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.

Is the doctors' white coat evidence of physician economic decline?

We've debated ditching the contaminated white coat many times. In these discussions, I've been struck by responses from colleagues who have clung to the white coat as a symbol of professionalism. I just didn't understand it. There are clearly other, safer ways to identify yourself as a physician, if you feel that is something you need to do. Of course, there are other ways to stay warm or have pockets (cool black vest anyone?) And it's not like the white coat ceremony dates back to Hippocrates or Osler. These modern ceremonies started in 1989 or 1993 depending on your definition.

So why did the modern white coat ceremony emerge and spread across the medical school landscape like...an infectious disease?  I think the answer might be the decline in status of physicians in both healthcare and society. Within healthcare, doctors have been replaced by administrators as primary medical decision makers and in society our salaries pale in comparison to corporate leaders and other professions. Could the white coat (and white coat ceremony) be a vestige of the economic decline of physicians - a psychological defense mechanism?

I was pondering that question, when I came across a fascinating discussion by Malcolm Gladwell on a recent Ezra Klein Show Podcast. In the middle of the interview, around minute 30, they began discussing the decline of journalism. They wondered how members of a profession, who are losing their economic place, respond to this status free-fall. Gladwell was specifically interested in the psychological defense mechanisms that the professional groups adopt when in this free-fall. He says that the group becomes "very particular about who they want to let in or let out, they start to fetishize certain moral stances or positions or codes as a way of enforcing the in-group." Gladwell then discusses a parallel example:

"It is this search for, when you lose one kind of status, one kind of point of differentiation, you have to replace it with something else. A very simple illustration of this is: why are pickup trucks so much larger than they were 25 years ago? Have you ever seen a standard Ford pickup truck of 1975 up against a Ford F-150 of today? The contemporary Ford pickup is literally twice the size...it dwarfs the old one. These are the same people buying those pickup trucks, doing the same jobs, but now their pickup truck is twice as big. And the answer is: in response to the falling economic status of white working class jobs, people have chosen to assert their status in another way. I may not make the kind of money or have the kind economic status that I had 25 years ago, so I'm now going to compensate by having a truck that is twice as big."

It seems that the white coat (ceremony) could be a response to a loss of status of physicians in society. Perhaps this compensatory mechanism would be OK if unwashed, contaminated white coats didn't increase the risk of pathogen transmission in hospital settings. Similarly, large pickups would be OK if they weren't associated with poorer gas mileage and global climate change. Given that physicians have not lost as much power (yet) as journalists or the working class, it might be better to develop strategies to increase our role in medical decision making and maintain our economic status, rather than cling to a cold dirty white coat.

image source: jalopnik.com

Getting rid of the white coat

I was just given a copy of the DecisionHealth publication Inside the Joint Commission.  The March 21 issue includes an article (posted below) that mentions our old white coat contamination study (free full text AJIC 2008). We reported that 23% of white coats were contaminated with S. aureus and 64% of physicians had not washed their white coats in more than a week.

The IJC article quotes the CEO of a healthcare consulting firm who suggests that many clinics have eliminated laundering services for cost-cutting reasons and didn't consider infection control.  The money quote:

"The best solution from an infection-control perspective may be to get rid of the white coat altogether, but “it’s part of the old culture,” Searfoss says, and may be difficult for some physicians to part with."

I couldn't agree more.

Festivus Grievances: Are Mandatory Influenza Vaccination Policies and Banning White Coat Ceremonies Ethically Equivalent?

"Welcome, new comers. The tradition of Festivus begins with the airing of grievances. I got a lot of problems with you people! And now you're gonna hear about it!"  - Frank Costanza

BB8 is for BBE

(Warning: Mild Star Wars spoiler at the end, although I surveyed folks here and no one complained)

Outside my recent posts on influenza vaccine mandates, I have very few infection control grievances to air this year. To start, 2015 saw the return of original science to the annual SHEA spring meeting, a tradition that will continue in the May 2016 meeting chaired by Silvia Munoz-Price and Tom Talbot. And the year ended with NIH planning to spend $461 million in FY 2016 on antimicrobial resistance research, an increase of $100 million over FY 2015. On a personal note, University of Iowa was selected as one of CDC's new Prevention Epicenters. Our team is honored and excited to join the other 5 new centers for the kick-off meeting this January. Thus, things are truly looking up in our fight against antimicrobial resistant bacteria. If we can convince congress, NIH and CDC to continue to gradually increase research funding over the next decade, we should have many things to celebrate in 2025. That is, if we can fix the ID fellowship match and the reimbursement issues that have plagued us the past 10+ years.

...but back to influenza vaccine mandates. Several folks have wondered how we bloggers could support banning white coats and at the same time question influenza vaccine mandates, especially since both interventions have similar levels of evidence (i.e. biological plausibility, math models, observational data, limited RCT data). This is an interesting question. Just to clarify, Mike is against compulsory influenza vaccine policies and I grudgingly support them and neither of us wants to ban white coats - we favor voluntary policies that make it OK not to wear a white coat - which is exactly what Mike instituted at VCU and plans here at Iowa, starting in 2016.

Yet ignoring our policy stances, the assertion that bare below elbow policies are somehow equivalent to vaccine mandates from an ethical standpoint is incorrect. Let's consider the current situation in the US with white coat ceremonies and the pressure that medical students, housestaff and faculty are under to wear white coats. If white coats are harmful (and many would agree that it is equally likely that white coats harm patients as influenza vaccines protects patients), then the current situation would be the ethical equivalent of forcing healthcare workers to not get vaccine.

That is, white coat ceremonies force healthcare workers to cause harm to their patients, which is not morally or ethically the same as requesting healthcare workers to help protect themselves and their patients by receiving an influenza shot. In a Star Wars context, forcing FN-2187 to murder villagers on Jakku (wearing white coats) is not ethically equivalent to requesting that Finn defend the people of Takodana from a First Order attack (influenza vaccine). 

Forcing healthcare workers to wear white coats that they deem to be harmful is wrong. We need to eliminate white coat ceremonies and stop coercing healthcare workers into wearing white coats.

Reader Survey: White coats contribute to the unsafe hierarchical culture in healthcare

Following on the heels of Mike's bare-below the elbows debate at IDWeek, I posted a quick survey to gauge your impression of the level of acceptable harm associated with white coats. I'm still working on the power calculations that will be informed by the survey, but wanted to say thank you to the many who answered the questions. In the meantime, I also wanted to post the comments left by you, our readers. I've posted almost all of the comments thus far apart from those with swearing or those that mention their answers to question #1 of the survey.

One thing that struck me when reading the comments is that the white coat is a symbol that perpetuates hierarchy and is part of an unsafe culture. We need to create healthcare systems without hierarchy and it seems that the white coat contributes to a system where 58% of nurses that see harm are afraid to speak up "and people need to be able to speak up." Thus, even if you are in the minority who believes that white coats are not involved in pathogen transmission, your white coat might be harming patients by contributing to an unsafe hierarchal culture.

An interesting patient-centered quote that seems to run counter to the current thinking associating white coats with professionalism: "If there are better options that would reduce transmission of infection then burn the white coats. As a patient I dislike them - intensely. Reminds me of a butcher shop or auto mechanic- not reassuring at all."

Pro White Coat:

"Not an issue as long as changed daily and sleeves rolled up above the elbow and they don't carry medical equipment in the pockets"

"The white coat continues to be an important identifier of the profession, and symbols are important"

"It is certainly useful to carry things but also represents antiquated power hierarchy. Although there is no evidence, it plausible that they could transmit infections. Then again so could stethoscopes which have more direct patient contact."

"Can't prove it is causing resistance-- and I think patients like it"

"Needs an RCT. Anything else is nonsense ... unless we say all healthcare providers put on and remove scrubs at work"

"We have white coats with short sleeves. This is no problem in my opinion. BUt bare below the elbows has become the standard in most Dutch hospitals. Probably the turning point was a documentary with a hidden camera showing that healthcare workers knew that handhygiene was important that they should not wear jewelry, but they just didn't take the rules serious. Sometimes we don't need science but a good mirror and public response"

"Fashion item"

Pro Bare Below Elbow (OK with eliminating White Coats):

"It's merely a badge of authority and seniority masquerading as cleanliness and something "sciencey"

"A disease-ridden, antiquated symbol. They project the same professional and scientific insecurity as when doctors started wearing them to appropriate the public legitimacy of science."

"I appreciate that for many, the white coat is a status symbol and helps create an instant first impression on patients. That being said, times are changing. The physician is not the most important person in the room. The healthcare team is what should be the focus now. Tear off the coat and tear down the hierarchy"

"I understand white coats as a part of PPE when you don't want to get something on yourself or to prevent things on you from spreading. But when the white coat goes EVERYWHERE you go, it doesn't maintain it's protective qualities. Also, as a pharmacist, I'd much rather have normal, professional or consulting coversations as a professionally dressed human than a white coat."

"If it's a vector for microorganisms, eliminate it. Simple"

"Not necessary. Wear scrubs like everyone else. If your ego needs the coat, get therapy"

"I hate it. Adds to elitism and difference. Separates us from our humanness"

"White gets filthy too quickly"

"In the past, it was a status symbol for physicians; this is now translated to our students, ancillary staff and physician extenders. It is not represent amount of fundamental knowledge or the ability to care for patients. It was an extension of the laboratory part of our profession transitioned from black coats earlier in the last century. Currently, it is nothing more than a status symbol or accessory"

"White coats offer no benefit. We should try to prevent infections by any means necessary"

"I don't think white coats are necessary, but then I'm also not American!"

"Don't wear them in Australia. If you're worried about getting dirty, wear scrubs"

"It's part of a bygone age"

"Given the association with pathogenic transmissions, I am appalled we are still handing them out to our medical trainees!"

"I work at a pediatric hospital where most physicians do not wear white coats. Anecdotally, pediatricians seem to eschew white coats in order to be more friendly and approachable. Don't know what impact this has on HAI at our hospital"

"Doctors don't walk around with head mirrors anymore; the white coat makes about as much sense to me. Why do we still have this thing that exists for no other reason than a vector for disease?!"

---
image source: NYT

The White Coat Debate Needs Your Opinion!

The white coat debate continues. If you'd like to see the latest and greatest discussion concerning the doctors white coat, head over to Phil Lederer's blog and read his White Coat FAQs. In the meantime, I have a couple quick questions for you. Thanks for taking our survey!

What can infection control learn from aviation safety?

We all like to believe that we work in a safe healthcare environment - one that is safe for our patients and colleagues. But the truth is, we care more about our own feelings and time than we do about patient and healthcare worker safety. 

We've discussed the white coat "debate" and the contact precaution "debate" many times already on this blog and elsewhere. If you want to see a nice overview of the white coat debate, Phil Lederer has a new post up on The Conversation. Thus, I don't want to get into the specifics too much, but as a reminder, clinicians wear white coats to carry things, stay warm and as part of our professional uniform. As far as contact precautions, we wear them to significantly (clinical and statistical significance) reduce MRSA infections with the majority of evidence suggesting contact precautions prevent transmission of clinically significant pathogens in inpatient settings.

The major barrier is that healthcare workers hate contact precuations (time, inconvenience) and cling to their white coats and no matter how much evidence we provide them through RCTs, cluster-RCTs and molecular epi studies, they will selectively interpret the data within their own subjective reality (ie cognitive bias). So when our patient safety leaders/deciders are immune from scientfic data (ie the BUGG study or the hundreds of studies that show white coats are covered in pathogens), what are we to do? How can we possibly overcome their cognitive bias (which they hide behind by demanding more and more cluster-RCTs)?

The first thing we can do is point them to the patient safety movement's favorite target: aviation safety. In aviation safety, do they require cluster randomized trials before making us put our tray tables up during takeoff or before banning us from sleeping in the aisles? Is their an RCT that proves that only folks 13yo and older can sit in an exit row? The answer is no. Airline safety is built on logic and scientific evidence but not randomzied trials. For example, you could test to see at what age children can open and lift an exit door safely and use that as a cut-off for setting age restrictions in exit rows. Amazing, huh?  The equivalent in patient safety would be the dozens of studies showing that white coats are coated with pathogens and that long sleeves touch patients. With that level of evidence, an airline safety person would ban white coats in 30 seconds. They wouldn't care if it's inconvenient to carry your iPad without a white coat, just like they don't care that it's inconvenient to put your 5 pound laptop away before landing. Common sense prevails in airline safety! It should also prevail in infection control.

So how do we ultimately create a safe healthcare environment? First, we should continue to demand the highest level of evidence and funding for trials that help develop and test new patient-safety interventions. But in the meantime, we need to put our patients first by using the proven tools (contact precautions) and scientifically sound policies (bare below the elbows) that we already have at our disposal. The highly resistant bacterial pathogens aren't going to sit around waiting for a $20 million dollar cluster randomized trial proving white coats harm patients. And even if they did, there would be folks who would find reasons not to listen anyway - it's cold! Just like aviation safety experts do, we should use the best data available and common sense to make for the safest hospitals today and we should also acknowledge how our cognitive biases cloud our decision making.

To have a truly safe healthcare system, we need to put our patients' safety first and not hide behind a lack of cluster-RCTs that may never be done. If we follow the logic of folks clinging to their white coats or contact precaution deniers, we will soon not even have to wash our hands between patients. Wait, we already don't wash our hands you say? Yes - my point exactly.

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.

Bacteria and Viruses to Humans -> I Am Invisible

Last week, in typical Controversies Blog fashion, we had a bit of a dust up discussing white coats and presenteeism. It occurred to me that in each instance, the primary barrier to infection prevention remains our inability to recognize that our adversaries are invisible. How else can we explain doctors insisting that washing white coats every three days is adequate and that they've never personally transmitted pathogens while caring for patients? So for those of us that still think hand hygiene compliance of 40% is satisfactory, contact precautions are bogus and that coming to work sick is cool, I have a three word reminder: pathogens are invisible. ciao

We need to rethink professionalism

A new study in JAMA Pediatrics (free full text here) should make hospital epidemiologists and infection preventionists cringe. All physicians and advanced practice providers at Children's Hospital of Philadelphia were sent a survey on presenteeism. Of the 929 providers surveyed, 58% responded.

The big findings were as follows:

• 95% felt that working while sick puts patients at risk
• 16% would come to work with fever 
• 30% would come to work with diarrhea
• 5% would come to work with vomiting
• 56% would come to work with acute onset of respiratory tract symptoms
• Asked several ways, >90% stated they would come to work while sick out of a sense of professional obligation

What I find most interesting about this paper is not how often sick healthcare workers come to work (though it's a big problem), but why they do so. And once again, professionalism rears its ugly head. Professionalism revolves around expectations and norms set by the profession. It seems to me that if we viewed this more through the lens of humanism rather than professionalism, we'd be better off. From a humanistic standpoint, which holds a universal rather than parochial view, all would agree that individuals who are ill with potentially contagious diseases should not come to work (doesn't matter whether you're a doctor, a teacher or a plumber). Similarly, in the white coat debate, professionalism drives the argument that physicians should wear a white coat. Humanism would dictate that attire should be practical, comfortable, safe, and personally desirable. Several years ago, Judah Goldberg wrote a great essay in Academic Medicine that I often quote and recently re-read on the conflict between humanism and professionalism. It really crystallized for me the differences between the two philosophies, which are often in conflict, and once the differences are made clear, it's easy to see the corrupting influence of professionalism. It's worth a read.

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.

The limitations of patient-centered infection control

"You can't just ask customers what they want and then try to give that to them. By the time you get it built, they'll want something new." - Steve Jobs

I woke up to Vineet Chopra and Sanjay Saint's editorial advocating for a patient-centered approach to selecting clinician attire. In the editorial they point out that in the 21 of 30 papers they reviewed "patients had strong preferences about what physicians wore. And it looks like patients more often prefer for their doctors to wear formal clothing and white lab coats than not." They also reference the SHEA guidance document on healthcare attire and state there is little evidence "that germs on male doctors’ neckties, long sleeves, or white coats actually spread infections in a nonsurgical setting. So bans on such garments, such as those in place in some countries, may go too far."

So how can we decide what the safest attire is for our patients? I would recommend epidemiological studies that track bacteria spreading in hospitals and attempt to determine if those same strains are contaminating clinician attire using whole genome sequencing.  In fact, CDC released a SHEPheRD Task Order 2015-006 last month that seeks to do just that and more. I very much look forward to the results.

Drs. Chopra and Saint recommend a different patient-centered approach as they "plan to survey thousands of patients from the US, Italy, Switzerland and Japan" and "will specifically assess how factors such as age or how often a person interacts with the health system shape patient opinions." Is this a rigorous or unbiased method? Will the surveyed patients know that a quarter of white coats are coated with invisible S. aureus or MRSA and that they are rarely washed? Will they understand that a lack of data supporting transmission from white coat or long sleeve or neck tie is because no one has ever funded such studies? Will they understand that the circumstantial evidence supporting bare below the elbows is as strong as that supporting a clean environment in hospitals? Will their next editorial say that bleach is stinky and irritating to patients, so we shouldn't use it in hospitals unless supported by a patient-centered survey?

Thus, there are several potential limitations to patient-centered infection control and the planned physician attire survey, which I hope they will consider before collecting data and selling the findings. I'm all for patient-centered healthcare where applicable and data are fairly presented to patients and I support evidence-based medicine when we fairly rate the science based on what studies have been funded or will ever be funded. I'm not sure any patients "feelings" about the dirty white coat are worth the increased risk of MRSA or Acinetobacter infection, but we can disagree. All I would ask is that if we do patient-centered research, it's with properly informed patients.

***
Oh, and if we're going to require evidence before making physician attire recommendations, how can the authors write that "scrubs do not belong outside the hospital environment. Especially not in the grocery store." Where is the study that scrubs spread bacteria outside of hospitals and that there is any risk to population health in grocery stores? Clearly the bacteria on cantaloupes are riskier than those on scrubs! And surely the immobile ICU patient with central venous and urinary catheters is at greater infection risk when you wipe your MRSA-contaminated white coat on their catheter than when you brush up against a healthy grocery store patron with your scrubs? Scrubs are at least washed daily - white coat laundering occurs somewhere between every two weeks and... never.

*****
Additional thought, I am not aware that the US, Italy, Switzerland and Japan have mandatory bare-below elbows policies. It might be important to add Scotland or England to the survey since they have had BBE policies for some time and patients may have adjusted their preferences for physician attire.

Laundering White Coats - We are asking the wrong question!

There is a very nice survey of bare-below-the-elbows perceptions and practice in this month's ICHE by co-blogger Mike's group. They asked 300 attendees (190 or 63% responded) at medical and surgical grand rounds about their beliefs and behavior concerning wearing white coats, neckties and wristwatches. I've posted the results below. As expected (since Mike has recommended BBE at his hospital since 2009), most thought that white coats were vectors and that not wearing a white coat would not alter patients' perceptions of them. Most did not wear white coats daily, neckties (males only) or wristwatches. Approximately half practiced the bare-below-the-elbows approach.

This all seems great except that it occurred to me that this group, and me and everyone else have asked the wrong questions as far as laundering practices of white coats. We've generally asked if the clinicians washed their coats daily, weekly, monthly, etc., when we should be asking them if they washed their white coats between patients! Asking about daily or monthly! laundering would be like asking about daily or monthly hand hygiene! Of course, this is ridiculous! I bet we could get hand hygiene compliance to 99% if the denominator was days instead of moments. By including a white coat laundering question with a lower bound of daily somehow implies that daily laundering is acceptable. Which it really isn't. Given that 96% of folks in this survey didn't wash their coats daily or every other day, this point is largely moot. Practically, we gotta give white coats the boot!

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.

SHEA: Obsessed, and proudly so

The SHEA guidance on healthcare personnel (HCP) attire is now available (free!), and is already drawing media attention. I particularly enjoyed the NBC News description of SHEA as “the group obsessed with stopping infections in hospitals and health care settings”. Obsessed? Miriam-Webster describes obsession as “a state in which someone thinks about something constantly or frequently, especially in a way that is not normal”*. And it got me thinking that this may be behind some of the general resistance to any guidance about HCP attire. What is this group doing, suggesting what I should wear (or not wear) in the hospital, and how often I should wash my garments? They must be obsessed or something. Show me the data, weirdos!

Therein lies the rub with HCP attire, as with so many other infection prevention practices. There may be biological plausibility that clothing plays a role in pathogen transmission, there may be evidence for pathogen contamination of HCP attire, and there may be a favorable balance of benefit versus harm in implementing changes in practice (such as a bare-below-the-elbows (BBE) approach). But we still lack that direct link between HCP attire and HAI risk. Thus the SHEA guidance ends with a laundry list (pun intended) of research priorities for HCP attire:

· Determine the role played by healthcare personnel (HCP) attire in the horizontal transmission of nosocomial pathogens and its impact on the burden of HAIs.
· Evaluate the impact of antimicrobial fabrics on the bacterial burden of HCP attire, horizontal transmission of pathogens, and HAIs. Concomitantly, a cost-benefit analysis should be conducted to determine the financial merit of this approach.
· Establish the effect of a bare-below-the-elbows (BBE) policy on both the horizontal transmission of nosocomial pathogens and the incidence of HAIs.
· Explore the behavioral determinants of laundering practices among HCP regarding different apparel and examine potential interventions to decrease barriers and improve compliance with laundering.
· Examine the impact of not wearing white coats on patients’ and colleagues’ perceptions of professionalism on the basis of HCP variables (e.g., gender, age).
· Evaluate the impact of compliance with hand hygiene and standard precautions on contamination of HCP apparel.

Now try to imagine the logistics, and costs, associated with a study large enough to demonstrate the incremental contribution of HCP attire to HAI infection risk, or the impact of BBE on HAI incidence. Knowing how long we will be waiting for such evidence, what do you plan to do in your hospital?

* I prefer the Urban Dictionary definition of obsessed: “just a word the lazy use to describe the dedicated”

Graphic credit to Ben Tremblay.

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.  

The Antimicrobial Hospital Room

Earlier this month I gave a talk at ICAAC where I shared my thoughts concerning the role that environmental coatings and antimicrobial textiles might play in limiting pathogen spread in hospital settings.  Several readers asked for copies of my talk, so I thought I'd just post a (moderately) modified version here.  In the same session, Mike gave an excellent talk describing the primary importance of hand hygiene, Andrew Stewardson discussed the counter point that hand hygiene wasn't the most important intervention and Andreas Widmer covered no touch disinfection methods (e.g. UV light hydrogen peroxide vapor). A great session - wish you were there!

You are what you wear

Mike has posted extensively on appropriate attire in clinical settings and perhaps folks are starting to notice. This month's ACP Hospitalist has a balanced piece by Charlotte Huff on the subject and quotes extensively from the good doctor Edmond. The most compelling part of the article for me was how much ideas and standards of what attire is considered appropriate change over time AND can be changed through education.  For example, a highlighted 1987 JAMA study reported that 34% of patients wanted female physicians to wear skirts. Can you imagine that in 2013? - makes 1987 seem almost Victorian. What was most encouraging to me was the 2008 JHI study Mike mentioned in the article. That study found that a simple education session could shift the proportion of patients preferring their surgeons wear scrubs from 24% to 62%. Hopefully soon, we will all be wearing scrubs... and black vests.

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!