This is the Reason Surgeons are Getting Mad as a Hatter

“Mad as a hatter.”

The term actually comes from the toxicity hat makers would develop from exposure to mercury fumes in the 1800s. So, what does this have to do with surgery? Recently Liz Kowalczyk’s “No More Surgical Caps for Surgeons?” September 1, 2016, Boston Globe discussed the anger some surgeons have had over new hospital policies regarding surgical caps worn in the operating room.

For years, most surgeons have worn a surgical cap that sits above the ears. Most are disposable, but some are custom made or personalized cloth caps. I have a Spiderman cap and a cap with musical notes all over it. The concern more recently has been the amount of hair left uncovered, and the potential risk of infection from this hair.

Standards of Surgeons in the Operating Room

Standards developed by the Association of periOperative Registered Nurses (AORN) include the importance of maintaining appropriate hair coverage to reduce the risk of infection. These guidelines indicate that personal head coverings in the operating room must cover all hair and that facial hair, if present, must be covered by an additional disposable hood. “Because hair and skin can harbor and disperse bacteria into the environment, covering the head, hair, ears, and facial hair reduces the patient’s exposure to potentially pathogenic microorganisms residing on the perioperative team member. The RP (Recommended Practices) recommends wearing a clean surgical head cover (e.g., bouffant cap) or hood that confines all hair and completely covers the ears, scalp, sideburns, and nape of the neck.”

The RP (Recommended Practices) recommends wearing a clean surgical head cover (e.g., bouffant cap) or hood that confines all hair and completely covers the ears, scalp, sideburns, and nape of the neck.”

The American College of Surgeons, of which I am a Fellow, released its own guidelines, “Statement on Operating Room Attire,” in which it notes, “During invasive procedures, the mouth, nose, and hair (skull and face) should be covered to avoid potential wound contamination. Large sideburns and ponytails should be covered or contained. There is no evidence that leaving ears, a limited amount of hair on the nape of the neck or a modest sideburn uncovered contributes to wound infections.”

Also noted, “The skullcap is symbolic of the surgical profession. The skullcap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered.” Interestingly, the AORN notes that wearing lab coats over one’s scrub suit when leaving the operating room (such as to see patient in a hospital floor) is not best practice, while the ACS recommends wearing a lab coat in this scenario.

Also noted, “The skullcap is symbolic of the surgical profession. The skullcap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered.” Interestingly, the AORN notes that wearing lab coats over one’s scrub suit when leaving the operating room (such as to see patient in a hospital floor) is not best practice, while the ACS recommends wearing a lab coat in this scenario.

What’s a Layperson to Think of Differing Surgeon’s Head Covering Guidelines?

Taking off my surgeon’s hat for a moment (pun intended), what would I make of all of this as a layperson? CMS, the Center for Medicare & Medicaid, has followed the AORN’s guidelines and has cited hospitals for lack of compliance. The Boston Globe reports that the Joint Commission, a hospital accreditation agency, is “conducting an analysis of the major guidelines.”

Not only has the ACS created its own guidelines, some of which differ from the AORN guidelines, but anesthesiologists have weighed in as well. Lauren A. Kosinski, MD, MS, reports that her hospital was cited by CMS for deficiencies, the response to which was a mandate by administration that traditional surgical caps no longer be worn. Instead, the bouffant cap, similar to a lightweight fiber shower cap, is to be worn. In addition to the questions raised by the ACS regarding true evidence that the surgical cap is less effective than the bouffant, both Kosinski and Kowalczyk bring up the fact that the surgeon’s cap is seen as a traditional symbol of the surgeon.

As I stated earlier, the ACS notes that the skullcap is the symbol of the surgical profession. Is this really about traditionalism and symbolism? Is this about surgeons and medical doctors in general losing control of their profession? Kosinski asks, “The question of whether we wear a traditional surgeon’s cap or a bouffant bonnet is not just about cap style. Will we choose to step up to the plate and wear the hat of the leader or don the hat of the subordinate? Will we—through our thoughtful dedication to patient care—set the example in the OR, or resign ourselves to being recalcitrant employees who bitterly swallow whatever pill we are administered for fear of diminishing our earnings?”

Putting traditionalism and symbolism aside, the evidence on which such decisions are made often comes into question. The layperson (remember that I took off my surgeon’s hat) hears about Evidence Based Medicine and understands that this is the medicine that should be practiced. What often goes unnoticed is the strength (or lack thereof) of such evidence, and how strong the recommendations are with respect to that evidence. With respect to surgical hats, the above noted ACS and anesthesia articles as well as the Boston Globe article, note that little evidence if any exists to support the use of one hat over the other.

Surgeons Have It All Covered

The public needs to understand that degrees of recommendations exist, from analyses of multiple randomized control trials (the best or Level I recommendations) down to opinions from expert committees or respected authorities (Level IV, the weakest level of recommendations). And such recommendations change as more evidence is available. This is why we sometimes feel as if this year red meat is bad for us again, but last year someone said it was good, and the year before that it was bad. It’s a bit like who is our enemy and who is our ally in Orwell’s 1984.

Putting my surgeon’s hat back on, my concern is what I asked above – what does the layperson think about all of this? How do we expect them to have faith in us as medical providers when we can’t decide about hats?

I am a big fan of David Sackett, the father of Evidence-Based Medicine (EBM), and Donald Berwick, a great proponent of EBM. The move in healthcare to pay-for-performance and value-based medicine will depend on EBM. However, the public needs to understand that there are levels of evidence with strong evidence and weak evidence leading to the levels of recommendations I noted above. Randomized control trials provide the best evidence but require time, a control group who does not receive the treatment, and resources. Retrospective studies are more easily done but may incur more bias. Then, of course, there are the expert opinion recommendations.

These can be very helpful but are also subject to small numbers of patients as well as to bias, usually without any controls. In residency, we used to describe such expert opinions as follows based on what a senior surgeon would say:

“In my experience, …” – they had done one such case

“Case after case, …” – they had done two such cases

“In my series of cases, …” – they had done three such cases.

The point is that these type of articles, whether they appear in the newspaper or online, can lead the public to question the medical community, its ability to analyze data, its ability to put tradition aside and focus on best results, and its very competency.

Surgeons Wear Lots of Hats Simultaneously

I ask the public to see this differently. The fact that the field of medicine – nurses, surgeons, anesthesiologists, etc. – are looking at details such as which hats we wear should give the public confidence that we continue to drill down on every detail of patient care, every aspect of operating room journey, to make sure that we maximize our ability to fight infection.

We are not focusing on which hat we wear and at the same time neglecting best surgical techniques, best antibiotic practices, or best sterilization techniques. We are focusing on hats, surgical attire, skin prep practices, etc. in addition to best surgical techniques, best antibiotic practices, etc.

At my own institution, we have a Surgical Site Infection (SSI) committee that looks at such practices and analyzes every surgical infection reported. We implement policies, including surgical attire policies, and adjust them as evidence becomes available. When an infection occurs, we assess which personnel was in the room, what skin prep was used, which antibiotics were given, which room was used, the equipment, the technique of the procedure – you get it – every possible detail.

The layperson should read between the lines of such articles and news reports to see that, although we sometimes are guilty of citing tradition as an explanation for why something is done, the medical field is getting much better at avoiding complacency. Grace Hopper once stated, “The most dangerous phrase in the language is, ‘We’ve always done it this way.’”

My own belief is that we constantly need to strive for new goals, as complacency is the breeding ground for failure. The medical profession does continue to set such goals, setting such big hairy audacious goals (Jim Collins’ BHAGs) as “zero surgical site infections.” We use national data such as that compiled by NSQIP (National Surgical Quality Improvement Program and by the Joint Commission using SCIP measures (Surgical Care Improvement Project). We are constantly comparing ourselves with similar institutions, national statistics, top percentiles – not much different than what we did in medical school and residency.

Ultimately, our goal is to provide the best care for our patients we possibly can. I think that is the take home message for the layperson.

My Own Bottom Line…

For now, I will continue to wear the bouffant hat that I have always worn. Unlike many of my colleagues, I have never looked good in the skullcap, so much of this discussion about tradition and symbolism has little impact on my own operating room fashion. And, by the way, one of the surgeons mentioned in the Boston Globe article was my former chief-of-surgery. He is a phenomenal surgeon and a great guy. I would let him operate on me even if he were wearing clown shoes, Groucho Marx glasses, and a Cat in the Hat chapeau.

Of course, for infection prevention, I would prefer that he cover that hat with a disposable bouffant.

 

My book, Do the Right Thing: A Surgeon’s Approach To Life is now available on Amazon! Read an excerpt here. 

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