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


  1. I’d like to put the record straight regarding my opinion piece on scruffy doctors in the BMJ (1). You say that I linked the absence of the White Coat with poor hygiene; I think you should re-read the article. I said that dishevelled dress suggested less than a passing interest in cleanliness as well as demeaning the status of doctors. Unhygienic practice was not directly related to the White Coat itself. In actual fact, the article was a plea to the medical schools in Scotland to review their undergraduate teaching on infection control.
    Is that insane? What would you advocate when the antibiotics finally run out?

    While you’re in the mood for a bit of reading, do look at this (2):

    In the meantime, please check your facts before you cast aspersions of insanity on a public blog. It’s less than professional.

    Yours respectfully

    Stephanie Dancer

    PS. Since you clearly enjoy debate, try this one for size: ‘Women are genetically programmed to better understand, and practice, hygiene than men’.

    1. Dancer SJ. Put your ties back on: scruffy doctors damage our reputation and indicate a decline in hygiene. BMJ 2013; 346:f3211
    2. Dancer SJ (not G) & Duerden BI. Changes to clinician attire have done more harm than good. J R Coll Physicians Edinb 2014; 44: 293–8

    1. Thanks Stephanie. I'm not sure I made any comments about your paper but do appreciate the debate in any case and agree with your plea to increase infection control in all levels of medical training.


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