Magical Thinking

About 10 years ago my hospital decided it needed to develop a drug testing policy for its residents. The goal was to prevent young doctors from working while impaired. As a seasoned residency director, I couldn’t make much sense of this. In my estimation, impairment at work was common among residents, but rarely, if ever, from drug use. Rather, the effects of acute and chronic sleep deprivation were widespread. Yet when I suggested we develop a policy to limit work hours rather than do drug testing, I was treated as if I were insane. It took another decade and reports and regulations from the Accreditation Council on Graduate Medical Education (ACGME) and the Institute of Medicine (IOM) to convince doctors what the average adult human being has known since the beginning of time: sleep deprivation is not healthy and it affects work performance.

In 2007 when the UK National Health Service announced its ban on white coats and neckties and mandated a “bare below the elbows” approach, I thought about this for awhile and came to realize how perfectly rational was this mandate. White coats are typically not laundered daily and come into contact with many patients over the course of time they are worn. Numerous studies have documented that pathogens, including MRSA, can be cultured from them. While most healthcare workers have come to appreciate the need for hand hygiene, they think nothing of donning their contaminated coats daily and carrying bad bugs from one hospital room to another. Moreover, when confronted, many physicians, including some experts in healthcare epidemiology, argue that no one has shown that lab coats transmit infections. While that is technically true, it’s another example of magical thinking. Many physicians have a great deal of difficulty thinking rationally about their white coats. The need to wear it is deeply inculcated, and for some I think it’s inextricably tied to their egos. Despite being among the most educated persons on earth, physicians often hold deeply rooted biases that trump rationality.

At the Society for Healthcare Epidemiology Meeting last week in San Diego, my group presented two papers that should help doctors rid themselves of their beloved white coats. Dan Markley presented results of a survey of doctors that showed that roughly one-third wash their white coats weekly, another third every other week, and the remaining third wash their coats monthly or even less often. Dawn Butler presented her work showing that in the laboratory organisms inoculated onto white coats can indeed be transferred from the coat to skin with little effort.

Over a year ago, I adopted the “bare below the elbows” approach when I work in the inpatient setting. It has made me cognizant of several things: how often the skin of my forearms touches patients in the course of care, how visibly dirty many lab coats are, and how much easier it is for me to wash my hands without worrying about getting the cuffs of my shirt or coat wet.

At this point, there’s enough evidence to conclude that the potential for white coats to transmit infection is biologically plausible. And while we rarely change practice on the basis of biologic plausibility alone in medicine, a strong argument can be made to do so when the intervention poses no harm, has the potential to improve care, and costs little. Therefore, the infection control committee at my hospital has recently recommended that all healthcare workers follow “bare below the elbows” in the inpatient setting.

I’ll discuss the white coat and professionalism issues in a future posting.