Yes we can!

In early 2009, I bought three North Face black vests for myself and my colleagues Gonzalo Bearman and Mike Stevens at VCU Medical Center. Our Infection Control Committee had recently recommended that all healthcare workers adopt a bare below the elbows approach when providing care in the inpatient setting. The vests were good at providing some additional warmth on winter days. We avoided fleece and opted for vests that were nylon on the external surface so that they could be easily cleaned with a disinfectant wipe. We started bare below the elbows with just three people in a hospital with a workforce of 10,000.

We didn’t mandate bare below the elbows and we didn’t aggressively push it. We rolled out an educational campaign with a personal infection prevention bundle that had three components: bare below the elbows, hand hygiene before and after patient contact, and stethoscope wipe down after every patient exam. We talked about it in new employee and new housestaff orientation sessions, always noting that this was a recommendation. We had no support from hospital administration, though no one tried to obstruct us. Importantly, we gave doctors permission to not wear white coats and neckties, and continued to role model the approach as we saw patients. Given how attached some physicians are to their white coats, we knew that a mandate would produce a backlash and doom our plans. Still we got some pushback, but our response to the naysayers was consistent, “You’re not required to do this. It’s just a recommendation.” It's hard for anyone to argue with that.

Here we are a decade later, and this week saw the publication of our results with this experiment in the American Journal of Infection Control. Across 40,000 observed encounters in calendar year 2017, overall compliance with bare below the elbows was 84%. Probably not too surprising, physicians were the laggards at 67%, with most other groups in the high 80s or even 90s. But having two-thirds of doctor-patient encounters occur without the 20-square-foot microbiological zoo (AKA white coat), is pretty damn astounding.

What’s also interesting is that in the prior year, overall compliance was only 40%. In hindsight, we can see that 2016 appears to have been the tipping point as compliance doubled in the ensuing year. Now, bare below the elbows is part of the institutional culture. I have given many talks in the past decade on this topic where I’ve been told repeatedly that doctors will never give up their white coats, but Gonzalo tells me that it is now unusual to see a doctor in a white coat on the wards.

There are a couple of lessons here. We’ve again confirmed that changing behavior in health-related interventions is a slow process (probably even slower when the person whose health is impacted isn’t the person whose behavior must be changed). But more importantly, you don’t have to beat people over the head to make it happen. Provide encouraging messaging, role model the behavior, and let uptake diffuse. Patience is key.

Kudos to Gonzalo and Mike for persisting, and to everyone at VCU in the 84% who stepped forward. When I start service tomorrow it will be 10°F here in Iowa, and though this poikilotherm would like to be bundled in 20 layers, you can bet your bottom dollar that I’ll be bare below the elbows.

Work Attire

I'm a creature of habit. My first activity every day is to read the New York Times. Depending on my schedule, some days I read more articles than others. This week I was away at a conference and found myself with some early morning extra time before the first meeting session, so I delved into the Arts section. I began to read the first article: Women of the Philharmonic Can Play It All. Just Not in Pants. It begins:

Women can wear pants at the Oscars, the Tony Awards and state dinners. They can wear pants while graduating from the Naval Academy, figure skating at the Olympics and running for president. They can wear them at just about any workplace in America.

But when the women of the New York Philharmonic walked on stage at David Geffen Hall recently to play Mozart and Tchaikovsky, they all wore floor-length black skirts or gowns. And they’re required to: The Philharmonic, alone among the nation’s 20 largest orchestras, does not allow women to wear pants for formal evening concerts.

The article goes on to discuss some of the unique problems that this dress code presents for musicians, such as the difficulties encountered when playing large stringed instruments, and one woman who plays the English horn recounted how the folds of her long dress got caught in the keys of her instrument during a critical passage.

I found the article interesting, but as an outsider to the music world simply thought that it's another example of how the frivolous often eclipses the big issues in life. Then I came to this quote from a female violinist, “One thing is really clear: People in the orchestra want to remain dressy. It’s important that we look like we care. That is sending a message. We put so much into the preparation of our programs that, yes, we need to look good as well.” At this point the light bulb turned on and all of the dots connected for me: here is the musical equivalent of the judgmental doctors who think that all doctors must wear white coats. And then I knew that the pathologic manifestations of professionalism are not limited to medicine.

Well at least in medicine our clothing police aren't sexist, I thought. But then I remembered that it was only three years ago that Mayo Clinic dropped its pantyhose requirement for women physicians. And in a recent essay, Roshini Pinto-Powell, the Associate Dean of Student Affairs at the Geisel School of Medicine at Dartmouth, writes about how professionalism forces nearly every woman interviewing for medical school or residency to follow rigid rules of dress that makes her look like a penguin. Maybe we aren't ahead of the New York Philharmonic after all.

You might think that in medicine we've overcome ageism and classism in our sartorial expectations. However, it's worth pointing out that the Department of Medicine at Johns Hopkins is just now dropping the requirement of short white coats for interns. In the video attached to this article about that in the Baltimore Sun, the Internal Medicine Chief Residents express their sorrow at the loss of the short coat. Really? In 2018? Yet almost everywhere medical students are still relegated to the short coat. How about we just get rid of them all given that hierarchy with its associated authority gradient in medicine makes it much less likely that a short-coated person will speak up when she sees a long-coated person about to make an error?

On a happy note, there are always positive deviants, and I want to point out two of them. In the musical world, there is Seiji Ozawa, who was the conductor of the Boston Symphony for three decades. Instead of wearing the customary white tie and tails, he boldly wore a white turtleneck and tails, a look that became his trademark. The other is Jorge Mario Bergolio. As he was about to step out onto the balcony in St. Peter's Square to be introduced to the world as Francis, he was handed the mozzetta, a short red velvet cape trimmed in ermine worn only by the pope. He declined this heirarchical symbol despite the professionalistic expectations of his peers in the College of Cardinals.

I remain convinced that we need to assess work attire using simple humanistic criteria. Your clothes should be clean, comfortable, functional, and safe. No need for white coats. No long gowns. No mozzetta. No penguin suits. And the only people that will care are those who remain blinded by professionalism.

How I chose my doctor

Four years ago after moving back to Iowa City, I needed to find a new primary care doctor. I went to the University’s website and scanned the list of general internists. There I noted a physician that I had known when she was a medical student during my prior stint at the University of Iowa twenty years earlier. She had been an amazing medical student--very bright, hardworking, conscientious, and intellectually curious. My guess was that she now was an amazing internist. I asked a few colleagues about her and the responses were consistent: a superb clinician, an internist’s internist. Exactly what I was looking for.

I scheduled a new patient visit with Dr. B. Was I ever impressed! No stone was left unturned. She didn’t treat me like a doctor (for non-medical readers, that's a good thing). She took a complete history, including asking me if I ever used IV drugs. She took a sexual history. She then performed a complete exam, including genital and rectal exams. I note this as sometimes doctors skip these parts of the H&P given the somewhat awkward situation when they know the patient (another doctor) personally. At the end of the visit, I recall telling her that the encounter should have been videotaped for use as an exemplar for students and residents. When I arrived back to my office, I sent a note to the Chair of Internal Medicine to apprise him of her superb care. He wrote me back: “Yes, Dr. B is the crown jewel of the Department of Internal Medicine.”

Now let’s leave my story for a minute and examine a new study in the BMJ from the University of Michigan on patient preference for physician attire. This is a survey of a convenience sample of 4,000 patients at 10 US academic medical centers. It included both inpatients and outpatients, and used the design of many previous studies, showing patients the same doctor dressed seven different ways (scrubs, formal with white coat, etc.). After viewing the photographs, patients were questioned as to their preference of physician based on attire, as well as asked to rate the physician in the areas of knowledge, trust, care, approachability, and comfort.

The survey is well-designed and well-executed. I’ll let you review the paper if you want to know the results, since I don’t think the results have much validity, don’t merit much discussion, and I’ve blogged about these types of studies, previously (here, here, here, and here). I’m much more interested in why such studies are conducted, the biases they may represent, whether the researchers have an underlying agenda, the utility of the results, and how these studies are pathologic manifestations of professionalism.

Back to my story. Never once, before, during or after my clinic visit with Dr B, did I for a millisecond think about how she would be or was dressed. Granted, I’m not the typical patient as I have insider knowledge regarding doctors that the average patient does not. Even still, all patients want an authentically kind, compassionate, competent doctor who listens intently, and makes access to them easy. While they may have a preference for physician attire, when placed in context (as shown in a previous study), appearance is the least important patient satisfier. When appearance is further studied, attire is the least important characteristic, with hygiene and grooming taking precedence.

To ask patients to infer characteristics such as knowledge and trust on the basis of clothing is ludicrous on its face, and an insult to the study participants. "I chose the doctor with the beautiful tie," said no patient ever. I dislike this study for the same reasons that I dislike the tactics of Disney service excellence and Press-Ganey patient satisfaction initiatives. The common theme is that you can and should manipulate patients' perceptions without changing reality. Per the Michigan study, a white coat makes the doctor look more caring, but all of us know that a jerk in a white coat is still a jerk. If the doctor sits down while talking to a patient, the patient will perceive that they stayed in their room longer. How about sitting down because it makes the patient more comfortable?

The authors argue for patient-centered care and that “attire may be an important, modifiable component of patient care.” How does this study help us to provide patient-centered care since no matter how the data were sliced there was always a sizable fraction (often nearly half) of patients that didn’t agree with the majority opinion? Does this mean we should ask each patient which of the seven attire modes they would prefer before entering the exam room?

Lastly, I don’t think this study is really about what patients think of how doctors dress. Underneath it all, it’s a study about what some doctors think about how other doctors dress. And this is the ugly side of professionalism. Imagine a study where physicians are surveyed on the attire of nurses or carpenters. I think most people would find that creepy. Don’t most of us think that judging people on the basis of how they dress is superficial and somewhat creepy? And the test of whether this is about professionalism is to remove the occupational label in the survey. If patients were told to assess the attire of other people (not doctors) what would be the study implications? If we look at attire through the lens of humanism rather than professionalism, then what matters is simply that your work clothes are clean, comfortable, functional, and safe.

My advice to the Michigan doctors is this: take good care of your patients and they will love you, white coats and all.

The skullcap feud

There's a feud brewing between two professional societies on appropriate attire in the operating room. Earlier this year, AORN (the Association of periOperative Registered Nurses) issued updated guidelines on OR attire. The guideline forbids the wearing of skullcaps because the head covering should cover the head, hair, ears, facial hair, and nape of neck when personnel enter the semi-restricted and restricted areas of the OR. This didn't sit well with some surgeons, and the American College of Surgeons (ACS) issued their own statement on OR attire earlier this month. With regards to the skullcap, they state, "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 skull caps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case."

From AORN's perspective, the issue with skullcaps is the exposed ears and exposed hair at the base of the head, from which pathogens may contaminate the surgical field as hair and skin squames are shed. The counterargument, of course, is that there is no evidence to suggest that skullcaps have been associated with surgical site infections. And now we find ourselves in essentially the same quagmire as with white coats.

This week, AORN shot back, and they punched the good old boys right in the gonads. Says AORN, "head coverings based on symbolism and a personal attachment to historical norms have no place in the patient benefits analysis expected of guidelines developers." AORN rightly took the moral high ground and called out the ACS for using a professionalism argument to justify their stance. As I have argued before with regards to the white coat, professionalism exists to protect the profession, not the patient. So while the surgeons' argument with regards to lack of evidence has validity, the professionalism argument does not. And my thinking about the skullcap is the same as for the white coat: the biologic plausibility for causing infection should lead to a suggestion to avoid the skullcap but not a mandate. While AORN may argue that their recommendations are guidelines, the reality is that the Joint Commission enforces them as mandates.

I'm not a surgeon, but if I were, I'd give up my skullcap, just in case bacteria were falling off my earlobes. And I think these issues are much easier to resolve if we simply follow the dictum, the patient comes first in everything that we do.

While I'm on my moral high horse, and since I'm an equal opportunity critic, I'd be remiss if I didn't point out an issue with the AORN. You may have noticed that there is no link to the AORN attire guideline in this post, and that's because AORN sells their guidelines for $225. It seems to me that when any professional society has something so important to say that it is written into a guideline, they have a moral imperative to make the guideline accessible free of charge to everyone, particularly when the guideline impacts patient safety. This is but another example of the ugly side of professionalism, a decrepit concept that continues to haunt us.

Debating Bare Below the Elbows

At IDWeek in San Diego this past Saturday, I debated Neil Fishman on bare below the elbows, a topic that regular readers of this blog know is one of my favorites. I had 10 minutes to deliver the pro argument and Neil had the same for the con. You can read an unbiased account of the debate here.

So in my 10 minutes, here's what I argued:

• We have conclusive evidence that healthcare workers' clothing becomes contaminated with pathogens during the care of patients.
• There is some in vitro evidence that pathogens can be transmitted from clothing to patients.
• There is no evidence that intervening (removing white coats and neckties and having HCWs go bare below the elbows) reduces healthcare associated infections, though of course, absence of evidence is not necessarily absence of effect.
• The literature on patient preference for physician attire shows mixed results in weak studies where patients look at pictures of doctors in different attire, while studies that randomized attire show no difference in patient satisfaction, and others that add context show that attire is one of the least important characteristics that patients consider in evaluating their physician.
• On the basis of biologic plausibility, I argued that we should recommend (but not mandate) bare below the elbows.

Neil argued the following (and I've added my comments in italics):

•  We already have too many metrics to follow and we shouldn't add one more. We can't be the "fashion police." (There's no added work to implement bare below the elbows. Give HCWs permission to do it and provide some encouragement).
• Bare below the elbows is not enforceable (With no mandate there is nothing to enforce).
• Arms are just as likely to be contaminated as the sleeves of the white coat (True, but you can wash your arms between patients; in a survey of physicians that we published, nearly 20% reported that they had NEVER washed their white coats).
• 5% of the population has eczema or psoriasis, and these individuals have higher rates of staphylococcal colonization (True, but we usually don't formulate policy on the 5% exception). 
• If the white coat goes, all measures of hygiene will decline. (This is a borderline insane argument borrowed from Stephanie Dancer, that I previously blogged about here).

So what was the verdict? Before the debate, 37% of the audience supported bare below the elbows, and after the debate 42% were in support. So in 10 minutes I moved the needle 5 percentage points. Not dramatic, but I'll take it. But just imagine having this debate 10 years ago, or even 5 years ago; I suspect supporters would account for <10%.

Any intervention that involves changing behavior produces incremental results. But from firsthand experience, I know it can be done. At VCU, we recommended a bare below the elbows approach to inpatient care in 2009. It was a very soft rollout--no mandate, just a recommendation. Gonzalo Bearman, Mike Stevens and I consistently wore scrubs and others slowly joined in. It started with just three people. Last year before I left VCU, we did a 12-week prevalence survey and we were pleasantly surprised to see that 69% of inpatient encounters were via HCWs bare below the elbows. This year, it has increased to 80%. Compliance was boosted when the medical school bought their students scrubs and nylon vests (see the photo of Gonzalo with some VCU medical students). I think this is an amazing accomplishment, and I will venture a guess that 10 years from now, the vast majority of doctors in the US will look just like those in that picture.

Clothing and corporate culture

Anyone who is a regular reader of our blog knows that healthcare worker clothing is a favorite topic, from the viewpoints of both infection control and "professionalism." And as we've recently blogged, colleagues at the University of Michigan are trying to ramp up professional attire, calling for doctors to put their white coats back on. But they've been outdone by Summa Health System in Ohio. Summa has now mandated that all healthcare workers at their hospital must wear underwear. That's right, no more going commando at Summa! [I did not make this up--see here]. Now as a pragmatist I have to wonder who is in charge of inspection and enforcement of that policy and exactly how they will inspect and enforce.

All of this reminds me of that classic SNL skit where Will Ferrell does indeed wear underwear to work.

I guess it's all about corporate culture. One company well known to many healthcare personnel is the behemoth EMR vendor, Epic. Its corporate culture makes it a place that is well known for employee engagement and friendliness. Having visited the Epic campus recently, I can attest to the palpable enthusiasm of its workers. Epic's dress code? When there are visitors, you must wear clothes. No mention of underwear, though.

Today's lesson: Take your zoo off and put your smile on

I ran across two great quotes regarding the white coat today:

• In a piece in KevinMD.com published today, Shivam Joshi, an internal medicine resident, writes about doctors wearing their white coats in grocery stores. He describes the white coat as "20 square feet of a microbiological zoo."
  
  
• Over at BMJ, Edmond Fernandes argues in an essay that physicians in India should stop wearing white coats. Here is the money quote: [White coats] are mere symbolism and wearing them does not itself confer status or professionalism. Dressing presentably and sporting a smile are more important than white coats.

The white coat debate continues on and on and on and on...

I couldn’t resist blogging in response to Eli’s recent post regarding doctors’ attire. I guess this debate continues on with some new warriors from the University of Michigan. They plan to do a bigger, worldwide study of patient preference for physician attire. We really do need another meaningless study on this topic, don’t you think? While they’re at it, I think they should ask patients their favorite color, favorite flower, and favorite season of the year, because it would have the same impact.

I have blogged on this topic many times (see here, here, here, here, and here) and I won’t rehash all the arguments in this post. But these are the most important ones, I believe:

1. I think we need to act consistently about the role of clothing in infection control. That is, if you believe that contaminated clothing plays no role in transmission of infection, then be consistent and eliminate contact precautions. If you do believe that clothing may transmit pathogens, ditch the white coat and employ bare below the elbows or contact precautions, or some combination of the two. Or if you believe that the white coat magically resists contamination by pathogens, disclose that as well and those of us who believe in the germ theory and other scientific concepts like global warming can move on.
2. If you think that we need more data about patient preference then put the issue of physician attire into context in your survey or test your hypothesis with a clinical trial. Both types of studies have been done. And the results are clear: when placed into context, patients find physician attire to not be very important (not really surprising—most patients would rather have a kind physician who listens well and wears scrubs than a mannequin in a white coat) and when formally tested in clinical trials, attire had no impact on patient satisfaction with their care (see here and here).
3. The white coat is all about the doctor, more specifically the doctor’s ego. It’s truly about professionalism in the most negative sense of that concept (physicians judging other physicians to “protect the profession”).

In my current job as Chief Quality Officer at an academic medical center, I am able to separate my time fairly cleanly into clinical time and administrative time. When I am seeing patients, I wear scrubs, have done so for the past 6 years, and have never had a complaint. Interestingly, when my CEO sees me in scrubs, he always points to the scrubs and comments, “that’s a good look!” I also don’t consistently introduce myself as “Doctor,” particularly in situations where I am likely to follow a patient over a long period of time, and in cases where the patient’s status is tenuous and they need to be able to reach me quickly, I give them my cell phone number. Call my crazy, but this approach to patient care works well for me. When I’m working in my administrative role, I frequently wear a tie, though not always, rarely wear a sports jacket, and almost never a suit. Most physicians have enough common sense to dress appropriately for work, so very few need to be told how to dress. And I respect the fact that each of us has our own style. How you dress is a personal decision, a reflection of who you are. By the same token, there are some patients who prefer their doctor to dress more casually. There is no one size fits all.

So to our colleagues in Michigan, a challenge: in your new survey ask patients the following question: which is more important to you—that your physician be dressed in a white coat or that your physician gives you his/her cell phone number? I can’t wait to see the results.

My on-again, off-again relationship with the white coat

Silvia Munoz-Price, MD

This is a guest post by Dr. Silvia Munoz-Price, Associate Professor of Clinical Medicine at the University of Miami Miller School of Medicine and Hospital Epidemiologist at Jackson Memorial Hospital.

All the comments after the SHEA attire guidance paper made me reflect a lot, in particular about white coats. So here are my two cents on the topic based on my very personal, and thus very biased experiences.

In a piece like this, I am forced to start with my first conscious experience with white coats, which came from my dad. He would come home –all dressed in white-- after his OB/GYN overnight calls, sit on the sofa with me on his lap and tell me about all his challenging cases. I wanted so badly to be as good of a doctor as he was…but especially, I wanted to look like him…wearing pristine white clothes. Thank you dad for those special moments you shared with me…they were very meaningful.

Let's fast-forward a decade or so to the first clinical rotations in medical school. Wearing the white coat…felt really good. Let’s pause here and give you some context: I did medical school during the nineties in a Latin American inner city public hospital. During my early clinical rotations I had one of my most profound realizations about gender and the medical profession: patients would address any male technician wearing a white coat as a Doctor. Here I come (very young, I admit, less than 20) wearing my white coat. How am I addressed? You guessed right, Miss…which was an accurate description and would have been ok if all my male classmates wearing their white coats wouldn’t have been addressed as Doctors. Those inequalities never ended throughout med school. I thought it was unfair but highly reflective of a male dominated society.

Let's move forward another 5 years, Internal Medicine residency in the US. There are two issues related to attire that I think are worth sharing. One: How often did I launder my white coat? Well, I think it was whenever my sleeves turned disgustingly gray and I could not possibly bear wearing it any longer. Two: nobody ever told me how frequently I was supposed to launder my white coat. While I write this piece I am trying to think if I ever thought the sleeve test was adequate or not…to be honest, I don’t think I ever thought about it. I was too busy and too tired to bother thinking on those alien thoughts.

Fast-forward 5 more years…my period in private practice in the Midwest. It was amazing to me how so few docs wore white coats across the many community hospitals I cross-covered. White coats were substituted by nice—and in some cases, expensive—clothes. During my first year I wore white coats but soon this faded into suits. This is interesting…not wearing a white coat was done by most and accepted by all. No attire guidance, no white coats, no fuss. I am not saying this is right or wrong, after all, it is indeed hard to do hand hygiene with the sleeves of a suit in the way. I just find it interesting how cultural this “white coat” or “no-white coat” phenomenon is.

Another 5 more years: my life in academia. There are at least three points that I frequently reflect on about white coats in this setting:

-One: white coats are a symbol of power. I see this every month in my hospital’s Board Room…towards one side of the table, Department Chairs predominantly males, in their late 50s to early 70s, all wearing impeccable and sparkling white coats (even though many do not see patients any time around that particular meeting)…on the other side, hospital administrators wearing suits. Interesting dynamics. Why do Chairs feel compelled to wear white coats to a meeting if there are no patients around? I understand that some medical professionals think that white coats provide reassurance to patients…but who gets reassurance with white coats in a board meeting? Themselves!

-Two: As an attending in academia, wearing white coats serves as a gender (and maybe age) equalizer.[I think the same might happen with suits in private practice. This is hard for me to explain, so let me give an example and I will let you make your own conclusions. Imagine you are a consultant that comes to a particular hospital rather infrequently. Imagine a fifty-year old male comes into the unit wearing a white coat. Who do you think he is? Probably a doctor. Now imagine a fifty-year old female comes into the same unit wearing the same white coat. Now what do you think? Probably also a doctor. Now, lets get rid of the white coats and put a suit on the male and a dress on the female. What would you think now? Responses will be less homogeneous this time, but whatever you argue would be strongly influenced by your social context and your own personal experiences. White coats are indeed powerful symbols; unfortunately, they do not fully equalize genders. As an example, let me share with you what happened to me a few days ago despite wearing a white coat… here comes a cute old Hispanic lady … “Señorita [Miss], how do I get to 7East?” Yes, sadly, even now in my late thirties and with a second doctoral degree…that continues to happen…but…does it matter? Should it matter? Should I even put any thought into the way family members or families perceive me?

-Three: During 2010-2012 I did a couple of studies looking at contamination of attire. We found that white coats were more contaminated than scrubs and that hand contamination was associated with contamination of white coats, but not with scrubs. Also, in a survey among our providers we found that scrubs were laundered daily but white coats were laundered in average every 2 weeks. This was interesting as nobody had told providers how frequently to launder either piece, but they spontaneously performed laundering with different frequencies on these two types of attires. Why? One is in intimate contact with our skin [scrubs] and the other one is not [white coats]. One has to do with our individual comfort and protection [scrubs], and the other one is mostly in contact with patient’s surfaces [white coats]. The reason why this differential behavior occurs is so far unexplored. Regardless, I decided to start the trend at my hospital to wear scrubs and forego white coats for my teams and me. This lasted about a year and ended as we were writing the SHEA attire guidance, as I decided that I wasn’t going to agree to one thing in that publication and do something else in real life. I have to admit that I really enjoyed being able to wear the white coat again…being able to look and to feel like a real doctor again…and to blend in with my colleagues in academia. My fellows were ecstatic because now they would be able to carry all their stuff in their white coats.

I think the SHEA attire guidance paper had a measured approach to white coats. Even though there is no hard data that attire contributes to horizontal transmission of bacteria, we still felt that there was a need to provide some guidance on how frequently to launder our attire. A minimum of once a week sounded like a good compromise (I wanted this to be a minimum of 3 times a week!!). Regardless, I think this guidance is very helpful, as somebody needed to establish a minimum laundering frequency so that the sleeve test stops occurring.

White coats…such strong symbols of who we are…they not only reassure patients…they reassure us, physicians. Look inside of you…do you think white coats might be hiding some of your own personal and professional insecurities? To some degree…yes. Some of the passionate reactions against the attire guidance paper seem to indicate so. But, we should all be clear that when we discuss white coats, we are not doing this because of infection control reasons. If we used an infection control rationale solely, then there wouldn’t be any use for white coats, as they do not protect patients or providers, I would argue that it is the opposite for patients (we just haven’t proved this yet). Culture, social context, age, gender, and perception… these are all issues tied to white coats.

Let me end this piece with something that happened a week ago in the Board Room. That day I was already writing this piece. The room, as usual, was filled with white coats or suits, and had a marked older male predominance. I was sitting to the side pondering about these thoughts, wearing a white blouse and a red pencil skirt, getting ready to address the crowd. How will this crowd perceive me? A relatively young, Latin physician with an accent…would this perception be different if I were wearing a white coat just like them? And most importantly…should this matter? As I approached the podium and gave them my Infection Control update…I can honestly say that I felt fully confident on what I was saying and how I looked, of what I had accomplished so far, and of all the wonderful things I will accomplish in the future…and all this happened without wearing a white coat.

Does the white coat make the doctor?

There's a new piece in The Atlantic entitled The Psychology of Lululemon (free full text here). I probably would not have read that article but for the fact that I was in Lululemon just a few days ago buying my wife some yoga clothes for Christmas. This turned out to be an interesting read. The premise of the piece is that athletic clothing makes people want to work out--that in some way, clothes have power over the wearer. Of course, I began to think about the implications of the white coat for doctors, particularly because I remembered a survey we did a few years ago where some physicians mentioned that wearing a white coat made them feel more confident. I must admit that at the time I thought that was fairly absurd.

The Atlantic article cites a study from the Journal of Experimental Social Psychology, which I reviewed. Turns out, Eli blogged on this paper last year, so I won't belabor all the details. In a nutshell, investigators at Northwestern University set up a series of experiments in which subjects performed cognitive tasks that measured selective or sustained attention. In one trial some subjects wore white coats and some didn't; interestingly, those who did performed better by a factor of two. In another experiment, all the subjects wore white coats but some were told they were wearing a doctor's coat, while others were told they were wearing a painter's coat. The doctor's coat group scored significantly better. The results led the investigators to coin the term enclothed cognition, which they defined as the systematic influence that clothes have on the wearer's psychological processes.

Rehashing this paper made me stop and wonder whether after being white-coat free for the past five years I should put that dirty old thing back on. It is true that I know some very smart physicians who are never to be seen without their white coats. On the other hand, I also know some white-coated doctors, probably just as many, that I hope to never meet on the other end of a stethoscope. Maybe I'm just too grounded in reality. As much as I wish that if I ensconced myself in Under Armour my athletic abilities would surge, there's not enough magical thinking on earth to tear me from the bitter reality that my skinny, scrawny body would not perform any differently.

While I'll have to bow to science and come to grips with the concept of enclothed cognition, I still believe that keeping patients from contact with contaminated coat sleeves trumps whatever small intellectual edge the white coat might provide. As the psychologists have shown, it's all in your head. So here's my recommendation: as you enter your next patient's room, bare below the elbows in your freshly laundered scrubs, stop for a split second and imagine yourself sporting a shiny white coat in all of its radiant splendor with a Superman logo blazing above the chest pocket. Then strut confidently into that room, and bedazzle the patient with your diagnostic brilliance.  

More dirty laundry......

A new study in the American Journal of Infection Control by Dr. Silvia Munoz-Price and her team at the University of Miami provides additional insights on laundering of clothing worn in the clinical setting. In a convenience sample of 160 physicians and medical students, the Miami team found that white coats were laundered on average every 12.4 days, while scrubs were laundered every 1.7 days. I found it a little surprising that for scrubs the frequency wasn't closer to 1.0, but that's tremendously better than 12 days! For both coats and scrubs, faculty laundered their attire more often than housestaff or students. Interestingly, the major reasons given for wearing white coats were: (1) ego (makes me looks and feel like a doctor, 29%), and (2) storage needs (25%). Neither is a good reason.

Late last year, the same team published a study that found that white coats were more commonly contaminated with pathogens than were scrubs in the ICU setting. Moreover, if the hands were contaminated with a pathogen, white coats were more commonly contaminated than were scrubs. And all of the HCWs with negative hand cultures were dressed in scrubs.

Both studies were relatively small and performed in a single (though very large) medical center. Nonetheless, there is a body of evidence accumulating that clothing contamination in the clinical setting is a real phenomenon and probably should no longer be ignored by infection prevention programs. So I was delighted a few days ago to see that West Virginia University Hospitals is considering banning ties and white coats.

Photo:  Dr. Munoz-Price (far right), in scrubs!

Am I an indicator of a decline in hygiene?

A few weeks ago I was seeing patients at a clinic in an affluent suburb. My first patient of the day was a professional woman. At the end of the encounter, she said: "Can I ask you a question?" I had no idea where this was going, sensing that this was probably not going to be a medical question, but said, "of course." She then proceeded to ask me how I liked my Toms, as she wanted to buy her husband a pair. I was in my typical summer clinic attire, which consists of a polo jersey, khakis, and Toms (no socks). Now I think Toms are great--they're comfortable, not made of leather (i.e., animal friendly), and for every pair sold a pair is given away to a child in need. But this post isn't really about Toms.

The Toms question from my patient was a great segue for me to ask the patient about doctor's clothing. I asked her what she thought about how I was dressed and her expectations of how physicians should dress. She said that she saw me walk into the clinic and knew I was her doctor because she had Googled me before the visit. She noted the way I was dressed and thought I would probably put a lab coat on (by the tone of her voice I could tell she didn't like the lab coat concept). She went on to tell me that my clothes made me "a real human" and it made her more comfortable in interacting with me. I suspect that some other patients may feel differently, but I carefully follow my patient satisfaction scores and must admit that if my clothes are problematic, it's not reflected in my scores. Patients don't really care how their doctor is dressed, as long as the doctor demonstrates empathy, communicates well, and ensures that the patient has access to him/her when they have a problem.

There's an essay in this week's BMJ by Dr. Stephanie Dancer, former editor of the Journal of Hospital Infection. It's entitled, Put your ties back on: scruffy doctors damage our reputation and indicate a decline in hygiene. In her poorly argued essay, which I think is sexist and borders on crazy talk, she attempts to link the bare-below-the-elbows concept to lower standards for infection prevention. She writes:

"No tie"--along with stubble, spitting, picking your nose, and gravity defying trousers--symbolize the real status of hygiene in today's society.

In one paragraph she discounts the role of clothing in infection prevention:

Given that bed linen and pajamas are habitually contaminated with their owners' personal microbial flora, the focus on transmission from what staff are wearing seems disproportionate and perhaps even irrelevant. 

This, of course, fails to distinguish between endogenous and exogenous pathogens. A paragraph later she chastises doctors for wearing the same clothes for several days as it "showers the environment with millions of skin organisms."  However, the vast majority of clinicians who wear white coats wear the same coat for days to weeks without laundering them.

I continue to believe that bare below the elbows is useful in infection prevention as it reduces clothing contamination and makes compliance with hand hygiene easier. And I wholeheartedly believe that doctors should appear neat and clean. But I'm still trying to determine biologic plausibility for how banning neck ties has led to nose picking... Maybe it's because neckties function as handkerchiefs!

The newest tool to prevent infections

Over the past few years there has been a huge push across the country to reduce healthcare associated infections (HAIs). This has created a big market for entrepreneurs. In fact, according to BCC Research the market for HAI prevention products is expected to be $14 billion by 2016, at which time the market for antibiotics to treat HAIs is expected to be only $6 billion. Some hospitals have purchased high-tech hand hygiene monitoring devices that use radiofrequency identification, some have installed video cameras to observe hand hygiene, while others have invested in hydrogen peroxide robots. At my hospital we're investing in coat hooks. As we prepare to roll back contact precautions (i.e., no longer requiring patients with VRE or MRSA to be isolated except in special circumstances), we thought it would be good to re-visit bare below the elbows to reduce clothing contamination and promote good hand hygiene.

Several years ago, our infection control committee endorsed the bare-below-the-elbows concept. This means short sleeves, no neck ties, and no white coats. We specifically crafted our policy as a recommendation not a mandate since we believed there was enough evidence to recommend this intervention but not enough to require it. It was an intentional soft sell. Since the recommendation was made we have seen more physicians in scrubs, and our nurses are nearly all in scrubs. We still have the issue of long sleeves under scrubs when the weather is chilly, and we still have many doctors who just can't ditch the white coat.

So our latest effort, the "Hang it up" campaign, is a little more pragmatic, giving healthcare workers more options to comply with bare below the elbows. We're placing coat hooks in all physician team rooms and nurse work rooms with a poster (the physician poster is shown below) asking healthcare workers to hang up their jacket or white coat before going to see a patient. If a male doctor feels compelled to wear a necktie, we advise him to tuck it in his shirt.

We would have preferred to have coat hooks placed between patient rooms on wards, but fire regulations wouldn't allow that.

As I have said before, the longer I work in infection prevention, the more I believe it's a behavioral science. Old habits die hard, so the next few months should be quite interesting to observe.

Coat hook photo:  Binns 

My new white coat is a cool black vest

Those of you who have followed our blog for the past few years probably know that one of my favorite topics in infection prevention is the role of clothing in transmission of pathogens. But I'm also fascinated by the sociologic aspects of clothing in medicine, which is usually framed around questions of professionalism (for example, is a doctor in a white coat more "professional" than a doctor wearing scrubs?). So I was interested to see another paper on this topic in JAMA Internal Medicine (the journal formerly known as Archives of Internal Medicine). The study was a survey of family members of ICU patients in three Canadian ICUs. Over three hundred persons viewed photographs of physicians dressed in scrubs, business suits, white coats with neckties, or blue jeans. The study subjects were then asked to match the variously dressed doctors with certain attributes. In a nutshell, they found that families deemed the doctors in white coats to be most knowledgable, most honest, and best overall. Doctors in scrubs and white coats were deemed equally most competent and most caring.

I'm always amused by these studies because I've never met a patient who chose their doctor on a sartorial basis. It would be like buying a red car because you love that color even though you know nothing else about the car and never took it for a test drive. These types of studies, in my opinion, sell patients short. Yes, all of us form rapid first opinions about those we encounter, but almost all of us are sophisticated enough to quickly move past superficial qualities to assess a person's honesty, ability to communicate, and for physicians, his/her ability to demonstrate empathy. Lastly, the entire premise of the study seems strange--while you might choose your primary care doctor, it's extremely unlikely that you will choose your intensivist. The accompanying editorial is congruent with my line of thinking and concludes that professional behavior is far more important to patients and families than professional appearance.

I stopped wearing a white coat a decade ago, but many physicians still cling to it. Some wear them for storage, which my wife (also a doctor) tells me is more important for women since their clothing has fewer pockets. Some wear white coats as a form of identification, which may have held true when doctors were the only people in the hospital wearing them. Some wear them for warmth. And some just need the ego boost.

I was an early adopter of bare below the elbows and have only worn scrubs when seeing inpatients for the last five years. Smart phones and cargo scrub pants have taken care of my storage needs. But the one downside of scrubs is feeling cold in the winter. My partners and I recently solved that problem. We found vests that are lined but are constructed of nylon on the exterior surface, which allows them to be easily wiped down. They fit snugly so they don't drape onto the patient when performing an exam. And yes, they are warm! I'd like to take credit for the idea, but actually we copied our intensivists, most of whom are also bare below the elbows.

On April 1, we embark on a new policy at my hospital that no longer requires contact precautions for patients with MRSA and VRE. As we educate our staff on the change, we're reminding them that it's ok to shed the white coat and tie. If we're not going to wrap ourselves in plastic, bare below the elbows seems even more important.

Don't tie one on!

A new study in the Journal of Hospital Infection seeks to shed some light on an area of true controversy in infection prevention: whether clothing is involved in the transmission of organisms between providers and patients. The party line thinking in the infection prevention world goes something like this: infrequently laundered white coats and neckties do not transmit pathogens to patients, but if a patient is infected or colonized with MRSA, VRE or MDR-gram negative organisms wear a plastic gown when you enter his room. I have yet to have anyone explain to me the logic behind this paradoxical thinking. In my simple mind, clothing either has the potential to transmit pathogens or it does not. If it does, then minimize that risk. Shedding white coats, ties and long sleeves makes sense to me. The real question, I believe, is not whether infections are reduced by these simple interventions, but to what degree.

In the JHI study, a physician simulated a physical exam on a mannequin. The physician wore 4 different combinations of shirts and neckties (short sleeved shirt, long sleeved shirt, with tie, without tie). Prior to each simulated physical exam, specified areas of the shirts and ties were inoculated with Micrococcus luteus. After the exam, the mannequin was then cultured for the presence of Micrococcus. Each clothing combo experiment was repeated 5 times.

The clothing combo resulting in the highest rate of mannequin contamination was long sleeves + tie (transmission occurred in 4/5 experiments) and lowest with short sleeves sans tie (0/5). Looking at each item separately, long sleeved shirts were associated with more frequent transmission than short sleeved (5/10 vs 2/10), and ties more frequently than no ties (6/10 vs 1/10). Based on the application of a statistical test to the proportions shown above, the investigators concluded that ties increased the risk of transmission of bacteria, but long sleeves did not. Given that there were only 20 experiments I don't think we can draw many conclusions here, except that it's another study which adds to the biologic plausibility that clothing may be involved in transmission of pathogens in the hospital. As a guy who still follows the bare-below-the-elbow approach (i.e., what follows may reflect my bias), I find it intriguing that the only clothing combo in which no transmission occurred was short sleeves + no tie. Aren't we still trying to get to zero?

Photo: Brown Medicine

Your dirty laundry

Photo:  Mary Ann's Cupboards

There's a new paper in Infection Control and Hospital Epidemiology that includes a series of experiments designed to evaluate the effectiveness of laundering scrubs in your home washing machine. This is important since most healthcare workers who do not work in the operating room launder their own scrubs at home, and some hospitals even have OR staff wash their scrubs at home as a cost-savings measure. The major difference between home and hospital laundering is water temperature--hospital laundries typically use water temperatures of 160°F, whereas home washing machines are generally set to deliver water temperatures at 60-80°F (cold), 90-110°F (warm), or >130°F (hot).

Key findings were:

• Hot water (140°F) with or without detergent was highly effective in killing MRSA and Acinetobacter.
• Warm water (104°) with detergent was highly effective in killing MRSA and Acinetobacter. Without detergent, warm water was still highly effective against MRSA, but only moderately so against Acinetobacter.
• When clothes are washed with warm water but no detergent, they become contaminated with gram-negative organisms (Klebsiella, Enterobacter, Serratia) from the washing machine's biofilm, though washed clothes are largely free of gram-positive skin flora.
• When fabric swatches that were inoculated with Acinetobacter were ironed (on the iron's highest setting) with a contact time of at least 7 seconds, the organisms were killed.

So warm or hot water with detergent is your best bet (though I have to wonder who washes their clothes without detergent?). I do iron my scrubs, though many people don't, but I'm sure that my ironing contact time is less than 7 seconds, and some scrub fabrics can't tolerate the iron's highest setting.

Hot topics in the news

Over the past week, there were 2 studies related to infection prevention that attracted a fair amount of attention by the mainstream media.

A paper in Psychological Science (full text here), looked at whether various messages on signs placed near sinks in hospitals could have an impact on handwashing compliance. Of note, the two authors of the study have no medical training--they're professors in business schools. They randomly assigned one of three signs to be posted near 66 soap dispensers, with the following messages:

• Hand hygiene prevents you from catching diseases
• Hand hygiene prevents patients from catching diseases
• Gel in, wash out (control message)

They hypothesized that healthcare workers are overconfident and overestimate their own invulnerability, thus a message that focused on protecting the patient rather than themselves would be more effective. Two experiments were performed: in the first, the effect of the messages was measured by the volume of soap used in the dispensers; in the second experiment, conducted 9 months later, covert observers who worked on the study units recorded hand hygiene compliance by direct observations. The results were a 33% increase in volume of product usage, and a 10% increase in hand hygiene compliance at sinks which had the sign that focused on protecting patients. Although these results were statistically significant, this study has many flaws. The methods section of the paper tells us little about the setting--the type of hospital, the size of the hospital, on how many patient care units the signs were posted, or the type of care units involved. The experiments were brief, each lasting only 2 weeks. We are not told how many healthcare workers were involved; this is particularly important since the number of hand hygiene observations was very small (a total of 322 opportunities before the intervention and 245 opportunities after the intervention). When the results were categorized by practitioner type (nurse, physicians, ancillary staff), the numbers of observations were  extremely small. All in all, it's hard to put much stock in this short, small study in a single hospital.

The other study in AJIC, cultured the clothing (white coats, nurse uniforms, and OR scrubs) of a convenience sample of 135 healthcare workers  in a hospital in Jerusalem. Cultures were set up to detect S. aureus, Enterobacteriaceae, Pseudomonas spp and Acinetobacter spp. Overall, 50% of the cultures were positive for one of the above pathogens. Acinetobacter was most common, found on 32% of white coats, 38% of nurses uniforms, and 43% of OR scrubs. So we have another study that documents what we already know: healthcare worker clothing is commonly contaminated. But the key question remains as to whether the organisms can be transferred to patients. More on that here.

Twisted logic



Graphic: WeirdSpace


There's a piece in this week's American Medical News on the New York bill to mandate bare below the elbows. It includes this quote from Dr. P.J. Brennan, former President of SHEA:

It's not as though, by eliminating sleeves, you eliminate germs. The key thing to understand is that these environments are not sterile and are never going to be sterile. That goal is unattainable in a clinical setting. The real goal is to adhere to good hand hygiene, isolation practices, gloving, barrier precautions -- that's where we'd put our money.

I think Dr. Brennan's argument represents the conventional wisdom among hospital epidemiologists, but it doesn't make sense to me. He supports contact precautions, but doesn't support bare below the elbows, both of which are based on the same evidence and assumptions. So I think his logic is twisted. It seems to me that you either believe that clothing has the potential to transmit pathogens or you don't.

Giving Doctors Orders

Maureen Dowd's column in the New York Times this morning begins as follows:

When my brother went into the hospital with pneumonia, he quickly contracted four other infections in the intensive care unit.

Anguished, I asked a young doctor why this was happening. Wearing a white lab coat and blue tie, he did a show-and-tell. He leaned over Michael and let his tie brush my sedated brother’s hospital gown.

“It could be anything,” he said. “It could be my tie spreading germs.”

I was dumbfounded. “Then why do you wear a tie?” I asked. He shrugged and left for rounds.

My answers to her question:  (1) ego, (2) dogma.

You can read the rest of her column here.

Pig-Pen went to medical school

There's another paper just recently published on contamination of white coats. This study from Nigeria cultured the white coats of 103 doctors. Pathogens were cultured from nearly half (48%) of the coats. Staph. aureus was found on 19% of the coats, Pseudomonas aeruginosa on 10%, and other gram-negative organisms were found on 19%. The authors of the paper made a number of recommendations regarding the white coat, including frequency of laundering. Unfortunately, they left out the most important one--just get rid of them!