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.

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.

Pronovost weighs in on the white coat

Peter Pronovost, arguably the nation's leading expert in patient safety, gave us his thoughts on the white coat debate yesterday on The Armstrong Institute's blog Voices for Safer Care. His conclusion: there's enough evidence to ditch the white coat.

Here is the core of his argument (in his words):

We could voluntarily ditch the white coats without needing a clinical trial to tell us it’s OK. We know that white coats can carry pathogens, and it is logical to think that germs could be transmitted from physician to patient. Given that confirming this theory could be prohibitively expensive, we can look at the implications of acting and not acting. While the risks of maintaining the white coat tradition are clear — potentially more infections and preventable deaths — the risks of removing this potent symbol of professionalism would be less significant, though certainly real for some clinicians. How would patients react? Studies disagree on whether they prefer the white coats — some may find them reassuring, but others may see them as elitist. 

Some experts may argue that we should instead focus on proven infection control practices, such as hand hygiene. Yet it's hard to see how voluntarily giving up your white coat would distract from that. It may even raise awareness in general about the importance of hand hygiene once clinicians consider the pervasiveness of germs on their attire, stethoscopes and keyboards. The risks of doing nothing seem much greater than of making the change.

As we have said for several years, mandates should be reserved for interventions with the highest level of evidence to support them. Neither banning the white coat nor mandating flu vaccine for healthcare workers are backed by evidence at that level. But there's enough evidence to suggest that hanging up your white coat and getting a flu shot are probably the right things to do. And to get a flu shot you have to take your white coat off anyway. So do both and leave the coat behind!

Art Caplan on the white coat

The noted medical ethicist, Arthur Caplan, was interviewed today by Boston Public Radio. He covered a number of topics, including the white coat, and recommended that doctors get rid of both neckties and the white coat on the basis of microbial contamination. He endorsed scrubs as the appropriate attire. Says Art:  "The old white coat is a fine garment, if you're in the 19th century." 

You can listen to the interview here. Scroll forward to hear the white coat discussion at about 8:55.

The white coat debate hits the mainstream media

Today's Boston Globe has an article on the white coat debate. This comes thanks to Dr. Phil Lederer, an infectious diseases fellow at Massachusetts General Hospital, who is working to rid the medical community of the unnecessary, germ-laden garment. You can also hear a great interview with Phil on this topic here.

I'm happy to report that the Infection Control Committee at the University of Iowa Hospitals and Clinics has recently recommended a bare-below-the-elbows approach to inpatient care beginning January 1, 2016.

This will continue to spread--one doctor and one hospital at a time. Incrementally, we will get there.

Graphic: Boston Globe

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!

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.

Is the white coat needed for identification?

If you haven't read Phil Lederer's piece on the white coat at the Conversation, I recommend that you do so. It is very well written and has stimulated a lot of discussion. One of the take-aways for me is that even among many of those who believe we should ditch the white coat, the one argument that gives them pause is the role of the white coat as a means of identification. This is particularly an issue for women and racial minorities, groups that have been historically underrepresented in medicine.

I have two problems with the argument that the white coat is needed for identification. First, unlike the situation in the 1960s, white coats are no longer exclusively worn by physicians. Members of practically every occupational group in the hospital (with the typical exception of students) may wear a long white coat. It's worn by chaplains, administrative assistants, nurse practitioners, physician assistants, you name it. The white coat no longer signifies that the wearer is a doctor. And we have more specific means of identification. Many hospitals now have large occupation-label tags attached to photo IDs (mine is shown), which should be more effective than the type of coat worn.

The second issue I'll articulate is controversial and will probably get me into trouble, but I think it's an important argument to explore. I'm really bothered when a physician says, "If I don't wear a white coat, patients think I'm a nurse." To feel insulted that someone might think you are a nurse implies what you really think about nurses--that they are beneath you. Would an internist (male or female) feel disrespected if someone thought he/she were a neurosurgeon or the chair of the department? I doubt it. And I've mentioned previously that I've been mistaken for a nurse or respiratory therapist many times when I'm wearing scrubs in the hospital, though less so now that I wear my name tag on my scrub shirt (I used to wear my name tag on my waist band but that's not allowed at Iowa). I don't find being misidentified insulting in the least. I just simply answer that I don't have the keys to the medication room or that I'm probably not the best person to change the ventilator settings.

Several years ago (long before I began thinking about killing the white coat) my wife and I and several other people were at a dinner with a visiting professor. My wife made a comment during the conversation about something medical and he said, “Oh, are you a nurse?” She said quite nicely, “no, I’m an oncologist.” He replied, “I’m so sorry that I asked if you were a nurse.” And she said, “Don’t be sorry! I was a nurse. I loved being a nurse. And if tomorrow I were a nurse again, I'd be very happy.” We discussed that interaction last night. As she reflected on the white coat issue, she pointed out that she thinks it's great when a person is proud of their profession, and how the white coat for many people symbolizes that pride and their achievement of completing a very long journey. For some, it also symbolizes the enormous barriers that they have overcome. But she noted that the white coat should not be used as a symbol of who you are not.

I've come to realize that a physician feeling insulted if someone misidentifies them is yet another negative manifestation of professionalism. We as physicians have been socialized to think that we are elite, that we are at the top of the pecking order, that we are better than all the other people who work in health care. That has been given to us unfortunately by our physician colleagues and is part of our culture.

I don’t want to be (or even appear to be) insensitive. I realize that as a white man I’ll never know what it feels like to be an African American woman. But we are trying to eliminate the white coat for patient safety, which should trump all else. Remember that one of the good tenets of medical professionalism, at least historically, is that the patient comes first. Moreover, we are all called, regardless of race or gender or socioeconomic status, to respect all humans (ahh, humanism!). And to verbalize disdain at being identified as a member of another occupation, in my opinion, is classist and incredibly disrespectful.

Ok, I'll get off my soapbox now and let the arrow slinging begin.