OR head covering controversy: ACS vs. AORN

In early August, the American College of Surgeons (ACS) issued a statement on operating room attire. Much to my surprise and delight, it said this about headgear:

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. Like OR scrubs, cloth skullcaps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case.

The Association of periOperative Registered Nurses (AORN) responded with a statement of its own:

Several types of evidence exist that support recommendations that perioperative personnel cover their head and ears in the OR. This evidence includes the fact that human skin and hair is naturally colonized with many bacteria, and perioperative personnel shed microorganisms into the air around them. We know airborne bacteria in the OR can fall into the operative field, contribute to the overall air contamination of the OR, and place patients at risk of surgical site infections. Completely covering the hair can reduce the number of bacteria introduced into OR air by perioperative personnel.

Unfortunately, the "evidence" cited by the AORN is all circumstantial. Yes, human hair and skin may be colonized with bacteria. There is no proof whatsoever that a single surgical patient has ever been infected by a hair or skin droppings from OR personnel. If you want to extend this logic to its inevitable conclusion, the entire neck and face should be covered too. Eyebrows and eyelashes could be deadly. Maybe all OR personnel, including circulating nurses and anesthesia, should wear helmets like those used by astronauts or deep-sea divers.

Some say it is impossible to do a study about this, but one of my Twitter followers came up with a perfectly reasonable suggestion. Simply have several teams of operating room personnel, some of whom are wearing bouffant caps and some wearing skullcaps, stand over an OR table. Instead of a patient, culture media could be placed in strategic locations. The OR teams should move about in scripted ways for an hour or two. Let's see whether there's any difference in the amount of bacteria grown in the cultures.

Perhaps the AORN should get its own house in order first. Many of the OR nurses and techs that I have worked with over the years wear their supposedly fully covering headgear like this:

Audition electives, applying to programs, and interviewing

By now most rising fourth-year medical students have chosen a specialty and are busy preparing residency applications. A paper from October of last year in Academic Medicine sheds some light on the process.

Researchers from Mass General and the University of Vermont surveyed 2884 fourth-year students from 20 US medical schools in 2014; 1367 (47.4%) responded—52% of them were female.

Just over half of the students applied to internal medicine, pediatrics, or surgery residencies.

While the average number of programs applied to was 36.4, those seeking surgery applied to a mean of 58.2 programs, significantly more (p < 0.001) than those applying to any other specialty.

Except for radiology, for which applicants averaged 16.9 interviews, all other specialties including surgery had a mean of about 12 interviews per applicant.

Of those who answered the survey, only 71 (5.2%) did not match in the specialty they wanted.

You failed the written boards: What to do now

I graduated this July and took the QE (written general surgery boards) on July 19th. I got my results today and I failed. Not only did I fail but my score placed me in the 5th percentile. Needless to say I'm disappointed. You hear stories about CE (oral exam) failure but never about QE failure. I never blew the ABSITE out of the water (50, 29, 20, 34, 38), but I never would have expected to perform so poorly. Rather than search for blame I'd like to form an effective strategy so that I pass the second time around.

I am sorry to hear of your misfortune. I can’t imagine how you must be feeling.

In your time as a PD did you have a resident or residents fail the QE? Several residents failed the QE. The most notable was a guy who never got below the 60th percentile on the ABSITE. To this day, I cannot understand how that happened.

What became of these people? You will be happy to learn that nearly everyone eventually passed. Patients never ask you how many times it took you to pass the boards. They don’t know about that sort of thing. As far as I know, failing the boards on the first attempt has no long term ramifications except for your program which is judged by the percentage of residents who pass the boards on their first attempt.

Any advice on how to avoid another failure? In order to help you answer the last question I will tell you that I went through SESAP 15 once. I listened to the audio as well. I stuck to high yield sources and UpToDate to supplement SESAP. I avoided reading any formal textbooks but I did read Cameron front to back during residency.

I have found that everyone learns in different ways. There is no single path to success.

One thing you said caught my attention. “I avoided reading any formal textbooks…” I think that would be a good place to start. You need to get a basic full-sized surgery textbook and read it carefully all the way through. I would advise you to take notes, make flashcards, or whatever else you think might help you to remember important points. Cameron is a great book but in my opinion it is more suited to studying for the oral boards because it is more clinically focused.

SESAP is geared more toward surgeons doing recertifying exams and is probably not worth spending time on for the QE.

Many of my residents used books of practice questions which may help, but only after you have done a lot of reading.


After you have studied your textbook and are feeling fairly comfortable, you should think about taking an intensive review course a few weeks before the exam. That may help solidify your knowledge. Taking a review course without studying beforehand probably won’t work because it is so much information over a short period of time that you will not be able to retain it all.

Study hard because the last thing you need is to fail the QE again. That would put tremendous pressure on the third attempt. You don’t want to be in that position.

I hope this helps. Good luck.

Can a US IMG with a marginal USMLE Step 1 score still match in surgery?

A US IMG with a USMLE Step 1 score between 200 and 210 wrote me with several questions.

Disclaimer: This is my opinion which may not be shared by the majority of surgical program directors. The questions are italicized.

Is there a way to find programs that don't have Step 1 cut offs? No.

Should I email them my 230 on the USMLE practice test? That would be of no use.

Should I explain my situation or will that seem like a sob story? I've had bad luck but just a string of it and I feel like it would sound like I was making too many excuses. As I read your story, it did sound like too many excuses. The problem for you is that there are numerous other candidates out there who don’t have these issues and have better scores.

Should I strategically book rotations during interview season and hope they decide they want me (does that happen and do you have any tips on this)? The value of so-called “audition electives” is controversial. I never put much stock in them, but I think many program directors do. If you decide to do some audition electives, you should focus on smaller community hospital programs. Many programs list where their residents went to medical school on their websites. You should pick places that have taken US IMGs recently.

Shortage of doctors in the future? Maybe

Shortage of residency positions for international medical school graduates in the future? Yes.

Google “shortage of doctors” and you’ll find that almost everyone believes what the Association of American Medical Colleges (AAMC) says—that we will need 90,000 to 130,000 more doctors by the year 2025.

There are a few naysayers such as Gail Wilensky, a health economist and co-chair of the Institute of Medicine panel that found no evidence to support those estimates and Princeton health economist Uwe Reinhardt, who says it’s in the best interests of the AAMC to predict a shortage.

A 2012 survey found that one-third of US physicians planned to retire by 2022. According to a study by the Kaiser Family Foundation, there are just over 900,000 active physicians in the US, meaning that if the survey is correct, about 300,000 doctors will have stopped practicing by 2022.

The AAMC says that about 18,000 medical students graduated from US schools in 2015. Will that be enough to replace those who say they are quitting? The number of residency positions available for med school graduates was 27,860 in the 2016 match.

If you multiply 27,860 residency slots x 10 years (between the years 2012 and 2022) you get 278,600, which approaches the projected number of 300,000 retirees lost.

No matter which side of the debate is correct, international medical graduates (IMGs) will be adversely affected. Here is why.

What has society come to?

A medical student who corresponds with me wrote the following. It has been edited for length.

She was shopping at a mall with her husband and their children.

As I walked underneath the escalators, I heard a horrific sound. I looked up and saw a body cartwheeling down. I ran to front of the escalator to push the stop button. An 80 or 90 year old gentleman was lying partly on and partly under his walker. He seemed unconscious with blood all over the place. I said "Sir, sir," saw his fingers move, and called 911.

A black man from the top of the escalator made eye contact with me and came running down to see how he could help. He hesitated, his face and body language screaming fear, but he came over. He knew he had to once we made eye contact because I was the only one actually doing something.

A security guard who was heading to work arrived. He had no gloves, no radio, nothing. Why wasn't anyone from security coming? What's the point of security cameras? Wasn't there anyone watching? I turned around to see who else could help. About a dozen people were just standing there with their cell phones taking pictures and videos. Not a soul asked me if they could call 911. In fact when I called 911 a second time, the dispatcher asked me if there were more people with me because I had placed the only two calls.