September 17, 2015
On a warm August 2004 day in Philadelphia, I joined 150 first-year medical students on stage at the University of Pennsylvania to celebrate the start of our medical careers. The dean called our names and, one by one, draped short white coats around our shoulders. We then stood together as a class and recited the Hippocratic Oath, reflecting on the importance of becoming humanistic physicians. My parents had driven up from Kentucky and proudly sat in the audience. It was a powerful ritual and a memorable day.
During my four years of medical school, I wore that short white coat on the hospital wards. After graduation, I moved to California and traded in the short white coat for a long one. Residency was exhausting. I was on call for 30 hours every few nights, my coat became sullied, and it was difficult to keep it pristine even with frequent washing. Once, after rounds in the intensive care unit, the attending physician took me aside. "Do a better job washing that coat," he admonished me. "Patients and their families shouldn't see you like that." But even with bleach, my coat never regained its original luster.
Several years later, I am an infectious diseases fellow at Massachusetts General Hospital and Brigham and Women's Hospital and help teach the Harvard Medical School students when they do their infectious diseases clinical rotations. When I came here, I was given new white coats embroidered with the names of the prestigious institutions where I work. But I have never worn them.
And now, with a few years of experience, I have come to believe that we should get rid of white coats and reorient rite-of-passage ceremonies away from them.
You wouldn't want to be cared for by a doctor who doesn't wash his or her hands. You wouldn't want to be operated on with instruments that weren't sterilized or stay in a hospital room that wasn't cleaned regularly. Why would you want to be treated by a doctor wearing a white coat that hasn't been washed in a week? Many white coats are covered in bacteria like MRSA -- they are dirty. And it's time to hang them up for good.
According to the Society of Healthcare Epidemiology (SHEA) guidelines:
Health care personnel (HCP) apparel can hypothetically serve as a vector for pathogen cross-transmission in healthcare settings; however, no clinical data yet exist to define the impact of HCP apparel on transmission."
Does the absence of evidence equal evidence of absence?
Eli Perencevich and Mike Edmond, physicians at the University of Iowa, have studied this issue in depth. They admit that while transmission to patients hasn't been definitely proven, there is strong circumstantial evidence that it could occur. But no one has ever funded the necessary studies to find out for sure.
Unfortunately, a randomized trial of white coats would cost upwards of US$20 million, and this money has not been budgeted by the National Institutes of Health, the premier research organization of the federal government. In the bigger picture, Perencevich and Edmond argue that just like we don't need a randomized trial to prove that parachutes save lives, we also don't need a trial of white coats. The circumstantial evidence that many of them are covered in germs is sufficient.
Physicians haven't always worn white coats. Until the late 19th century, surgeons operated wearing black coats, as Atul Gawande explained in his fine article, "Slow Ideas."
Although Edinburgh physician Dr. Joseph Lister had discovered that being free of microorganisms (antisepsis) reduced the risk of hospital-acquired infections, it took years for doctors to get rid of their black coats.
... hand washing was still perfunctory. Surgeons soaked their instruments in carbolic acid, but they continued to operate in black frock coats stiffened with the blood and viscera of previous operations -- the badge of a busy practice.
But, Gawande goes on, some surgeons wanted to promote a different vision of their profession.
A few pioneering Germans, however, seized on the idea of the surgeon as scientist. They traded in their black coats for pristine laboratory whites, refashioned their operating rooms to achieve the exacting sterility of a bacteriological lab, and embraced anatomic precision over speed.
And white coats took off. They have always been a symbol, but the white coat ceremony is actually a recent invention, having been developed in 1993 by the Arnold P. Gold Foundation. This ceremony is now a mainstay at the majority of medical schools and many nursing and allied health schools as well, meant to connect student to the "noble tradition of doctoring."
And it's not just tradition that keeps physicians in white coats. Doctors give a variety of reasons for wearing them -- to carry papers, because hospitals are cold or for a confidence boost when facing a stressful situation. Female physicians also face the challenge of being misidentified if they don't wear a white coat.
Yet the situation is notably different in many countries in Europe. In the United Kingdom, for example, physicians simply don't wear white coats when seeing patients because they have adopted a "bare below the elbows" policy. In the UK, only pathologists and other laboratory based physicians wear them, and those coats don't leave the lab.
A few months ago Dr. Vineet Chopra and Dr. Sanjay Saint wrote an article arguing that patients prefer white coats. They suggested that formal attire with long-sleeved shirts and ties for men and business attire for women be worn while they conduct a survey of thousands of patients from the US, Italy, Switzerland and Japan.
I disagree. At least one study from Scotland suggested that patients feel that their doctors' appearance was not as important as compassion, politeness and knowledge. Only half of patients felt that the style of clothing mattered. And patients felt an impression of cleanliness and good personal hygiene were more important. In fact, patients preferred a "smart casual" style of dress, which conformed with a "bare below the elbows" dress code policy. This would presumably reduce the transmission of bacteria to patients if rigorous handwashing were employed.
And in any event, patient preferences are primarily shaped by cultural norms rather than medical evidence. Patients rarely perceive that white coats can be covered with bacteria, that coats are infrequently washed, that white coats can make a health care worker's hands dirtier, and that coats could lead to serious infections.
Patients also don't realize that this debate has been going in circles for years with little action in the United States.
The culture of medicine is very powerful, and old habits, like white coats, are hard to break. But doctors are still doctors whether they wear a coat or not. And even if white coats inspire trust in some patients, whatever theoretical benefits the coats may have aren't worth the downsides. There is no harm in avoiding white coats, but there could be danger in wearing one.
Primum non nocere. First, do no harm, my fellow physicians. That starts with rethinking the white coat ceremony.
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