Dressing for Success? – the White Coat Dilemma




For nearly 200 years, the white coat has served as a symbol of the medical profession. Originally, the white coat was worn to symbolize hope and life — an absolute contrast to the black of death and mourning that was widespread at the time. Hospitals, and the physicians who worked in them, became places of hopefulness and healing, and the white coat embodied these sentiments.

As the medical profession evolved into a scientific discipline, the white coat began to represent the physician as a scientist. It also epitomized a feeling of cleanliness, and served as a barrier between the physician and his patient. As time passed, the white coat became so symbolic of physicians that medical students began taking part in “white coat ceremonies” to signify the beginning of a professional journey and undertaking of considerable responsibility. Many medical students see the white coat ceremony as the transition from nonphysician to physician and donning the coat helps to symbolize the commission they are accepting.

Still, the white coat – in all cleanliness and purity — is losing favor among some circles. Remarkably, white coats were actually banned in England in September of 2007 by the United Kingdom Department of Health. Physicians are now required to adhere to a “bare below the elbows” dress code. That is, short sleeves and no watches or jewelry when engaging in clinical activity. (Neckties are also banned.) The reason? Infection control. It was believed that white coats worn in clinical environments, and laundered infrequently, contribute to the spread of hospital-associated infections. Also, the dress code is believed to promote effective hand washing. On a smaller scale, some infectious disease departments in the United States, as well as some hospitals, have implemented, or are considering implementing, a similar policy.

While the dress code is well intentioned, it is not based on many facts. Many studies have shown that health care workers’ uniforms, as well as hospital curtains and linens, can be contaminated with pathogens from the clinical environment, but there is a lack of evidence that the colonization actually leads to the spread of disease. A recent poster presented at the annual meeting of the Society for Healthcare Epidemiology of America reported that bacteria common in hospital-acquired infections (methicillin-resistant Staphylococcus aureus, Vancomycin-resistant Enterococcus, and pan-resistant Acinetobacter) could be isolated from lab coats, transferred to pig skin, and re-isolated from the skin. The isolates were obtained from the white coats at 1-minute, 5-minute, and 30-minutes intervals after contamination. While this investigation shows the biological plausibility of white coats transmitting infections, it is a long way from proving disease transmission.

So, should all physicians ditch the white coat? Not so fast, say the patients. In numerous studies, patients significantly favor physicians who dress professionally and wear white coats. Patients are also more likely to attribute competence to a physician who is professionally dressed. Many patients favor white coats owing to the ease of identification, as well as tradition. There are very few patients who believe white coats are an infection risk, though many do view them as intimidating.

Physicians who choose to wear white coats in daily practice do so for many reasons: tradition, peer pressure, identification, keeping underlying clothes clean, and pockets for carrying references and equipment. Also, many physicians still like the prestige that accompanies the white coat. However, with more and more health professionals working in clinical settings, everyone from pharmacists and nurse practitioners to phlebotomists and dietitians are dressing in white coats, making identification and stature harder to ascertain.

The English ban on white coats is not likely to cross its borders, so physicians in the United States can keep wearing the traditional cloak of hope and purity for now. Medical professionals would be better advised to focus on hand washing, high hospital bed occupancy, and the excessive use antibiotics to combat the spread of disease.

References

Douse, J. (2004). Should doctors wear white coats? Postgraduate Medical Journal, 80 (943), 284-286 DOI: 10.1136/pgmj.2003.017483

KAZORY, A. (2008). Physicians, Their Appearance, and the White Coat The American Journal of Medicine, 121 (9), 825-828 DOI: 10.1016/j.amjmed.2008.05.030

REHMAN, S., NIETERT, P., COPE, D., & KILPATRICK, A. (2005). What to wear today? Effect of doctor’s attire on the trust and confidence of patients The American Journal of Medicine, 118 (11), 1279-1286 DOI: 10.1016/j.amjmed.2005.04.026

Wilson, J., Loveday, H., Hoffman, P., & Pratt, R. (2007). Uniform: an evidence review of the microbiological significance of uniforms and uniform policy in the prevention and control of healthcare-associated infections. Report to the Department of Health (England) Journal of Hospital Infection, 66 (4), 301-307 DOI: 10.1016/j.jhin.2007.03.026

  • In a large study from New Zealand with outpatients attending clinics that covered a range of medical and surgical specialties patients prefer a semiformal style of dress over formal suits and white coats. Casual dress styles were less popular.

    In a study done in the US, South Carolina, respondents from an internal medicine outpatient clinics overwhelmingly favor professional attire with white coats for physicians. This could be due to a more formal attitude in the south of the US.

    So it is also a cultural thing and media also play a role, what would be the effects of House and Grey’s anatomy.

    In pictures in the 2 largest medical journals in Sweden over a period of 1 year the majority (64%) of women doctors were dressed in white coats. The majority of male doctors (59%) appeared in civil dress.

    Many variables responsible for attire, in The Netherlands most physicians working in a hospital dress in white tenure or coat, out patient departments and general practitioner never wear white coats, how is it in your country?

    Psychiatrists definitely don’t wear white coats: http://www.shockmd.com/2008/12/04/should-a-psychiatrist-wear-a-white-coat/

    Kind regards Dr Shock

  • Studies that have evaluated patients’ preferences for physician attire are confounded by geography/culture, socioeconomic status, and age of the patients surveyed. The studies also lack context–does any patient chose their physician on the basis of attire alone? Would a patient rather have a doctor in a white coat who failed his board certification exam, or a doctor in scrubs who aced the test?

    A more recent study from the UK demonstrated the usual preference for the white coat, but interestingly this study then did a short educational intervention regarding contamination of the coat with hospital pathogens, and when the patients were re-surveyed nearly 2/3 opted for scrubs. Two other recent studies from the UK show that the proportion of patients desiring physicians to wear white coats is falling. And two other controlled studies show that physician attire is not correlated with patient satisfaction with regards to the care they received.

    As a hospital epidemiologist, I have thought long and hard about this issue, and I am convinced that even though we don’t have data proving that lab coats can transmit organisms to patients, it’s magical thinking to believe otherwise (see my blog on this). No one has done a clinical trial to prove that jumping out of a plane requires a parachute. Sometimes common sense is enough. Given that 2/3 of physicians wash their white coats at intervals greater than 2 weeks, that some organisms can live on the fabric for more than 3 months, and that the coats are often visibly dirty, it defies logic to somehow think that the beloved white coat cannot be involved in the transfer of organisms to patients. Our in vitro study using pig skin that you cited adds further proof. Plus, removing the coat and long sleeves makes hand washing much easier. For all these reasons, the Infection Control Committee at my hospital has recommended a bare below the elbows approach (no white coat, long sleeves, wrist watch or bracelets).

  • As a patient, I’d be happy if phlebotomists changed their gloves in my presence, so I wouldn’t be wondering if they had worn the same pair for the entire shift.

    The most amazing thing I’ve seen recently involved a nurse trying to start an IV on me prior to outpatient surgery. She donned a new pair of gloves for each try (3 of them before success — I’m a tough stick, so not her fault.) Immediately after putting the new gloves on, she bit the tip off of it covering the index finger she used to feel for a vein.

    My observations have led me to wonder if wearing gloves has led to less sanitation for the patient than even less than ideal hand washing.

  • Blev

    It is rather degrading to put the dietitian at the end along with the phlebotomist, considering dietitians have usually 6 years of education, same as the nurse practitioner/physical therapist.

Jennifer Gibson, PharmD

Jennifer Gibson, PharmD, is a practicing clinical pharmacist and medical writer/editor with experience in researching and preparing scientific publications, developing public relations materials, creating educational resources and presentations, and editing technical manuscripts. She is the owner of Excalibur Scientific, LLC.
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