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.


  1. Great post Mike. How much does a black vest cost compared to white coat? Seems like everyone should make the switch, particularly in non-summer months. You could imagine different color vests depending on your clinical role: med student - green, resident - red, etc. This would be helpful for recognizing different clinical roles at a distance, which you can't do with white coats or name tags.

    Anyway, I can't wait to order my UI vest.

  2. Nylon vests cost $30-100. Agree--I only wear it in the winter for warmth.

  3. "the vast majority of doctors in the US will look just like those in that picture"

    Except some of them will be women. Right?


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