CIRCUMCISION healthcare resources. complications, and
even death with the
medical service
rendered.
 • What is a low-value medical care? UNNECESSARY COST
Health Issue TO PATIENTS is in
Course– Low-value medical care is defined as medical terms of money
care or services that provide little or no benefit spent by patients
Low-value to patients, have potential to cause harm, incur
Medical Care: and families for the
unnecessary cost to patients, or waste limited medical service
CIRCUMCISION healthcare resources. rendered which is
considered
UNNECESSARY.
 • What is a low-value medical care? WASTE LIMITED
Health Issue HEALTHCARE
Low-value medical care is defined as medical RESOURCES is in terms
Course–
care or services that provide little or no benefit of UNNECESSARY
Low-value to patients, have potential to cause harm, incur USAGE of a FINITE
Medical Care: unnecessary cost to patients, or waste limited government
CIRCUMCISION healthcare resources. FUNDING / BUDGET
for health of the
citizens like the
PhilHealth and
UNNECESSARY USAGE
of FINITE number of
services like hospital
beds, tests, and
 • What is a low-value medical care?
Health Issue
Low-value medical care is defined as medical
Course– care or services that provide little or no benefit
Low-value to patients, have potential to cause harm, incur
Medical Care: unnecessary cost to patients, or waste limited
CIRCUMCISION healthcare resources.
Low-value medical care can be equated to
UNNECESSARY or NOT NEEDED medical care
rendered to patients primarily because of NO or
LITTLE BENEFIT and with POTENTIAL to cause
HARM and secondarily because of unnecessary
cost to patients and waste of limited healthcare
resources.
 • What is a low-value medical care?
Health Issue
Course– Low-value medical care is defined as medical
care or services that provide little or no benefit
Low-value to patients, have potential to cause harm, incur
Medical Care: unnecessary cost to patients, or waste limited
CIRCUMCISION healthcare resources.

Low-value medical care can be equated to

UNNECESSARY or NOT NEEDED or NOT
INDICATED or NOT in the patient’s best interest
when weighed against other available options,
including watchful waiting and other more
conservative measures.
 • What is a low-value medical care? vs high-
Health Issue value medical care?
Course–
Low-value
Low-value medical care is defined as medical
Medical Care: care or services that provide little or no benefit
CIRCUMCISION to patients, have potential to cause harm, incur
unnecessary cost to patients, or waste limited
healthcare resources.

High-value medical care is providing the best

medical care possible, efficiently using resources,
and achieving optimal results for each patient.
 • What are the different types of low-value
Health Issue medical care?
Course–
Low-value
Medical Care:
CIRCUMCISION
 • What are the different types of low-value
Health Issue medical care?
Course–
• Low-value Medical Care: Unnecessary
Low-value Medications
Medical Care: • Low-value Medical Care: Unnecessary
CIRCUMCISION Diagnostic Tests
• Low-value Medical Care: Unnecessary
Operations or Surgeries
 • What are low-value operations or surgeries? Low-value operations
Health Issue or surgeries –
Course– performance of
• Low-value Medical Care: Unnecessary
Low-value Prescription of Medications
operations or
Medical Care: • Low-value Medical Care: Unnecessary surgeries that
CIRCUMCISION provide little or no
Diagnostic Tests
benefit to patients,
• Low-value Medical Care: Unnecessary
may be harmful,
Operations or Surgeries
incur unnecessary
costs and waste
healthcare resources.
 • What are low-value operations or surgeries? Low-value operations
Health Issue or surgeries –
Course– performance of
• Low-value Medical Care: Unnecessary
Low-value Operations or Surgeries
operations or
Medical Care: surgeries that
CIRCUMCISION provide little or no
Examples: benefit to patients,
• Circumcision may be harmful,
• Cholecystectomy for asymptomatic gallbladder incur unnecessary
stones costs and waste
• Cholecystectomy for gallbladder polyps healthcare resources.
 • Why is male circumcision considered as a low-
Health Issue value operation?
Course–
Low-value
Medical Care:
CIRCUMCISION
 • Why is male circumcision considered as a low-
Health Issue value operation?
Course–
MALE circumcisions – TULE or TULI
Low-value
Medical Care: • The use of circumcision for medical or health
CIRCUMCISION reasons is an issue that continues to be
debated.
 CONCLUSION:
• Why is male circumcision considered as a low- NOT ROUTINE
Health Issue value operation?
Course– AS NEEDED –
Low-value MALE circumcisions – TULE or TULI INDICATIONS:
Medical Care: - Phimosis (foreskin is
too tight to be pulled
CIRCUMCISION • The American Academy of Pediatrics (AAP) back over the head or
found that the health benefits glans of the penis)
of newborn male circumcision outweigh the - paraphimosis (the
risks, but the benefits are not great enough to inability to return the
foreskin to its original
recommend universal newborn circumcision.
location)
- Recurrent urinary tract
WebMD, 2020 infections due to
foreskin problem
 • Why is male circumcision considered as a low-
Health Issue value operation?
Course– MALE circumcisions – TULE or TULI
Low-value Cited Circumcision Benefits: In reality, these are
Medical Care: • Less risk of urinary tract infections [not totally true] uncommon and can
• A reduced risk of sexually transmitted diseases in men be prevented with
CIRCUMCISION [not totally true]
• Protection against penile cancer and a lower risk
non-circumcision:
of cervical cancer in female sex partners (rare) • Hygienic practices
• Prevention of balanitis (inflammation of the glans) and • Safe sex
balanoposthitis (inflammation of the glans and foreskin)
[rare]
 • Why is male circumcision considered as a low-
Health Issue value operation?
Course– MALE circumcisions – TULE or TULI
Low-value
Medical Care: Circumcision Risks:
CIRCUMCISION • Pain (common)
• Risk of bleeding and infection at the site of the
circumcision (common)
• Irritation of the glans
• Higher chance of meatitis (inflammation of the
opening of the penis)
• Risk of injury to the penis
• Death
 • Why is male circumcision considered as a low-
Health Issue value operation?
Course– MALE circumcisions – TULE or TULI
Low-value
Medical Care: Circumcision Risks:
CIRCUMCISION • Pain (common)
• Risk of bleeding and infection at the site of the
circumcision (common)
• Irritation of the glans
• Higher chance of meatitis (inflammation of the
opening of the penis)
• Risk of injury to the penis
• Death
 • Why is male circumcision considered as a low-
Health Issue value operation?
Course– MALE circumcisions – TULE or TULI
Low-value
Medical Care: Circumcision Risks:
CIRCUMCISION • Pain (common)
• Risk of bleeding and infection at the site of the
circumcision (common)
• Irritation of the glans
• Higher chance of meatitis (inflammation of the
opening of the penis)
• Risk of injury to the penis
• Death
 • Why is male circumcision considered as a low- Low-value operations
Health Issue value operation? or surgeries –
Course– performance of
MALE circumcisions – TULE or TULI
Low-value operations or
Medical Care: Those routinely done for cultural reasons and for surgeries that
CIRCUMCISION peer-pressure = are low-value operations provide little or no
- Provide NO or little benefit benefit to patients,
- Cause HARM may be harmful,
- Incur unnecessary cost incur unnecessary
- Waste limited healthcare resources costs and waste
healthcare resources.
 • What are the causes of the low-value
Health Issue operation?
Course– 3 factors:
Low-value • Primary factor: Physician-driven factors
Medical Care: • Secondary factor: Patient-or-consumer driven
CIRCUMCISION factors
• Tertiary factor: Health systems factor
 • What are the causes of the low-value
Health Issue operation?
Course– Factors:
Low-value • Primary factor: Physician-driven factors
Medical Care:
Physicians are the primary factor because they
CIRCUMCISION encourage and promote circumcision despite
knowing it is driven more by cultural reason and
fear of peer pressure than medical reasons.
Also, they stand to earn (financially).
 • What are the causes of low-value operation?
Health Issue
Course–
Physician-driven factors
Low-value • Mindset in medical management – ritualistic
Medical Care: and maximalist physicians
CIRCUMCISION • Financial gain – incentivized or non- More business than
incentivized (personal) compassion sense
• Wish to please patients or consumers – their
mindsets and desires over the rationalization of
care
• NO clear presentation and discussion of
options of management
 • What are the causes of the low-value
Health Issue operation?
Course–
There are 3 types of physicians based on their
Low-value approach to medical problem-solving, decision-
Medical Care: making and recommendations: (MINDSETS)
CIRCUMCISION • RITUALIST physicians
• MAXIMALIST physicians
• MINIMALIST physicians
 • What are the causes of the low-value RITUALIST physicians
Health Issue operation? are those who make
Course– medical
There are 3 types of physicians based on their management
Low-value approach to medical problem-solving, decision-
Medical Care: decisions based on
making and recommendations: (MINDSET) HABITS and not
CIRCUMCISION • RITUALIST physicians mainly on CRITICAL
• MAXIMALIST physicians ANALYSIS. 
• MINIMALIST physicians

LOW-VALUE
MEDICAL CARE
 • What are the causes of the low-value MAXIMALIST
Health Issue operation? physicians are those
Course– who institute medical
There are 3 types of physicians based on their management that
Low-value approach to medical problem-solving, decision-
Medical Care: includes a lot of things
making and recommendations: (MINDSETS) that are NOT essential
CIRCUMCISION • RITUALIST physicians Nice to have and needed by a
• MAXIMALIST physicians patient in health
• MINIMALIST physicians restoration and
maintenance. 

LOW-VALUE
MEDICAL CARE
 • What are the causes of the low-value MINIMALIST
Health Issue operation? physicians are those
Course– who institute medical
There are 3 types of physicians based on their management that
Low-value approach to medical problem-solving, decision-
Medical Care: includes only which
making and recommendations: (MINDSETS) are essential and
CIRCUMCISION • RITUALIST physicians needed by a patient in
• MAXIMALIST physicians health restoration and
• MINIMALIST physicians maintenance.

HIGH-VALUE
MEDICAL CARE
 • What are the causes of the low-value FINANCIAL GAIN –
Health Issue operation? incentivized by a
Course– system in the health
Physician-driven factors care institutions –
Low-value • Mindset in medical management – ritualistic
Medical Care: with rewards such as
and maximalist physicians stock dividends,
CIRCUMCISION • Financial gain – incentivized or non- perks, free trip
incentivized (personal) abroad, etc.
• Wish to please patients or consumers – their
mindset over the rationalization of care
• Fear of malpractice suits
• NO clear presentation and discussion of
options of management
 • What are the causes of low-value operation? FINANCIAL GAIN –
Health Issue non-incentivized but
Course– with enrichment on a
Physician-driven factors personal basis – such
Low-value • Mindset in medical management – ritualistic
Medical Care: as from more
and maximalist physicians revenues from
CIRCUMCISION • Financial gain – incentivized or non- personally own
incentivized (personal) pharmacy or
• Wish to please patients or More business
consumers than
– their diagnostic business;
compassion
mindset over the rationalization of caresense want more revenues
• Fear of malpractice suits with procedures
• NO clear presentation and discussion of rather than
options of management medications; etc.
 • What are the causes of the low-value Pleasing patients on
Health Issue operation? their mindsets and
Course– desires rather than
Physician-driven factors explaining, educating
Low-value • Mindset in medical management – ritualistic
Medical Care: and convincing them
and maximalist physicians on rationalization of
CIRCUMCISION • Financial gain – incentivized or non- care.
incentivized (personal)
• Wish to please patients or consumers – their
mindset and desires over the rationalization of
care
• Fear of malpractice suits
• NO clear presentation and discussion of
options of management
 • What are the causes of the low-value NO presentation and
Health Issue operation? discussion of BRCA
Course– data and processes in
Physician-driven factors selection of cost-
Low-value • Mindset in medical management – ritualistic
Medical Care: effective option.
and maximalist physicians B – benefit
CIRCUMCISION • Financial gain – incentivized or non- R – risk
incentivized (personal) C – cost
• Wish to please patients or consumers – their A – availability
mindset and desires over the rationalization of
care Options B - R - C - A
• Fear of malpractice suits 1
• NO clear presentation and discussion of 2
options of management 3
 • What are the causes of the low-value NO presentation and
Health Issue operation? discussion of BRCA
Course– data and processes in
Physician-driven factors selection of cost-
Low-value • Mindset inNOTE:
medical management – ritualistic
Medical Care: High-value medical care effective option.
and maximalist physicians B – benefit
looks
CIRCUMCISION • Financial gain for most cost-effective
– incentivized or non-
option and not just most R – risk
incentivized (personal) C – cost
effective
• Wish to please option.
patients or consumers – their A – availability
mindset and desires over the rationalization of
care Options B - R - C - A
• Fear of malpractice suits 1
• NO clear presentation and discussion of 2
options of management 3
 • What are the causes of the low-value NO presentation and
Health Issue operation? discussion of BRCA
Course– data and processes in
Physician-driven factors
NOTE: High-value medical care looks for most cost-effective
selection of cost-
Low-value •option and not
Mindset injust most effective
medical option. – ritualistic
management
Medical Care: Options effective option.
and maximalist Benefitphysicians
Risk Cost Availability
B – benefit
CIRCUMCISION • Procedures /
Operations gain – incentivized or non-
Financial R – risk
incentivized
Option 1   (personal)
      C – cost
• Wish
Option 2 to please
  patients
  or consumers
  – 
their A – availability
Option 3        
mindset and desires over the rationalization of
care Options B - R - C - A
• Fear of malpractice suits 1
• NO clear presentation and discussion of 2
options of management 3
 • What are the causes of the low-value Patients or
Health Issue operation? consumers are the
Course– secondary factor
Factors: because of their
Low-value • Secondary factor: Patient-or-consumer-driven
Medical Care: mindset and desires
factors which the physicians
CIRCUMCISION want to satisfy above
anything else and
Patient-or-consumer-driven factors which usually lead to
• Mindset and desires of patients low-value medical
care.
 • What are the causes of the low-value
Health Issue operation?
Course–
There are 3 types of patients based on their
Low-value approach to medical problem-solving and
Medical Care: decision-making: (MINDSETS and DESIRES)
CIRCUMCISION • RITUALIST patients
• MAXIMALIST patients
• MINIMALIST patients
 • What are the causes of the low-value RITUALIST patients
Health Issue operation? are those who make
Course– medical management
There are 3 types of patients based on their decisions based on
Low-value approach to medical problem-solving and
Medical Care: HABITS, FADS, and
decision-making: (MINDSET and DESIRES) not mainly on
CIRCUMCISION • RITUALIST patients CRITICAL ANALYSIS. 
• MAXIMALIST patients
• MINIMALIST patients

LOW-VALUE
MEDICAL CARE
 • What are the causes of the low-value MAXIMALIST patients
Health Issue operation? are those who desire
Course– medical management
There are 3 types of patients based on their that includes a lot of
Low-value approach to medical problem-solving and
Medical Care: things that are NOT
decision-making: (MINDSET and DESIRES) essential and needed
CIRCUMCISION • RITUALIST patients “Nice to have” by a patient in health
• MAXIMALIST patients restoration and
• MINIMALIST patients maintenance. 

LOW-VALUE
MEDICAL CARE
 • What are the causes of the low-value MINIMALIST patients
Health Issue operation? are those who desire
Course– medical management
There are 3 types of patients based on their that includes only
Low-value approach to medical problem-solving and
Medical Care: which are essential
decision-making: (MINDSET and DESIRES) and needed by a
CIRCUMCISION • RITUALIST patients patient in health
• MAXIMALIST patients restoration and
• MINIMALIST patients maintenance.

HIGH-VALUE
MEDICAL CARE
 • What are the causes of low-value operation?
Health Issue
Course–
Factors:
Low-value Tertiary factor: health system factors
Medical Care: • Facilitating, allowing, no policing, no quality
CIRCUMCISION control of practices of physicians
• Inadequate public health education, patient-
centered care management program or
patient-empowerment program
 • What are the types of the low-value
Health Issue circumcision?
Course–
Low-value Circumcisions that are:
Medical Care: • Not needed (just watchful waiting or
medications will do)
CIRCUMCISION • Not proven effective
• Unsafe
• Costlier than other equivalently effective treatment
(not cost-effective)
 • What are the side-effects of low-value
Health Issue circumcision?
Course–
All operations / surgeries have side-effects, both
Low-value expected and potential.
Medical Care:
CIRCUMCISION After the expected side-effects, the surgeons will
try to control all the risks for potential side-effects
or complications of the operation like bleeding,
infections, dehiscence, even death, etc.
However, NO surgeon will guarantee against their
occurrence.
 • Why is male circumcision considered as a low- Low-value operations
Health Issue value operation? or surgeries –
Course– performance of
MALE circumcisions – TULE or TULI
Low-value operations or
Medical Care: Those routinely done for cultural reasons and for surgeries that
CIRCUMCISION peer-pressure = are low-value operations provide little or no
- Provide NO or little benefit benefit to patients,
- Cause HARM may be harmful,
- Incur unnecessary cost incur unnecessary
- Waste limited healthcare resources costs and waste
healthcare resources.
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value
Medical Care:
CIRCUMCISION
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value
Medical Care: 3 factors on the causes:
• Primary factor: Physician-driven factors
CIRCUMCISION How do you
• Secondary factor: Patient-or-consumer driven
factors control these?
• Tertiary factor: Health systems factors
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value
Medical Care: 3 factors on the causes:
• Primary factor: Physician-driven factors
CIRCUMCISION
• Secondary factor: Patient-or-consumer driven
factors
• Tertiary factor: Health systems factors

What can you do as a layperson or patient?

 • What are tips on avoiding or reducing Help in the ADVOCACY
Health Issue against unnecessary
circumcision as a low-value or unnecessary
routine male
Course– operation?
circumcisions,
Low-value especially those done
Medical Care: 3 factors on the causes: for cultural reasons
• Primary factor: Physician-driven factors
CIRCUMCISION and for fear of peer
• Secondary factor: Patient-or-consumer driven
pressure.
factors
• Tertiary factor: Health systems factors
BREAK the VICIOUS
CYCLE of peer-pressure
driven circumcisions
What can you do as a layperson or patient? for the sake of your
sons and grandsons.
 • What are tips on avoiding or reducing Help in the
Health Issue circumcision as a low-value or unnecessary ADVOCACY against
Course– operation? unnecessary routine
male circumcisions,
Low-value especially those done
Medical Care: 3 factors on the causes: for cultural reasons
• Primary factor: Physician-driven factors
CIRCUMCISION and for fear of peer
• Secondary factor: Patient-or-consumer driven
factors pressure.
• Tertiary factor: Health systems factors
Inform and educate
other people of the
low-value
What can you do as a layperson or patient? (unnecessary routine
male circumcisions).
 • What are tips on avoiding or reducing BE EMPOWERED AS
Health Issue circumcision as a low-value or unnecessary A PATIENT!
Course– operation?
Low-value ADVOCATE PATIENT
Medical Care: 3 factors on the causes: EMPOWERMENT!
• Primary factor: Physician-driven factors
CIRCUMCISION
• Secondary factor: Patient-or-consumer driven You can do
factors your part here!
• Tertiary factor: Health systems factors For your own
sake!
For your
brethens’ sake!
What can you do as a layperson or patient?
 Be always in touch with reliable medical
HIGH-VALUE
Health Issue information on low-value (unnecessary) and high-
MEDICAL CARE
Course– value (highly recommended) medical care.
Low-value
Medical Care: Knowledge is power; it gives power.
Low-value Medical
Care:
CIRCUMCISION Use the 4Ks of Patient Empowerment: • Unnecessary
Kaalaman, Kakayanan, Karapatan and Medications
Kapangyarihan • Unnecessary
Diagnostic Tests
to gain greater control over decisions in
• Unnecessary
medical management of oneself in Operations or
promoting high-value medical care and Surgeries
avoiding low-value medical care.
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value Strategies:
Medical Care:
• Be constantly aware of and vigilant against
CIRCUMCISION potential for low-value performance of
operations / surgeries by physicians /
surgeons. Always aim and insist for a high-
value operations / surgeries from them.
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value Strategies:
Medical Care:
• Be proactive
constantlyinaware
controlling
of andand
vigilant
avoiding
against
low-
CIRCUMCISION potential
value operations.
for low-value
Makeperformance
the physicians
of aware
that you know
operations / surgeries
the processes
by physicians
on how/to
surgeons.
reduce low-value
Alwaysand
aimhow
and insist
to promote
for a high-
high-
value operations.
operations /Have
surgeries
a shared
fromcollaboration
them.
with the physicians in accomplishing these.
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value
Strategies:
Medical Care:
• Before accepting the recommendation for an
CIRCUMCISION
operation (circumcision), ask the physician:
• What is the diagnosis?
• What is the indication for circumcision?
• What is the goal of the operation?
• What are the options? Including no
circumcision.
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value
Strategies:
Medical Care:
CIRCUMCISION • Before accepting the recommendation for an operation (circumcision),
ask the physician:
• What are the comparative data and information on the various
options in terms of benefit (effectiveness); risk; cost; and
availability parameters? What is his recommendation on the cost-
effective option?
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value
Always use BRCA Process in selecting cost-
Medical Care: effective treatment (include watchful waiting and
CIRCUMCISION more conservative measures like medications as
options)
Options Benefit Risk Cost Availability
 Treatment
Option 1        
Option 2        
Option 3        
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value
Strategies:
Medical Care:
• Before accepting the recommendation for an operation (circumcision),
CIRCUMCISION
ask the physician:
• When the physician asks for your response to his recommendation,
feel free to ask as many questions that you may have on the data
and information presented and also, ask him to temper and
validate your personal biases (mindset and desires) in favor of an
objective decision-making.
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value
Strategies:
Medical Care:
• You are free and have a right to seek a second
CIRCUMCISION
opinion if you want. However, when you do
this, follow the same processes mentioned
above.
 • What are tips on avoiding or reducing Patients do not
Health Issue circumcision as a low-value or unnecessary know whether there
Course– operation? are ulterior motives
Low-value behind physicians’
Medical Care: Some more recommendations. recommendation for
operation such as
CIRCUMCISION incentivization and
personal business
sense.
 • What are tips on avoiding or reducing Patients do not
Health Issue circumcision as a low-value or unnecessary know whether there
Course– operation? are ulterior motives
Low-value The best diplomatic strategy to prevent this ulterior motive behind physicians’
Medical Care: is to ask the physicians to present and discuss the recommendation for
comparative data and information on the benefit, risk, cost operation such as
CIRCUMCISION and availability of the different options of treatment. incentivization and
Analyze them and then make a judgement on physician’s
personal business
competency and presence of ulterior motives.
sense.
Options Benefit Risk Cost Availability
 Treatment
Option 1        
Option 2        
Option 3        
 • What are tips on avoiding or reducing Commendable
Health Issue circumcision as a low-value or unnecessary physician’s attitude
Course– operation? that will prevent
Low-value low-value operation
“I am sorry your perceptions on a particular
Medical Care: option of treatment for this medical condition are just because of
wanting to satisfy
CIRCUMCISION myths, incorrect and unfounded. I have to correct mindsets and desires
you through these explanations.”
of patients.
“I am sorry we have to decide on what type of
treatment option to take based on hard evidences
and not based on fad and popular practices.”
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value My personal practice:
Medical Care:
- I don’t do routine male circumcisions, only
CIRCUMCISION
when indicated such as phimosis,
paraphimosis, and recurrent urinary tract
infection.
- I don’t subscribe to routine neonatal
circumcision.
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value My personal practice:
Medical Care: -
I use the BRCA to advise and to make
CIRCUMCISION recommendations as objectively as possible
and honestly and compassionately.

Options Benefit Risk Cost Availability

 Treatment
Option 1        
Option 2        
Option 3        
 • What are tips on avoiding or reducing
Health Issue circumcision as a low-value or unnecessary
Course– operation?
Low-value My personal practice:
Medical Care:
- I respect patients’ mindsets and desires but I
CIRCUMCISION
enlighten them if they have misconceptions.
- If parents are insistent on having their sons of
minor age circumcised just because of cultural
reason and fear peer pressure, after failure to
convince them of the non-necessity (low-
value), I would politely beg off. (I will not do
the circumcision.)
 Contents of PEP TALK on Low-value Medical Care: Summary
Health Issue CIRCUMCISION Take Away
Course– • What is a circumcision?
Low-value • What are the different types of circumcision?
Medical Care: • What is a low-value medical care? low-value
operation?
CIRCUMCISION • Why is male circumcision considered as a low-
value operation?
• What are tips on avoiding or reducing
circumcision as a low-value or unnecessary
operation?
 • Why is male circumcision considered as a low- Low-value operations
Health Issue value operation? or surgeries –
Course– performance of
MALE circumcisions – TULE or TULI
Low-value operations or
Medical Care: Those routinely done for cultural reasons and for surgeries that
CIRCUMCISION peer-pressure = are low-value operations provide little or no
- Provide NO or little benefit benefit to patients,
- Cause HARM may be harmful,
- Incur unnecessary cost incur unnecessary
- Waste limited healthcare resources costs and waste
healthcare resources.
 • Why is male circumcision considered as a low- Low-value operations
Health Issue value operation? or surgeries –
Course– performance of
MALE circumcisions – TULE or TULI
Low-value operations or
Medical Care: Those routinely done for cultural reasons and for surgeries that
CIRCUMCISION peer-pressure = are low-value operations provide little or no
- Provide NO or little benefit benefit to patients,
- Cause HARM may be harmful,
- Incur unnecessary cost incur unnecessary
- Waste limited healthcare resources costs and waste
healthcare resources.
 Be always in touch with reliable medical Take Away in
Health Issue information on low-value (unnecessary) and high- relation to
Course– value (highly recommended) medical care.
Patient
Low-value Empowerment
Medical Care: Knowledge is power; it gives power.
CIRCUMCISION Use the 4Ks of Patient Empowerment:
Kaalaman, Kakayanan, Karapatan and
Kapangyarihan
to gain greater control over decisions in
medical management of oneself in
promoting high-value medical care and
avoiding low-value medical care.
 Empowerment
Health Issue objective - for
Course– laypeople to have an
Low-value understanding of the
Medical Care: issues of
CIRCUMCISION CIRCUMCISION as a
Low-value
Operation.