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