It's time to hang up the white coat

This morning’s New York Times Week in Review section has an article on the white coat and the concerns about contamination by microbes. In a previous posting, I discussed the infection control aspect of the problem with white coats, and the magical thinking held by most physicians that somehow the coat has received a dispensation from the germ theory. Perhaps as interesting as the infection control angle is the issue of the coat’s symbolism and its link to professionalism. There are several papers in the medical literature that discuss the coat’s symbolism. The positive symbolic aspects include candor, integrity, and goodness. Also, it is viewed as a symbol of purity and cleanliness, which is ironic given that two-thirds of doctors wash their coats no more frequently than every two weeks. Negative symbolism has also been described. Some view the coat as a symbol of hierarchy and authority, a marker of social and economic privilege, and a way to denote that the physician is part of an elite community somehow separated from the rest of society.

Dr. Judah Goldberg, an emergency medicine physician and ethicist, wrote a compelling paper in Academic Medicine last year, in which he compares and contrasts professionalism and humanism, and how the white coat fits into these constructs. It's a must-read for those interested in the white coat debate. He writes that one comes to understand humanism simply through the experience of life, whereas, professionalism is acquired through the socialization process of entering a profession. Humanism’s motivation is to serve the welfare of humankind. On the other hand, professionalism’s primary motive is to strengthen professional identity. Most importantly, Dr. Goldberg points out that the outcome of humanism in medicine is to link the physician to the patient. The outcome of professionalism is to separate the doctor from the patient. Thus, once the differences between humanism and professionalism are delineated, it becomes apparent that the white coat serves the latter.

Another physician, Dr. Matt Bianchi, in a paper in the Journal of General Internal Medicine, is able to distill the entire issue into a few sentences as he writes about his own experience:

“I have had the good fortune to encounter a wide and rich spectrum of opinions from patients, friends, and colleagues on the matter of proper physician attire, perhaps encouraged by my absent white coat, absent necktie, shaved head, bilateral black hoop earrings, and tattoos covering approximately 17% of my skin (according to the Lund-Browder burn chart). With only one exception (a mildly demented man in heart failure), every one of the uncommon suggestions to upgrade my appearance for the sake of patient care has come from a physician colleague. In contrast, there have been countless moments of connection with patients who confided that some aspect of my appearance made them feel more comfortable… One can only hope that each doctor-patient interaction affords the participants the chance to transcend the cursory impressions of attire and engage in the “real” work of medicine, the alleviation of suffering and the healing potential of a positive, productive relationship.”

In the end, the white coat is all about the doctor, not the patient. The New York Times article quotes a physician who says, “The coat is part of what defines me, and I couldn’t function without it.” Now that’s magical thinking at it's finest!

WSJ Health Blog Goofs!

The Wall Street Journal Health Blog has now corrected its previous post on the AMA House of Delegates voting in favor of a ban on white coats. The official AMA response (on p. 15 of this document) was to refer the resolution to another committee for further study. As I stated in a previous posting, it would have been surprising for the AMA to pass the resolution given the AMA's generally conservative approach, coupled with the iconic status of the white coat for the profession. Nonetheless, I still believe it makes sense to hang up those germ-laden coats for good.

AMA calls for banning white coats

The Wall Street Journal Health Blog is reporting that the AMA House of Delegates voted today to recommend that hospitals ban white coats. Given the iconic stature of the white coat, I am quite surprised by the vote. Now a real debate will likely begin in the US on the topic. Click here to read more on why the white coat poses infectious risks.

Quote of the day

From Peter Ragusa, a new medical graduate from the University of Minnesota, in the Wall Street Journal Health Blog, on the resolution before the AMA House of Delegates to urge physicians to give up their white coats:

As with many things in medicine, just because we can’t prove it doesn’t mean it’s not true. It’s hard to do randomized double-blind controlled trials with something like this. But I’m a med student and I can look down at my sleeve and see it’s dirty, I can look down at my tie and see it’s dirty.

Bare below the elbows: Coming to a hospital near you?

It's encouraging and even surprising that the AMA is considering a resolution to encourage a bare below the elbows approach in US hospitals. Unfortunately, it's unlikely to pass. There's never been an organization more symbolically linked to the white coat than the AMA. Most hospital epidemiologists in the US seem to be unable to connect the dots between contact precautions and bare below the elbow, generally endorsing the former but not the latter. The paradox, of course, is that both interventions are based on undisputed findings that clothing can become contaminated and the assumption that contaminated clothing may serve as a fomite. But between those two dots is a lot of magical thinking about the white coat. Given the UK's success in reducing MRSA and C. difficile, part of which may be due to bare below the elbows, and the public's interest in healthcare associated infections, I would predict that five years from now scrubs will be de rigueur.

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.