Justin Hollander, DO

There's something about a surgeon in a form-fitting skullcap that identifies him as the leader of the pack. Plus, it looks kind of badass, much cooler than the shower-cap look of a surgeon in a wispy bouffant bonnet.

"The skullcap looks good. It looks better than a big puffy thing on my head," says orthopedic surgeon Justin Hollander, DO, of Munson Medical Center in Traverse City, Mich., the Michigan State Spartans fan in the picture to your right. "It's a prestige thing. We are the captains of the ship. And we want people to know who's in charge. It's my room. It's my patient."

Dr. Hollander has worn a skullcap for 10 years and 10,000 cases, for all of his residency and most of his practice. But he's now donning a bonnet "that comes out of cardboard box that sits near the floor" because the Association of periOperative Registered Nurses (AORN) pointed out that, ahem, skullcaps don't cover all of the head, hair and ears.

In an odd exchange of clothes-minded discussion about proper dress in the OR last month, first the American College of Surgeons (ACS) released its surgical attire guidelines, describing the skullcap as "symbolic of the surgical profession" and calling for its continued use. The ACS said that it was acceptable for "only a limited amount of hair" on the nape of the neck and "modest sideburns" to be left uncovered by surgeons wearing skullcaps.

A couple weeks later, the AORN released a response to the ACS guidelines that challenged its backing of skullcaps, noting that they may leave the nape of the neck, and possibly hair on the sideburns, exposed.

"Wearing a particular head covering based on its symbolism is not evidence-based, and should not be a basis for a nationwide practice recommendation," AORN wrote. "Several types of evidence exist that support recommendations that perioperative personnel cover their head and ears in the OR."

AORN's director of evidence-based perioperative practice compared surgeons wearing skullcaps to OR nurses wearing white wing-tipped nursing caps. "It's a symbol of the nursing profession, but that doesn't mean it has any place in the operating room," says Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN.

As you might imagine, Dr. Hollander does not appreciate being told what to wear in the OR by a surgical nurse association.

"No offense to nurses, but they're not surgeons," he says. "The surgeons are the ones who are responsible for the patients. Why are nurses dictating to the surgeons how you're going to dress for surgery? I'm kind of shocked. It seems like a silly thing. You kind of giggle a little bit about this kind of discussion."

But this is no laughing matter. Dr. Hollander says his hospital's chief of surgery sat him down to ask him to comply with the new dress code and to leave his skullcaps at home. He says he'll wear the hat of the underling, even though skullcaps fit better, absorb perspiration better and look better than cloth bouffant hats. Even though long hair slips out of bouffants. And even though no evidence exists that bouffants do a better job of decreasing patient exposure to a surgeon's hair, dandruff or flaking skin than skullcaps. He'll do it, but he won't like it. OSM