More germs Planes desks and even kisses

Airplanes are so permeated with bacteria that it is truly a wonder that anyone survives a flight. Ill bet you thought it was the air in the cabin, but a recent story in USA Today says otherwise. "The real problems lie on the chair upholstery, the tray table, the armrests and the toilet handle."

What should germophobic passengers do? "First, they should travel with and use an alcohol-based hand sanitizer. They should also travel with a small pack of disinfectant wipes," said the microbiologist who did the study. "The first thing I do when I sit down is to wipe down the armrest and tray table because thats where my arms will be. You need to decontaminate where youll be spending your time and eating."

From MailOnline: "Millions of us spend our days slaving over a keyboard. But lurking between the keys, hidden on the mouse and nestled in your phone lies [sic] more than 10 million bacteria—400 times more than on the average toilet seat." [Despite what I reported in my last post, the toilet seat will remain the gold standard for comparing contamination levels until it is unseated.]

At least that is way fewer bacteria than the next study found.

"Every Kiss Begins With 80 Million Germs" headlines WebMD about a paper published in the journal Microbiome. WebMD story says, "In one experiment, the researchers gave 21 couples a probiotic drink containing bacteria before they kissed. Swab samples afterwards showed the transfer of those 80 million germs."

From the methods section of the paper: "One of the partners was invited to consume 50 ml of a probiotic yogurt drink containing L. rhamnosus GG, L. acidophilus LA5, and B. lactis BB12 [all non-pathogens]. After 10 seconds, saliva and tongue swabs were collected from this partner (donator) and after a second intimate ["full tongue contact and saliva exchange"] kiss of 10 seconds, saliva and tongue swabs were directly collected from the other partner (receiver)."

Saliva has some antibacterial properties. Maybe the researchers didnt wait long enough to test for bacteria after one of the partners drank the yogurt? People who have 80 million pathogenic bacteria in their mouths probably have bad breath and poor oral hygiene. I doubt they are indulging in 10 second tongue kissing.

And heres an excerpt from the conclusion. "This study indicates that a shared salivary microbiota requires a frequent and recent bacterial exchange and is most pronounced in couples with relatively high intimate kiss frequencies of at least nine intimate kisses per day [my emphasis] or in couples sampled no longer than 1.5 hours after the latest kiss."

Ten second kisses? Nine intimate kisses per day? Other than perhaps high school kids, who is kissing 9 times a day for 10 seconds at a time?

Bottom line? After eating yogurt, wait at least 90 minutes before tongue kissing someone.

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How to rank surgical residency programs

In September, Doximity, a closed online community of over 300,000 physicians, released its ratings of residency programs in nearly every specialty. Many, including me, took issue with the methodology. Emergency medicine societies met with Doximitys co-founder over the issue and echoed some of the comments I had made about the lack of objectivity and emphasis on reputation.

I wonder if it is even possible to develop a set of valid criteria to rate residency programs. Every one I can think of is open to question. Lets take a look at some of them.

Reputation is an unavoidable component in any rating system. Unfortunately, it is rarely based on personal knowledge of any program because there is no way for anyone not directly involved with a program to assess its quality. Reputation is built on history, but all programs have turnover of chairs and faculty. Just as in sports, maintaining a dynasty over many years can sometimes be difficult. Deciding how much weight should be given to reputation is also problematic.

The schools that residents come from might be indicative of a programs quality, but university-based residencies tend to attract applicants from better medical schools. The other issue is who is to say which schools are the best?

Faculty and resident research is easy to measure but may be irrelevant when trying to answer the question of which programs produce the best clinical surgeons. Since professors tend to move from place to place, the current faculty may not be around for the entire 5 years of a surgery residents training.

The number of residents who obtain subspecialty fellowships and where those fellowships are might be worthwhile, but would penalize programs that attract candidates who may be exceptional but are happy to become mere general surgeons.

Resident case loads including volume and breadth of experience would be very useful. However, these numbers have to be self-reported by programs. Self-reported data are often unreliable. Here are some examples why.

For several years, M.D. Anderson has been number one on the list of cancer hospitals as compiled by US News. It turns out that for 7 of those years, the hospital was counting all patients who were admitted through its emergency department as transfers and therefore not included in mortality figures. This resulted in the exclusion of 40% of M.D. Andersons admissions, many of whom were likely the sickest patients.

The number and types of cases done by residents in a program have always been self-reported. The Residency Review Committee for Surgery and The American Board of Surgery have no way of independently verifying the number of cases done by residents, the level of resident participation in any specific case, or whether the minimum numbers for certain complex cases have truly been met.

So where does that leave us?

Im not sure. I am interested in hearing what you have to say about how residency programs can be ranked.

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