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The Curious Case of the Skull Cap

Nothing is quite as strange as the first day of your surgery clerkship. It isn’t just the shock of seeing a living human intentionally cut-open or the unforgettable smell of cautery for the first time — even just getting into the operating room can be an obstacle. Prior to this rotation I had no idea it was even possible to operate a sink using my feet. In my first attempt to scrub-in I managed to scald both arms from the elbow down and splashed so much water on myself that I looked completely incontinent. Finally, drenched in water, I approached the O.R., praying that I wouldn’t bump my arms into anything and render myself non-sterile, a surgical tech noticed me out of the corner of his eye and nonchalantly said, “You forgot your mask.” Smiling stupidly as only a medical student on the first day of clerkships can, I dejectedly went back to grab a mask and start round two with the sink.

After getting a mask on and autoclaving my arms in the sink again, I snuck into the O.R. hoping that I hadn’t forgotten anything else in the process. While waiting to gown-up, I studiously observed as the anesthesiologist intubated the patient and the scrub nurse made last-minute preparations to the instrument tray. During my observation I found something very peculiar in the choice of surgical attire: the physicians were the only ones with skull caps while everyone else wore bouffants. I was wearing a bouffant because it was the closest option as I franticly rushed to the O.R. that morning. I had no idea why anyone who had a choice would pick a bouffant over a skull cap since the bouffant was clearly ridiculous looking — or so I thought.

As it turns out, my curiosity over the choice of headdress wasn’t unfounded. Just this past August, the American College of Surgeons (ACS) released a statement on surgical attire that included a specific endorsement of the skull cap, stating that the skull cap is “symbolic” of the surgical profession. The Association of Perioperative Registered Nurses (AORN) took issue with the ACS’s opinion, citing the potential increased risk for infection using skull caps, since it normally leaves some hair uncovered. They stated that wearing a particular head covering based on its symbolism is not evidence-based and should not be a basis for a nationwide practice recommendation. Apparently I was not the only person who had wondered about the difference between skull caps and bouffants.

Exploring a little further I was a bit astounded that two of the biggest health care worker advocacy groups in the U.S. were bickering over paper hats. While I can understand the argument for changing headdress if it were to decrease post-op infection rates, it turns out that data on the subject is sparse and mixed. What intrigues me even more than a discussion on post-op infection rates is that the ACS chose to use “symbolism” as the reason for the skull cap’s continued use. They could have chosen to argue any number of other reasons like functionality or aesthetics, but instead argued its symbolic value. This led me to wonder if a disposable paper hat can realistically act as a symbol to convey the expertise, authority and prestige of the surgical profession.

Medical culture is one of the world’s oldest professions and as such has rich symbolism in the images, clothing and words associated with it. Staples of medical symbolism include the rod of Asclepius or the Hippocratic Oath which are still in use thousands of years after their creation. Each year in the medical world we have ‘white-coat ceremonies’ where students receive a physical white mantle which is used to designate their place in the medical hierarchy to everyone around them. This symbolic clothing continues after graduation as you transfer from a short white coat to the long white coat, representing your advancement in knowledge, expertise and authority. Words and titles are likewise heavily symbolic in medicine. The term “doctor” has become so symbolic of the skills and expertise of a physician that it’s application to other professions has been hotly debated among MDs, DOs, NDs and PhDs for years. The debate continues into our day as NPs, PAs and other health care workers assume roles once occupied solely by physicians.

Not all of these symbols are inherently bad. After all, it is pretty important to delineate the trainee from the attending, the physical therapist from the nurse, and the ophthalmologist from the cardiologist and we do this through symbolic clothing and titles. So is the ACS really unwarranted in their use of skull caps to the same end? If the ACS’s reasoning is flawed, then so might be many symbols of the medical hierarchy and without at least some symbolism confusion may result. However, it could also be argued that some symbols are unnecessary and only work to segregate what should be a cohesive team of health care workers. Being a novice in medicine I don’t pretend to have the answer to this question but I have had experiences that help me live with them.

One such experience occurred during that same surgery rotation. Contrary to my previous experience in surgery, this time I had managed to put on all my PPE correctly, not scald my hands and be in the O.R. early enough to witness the entire surgery from start to finish. For the team around me this was an unglamorous, uncomplicated, routine bowel resection, but to me it was something different. I was amazed at how the surgeon expertly manipulated the anatomy to achieve her goal. I was equally impressed at how the anesthesiologist maintained the patient safely between inadequate and over sedation no matter what was going on in the case. The circulator’s and scrub nurse’s coordination of so many moving parts was the epitome of precision. As I tore off my gown and gloves at the end of the case and helped transition the patient back to their bed, I was struck with how perfectly everyone had performed.

Reflecting on this experience I noticed how important authority and position actually were to the function of that O.R. but that it had nothing to do with a person’s headwear. Everyone in that room had a very specific authority, expertise and role. If the anesthesiologist told the surgeon to stop because of a rapid drop in blood pressure, the surgeon stopped. If the surgeon asked for an instrument, the scrub nurse swiftly provided it. If the scrub nurse found that a needle was missing, everyone stopped until it was accounted for. I noticed that with everyone’s specific authority and expertise also came a mutual respect for other’s authority and responsibilities. I imagine that if anyone had become too fixated on their own authority or importance the O.R. would have ceased to function as smoothly as I observed and, in the end, the patient would have been the one dealing with the repercussions.

This isn’t to say that I have never seen a dysfunctional O.R. or that they don’t exist. We have all seen dysfunctional O.R.s and this is exactly why this particular experience struck me. For the best outcomes, we do need authority, power and expertise as physicians. Moreover it is important that others recognize that at appropriate times. Yet, even more importantly, that same authority and recognition should be afforded to our team. In the end, it has nothing to do with bouffants, skull caps, white coats or how many letters are written behind our name. It depends on the individual and how they wield their own authority and expertise while respecting the same in others. Our unique challenge as the next generation of physicians is to define the capabilities and boundaries of this authority and then employ it wisely for the benefit of our team and patients.

Brian Walker Brian Walker (1 Posts)

Contributing Writer

University of Washington School of Medicine

Medical student at the University of Washington in Seattle, WA. Enjoys spending time in the great outdoors, especially with his wife and children.