White Coat FAQs — making hospitals safer

Recent Updates:

3/31/2016- “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.” 

1/20/2016 – NPR, Lexington, Kentucky (WUKY) with Dr. Greg Davis

1/9/2016 – Dr. Keren Landman on the Canadian Broadcast Corporation.

12/23/2015 – Boston Magazine blog post

12/18/2015 – Peter Pronovost blog post

11/23/2015- NPR article

11/19/2015- Boston Globe article

11/17/2015- Public Radio Tulsa audio interview

9/17/2015- The Conversation article

 

About the Petition

Our campaign to have clinicians voluntarily take off our white coats and roll up our sleeves started with concern about health-care associated infections (HAIs). HAIs are a leading cause of illness and death in the United States and worldwide. In 2011, an estimated 721,800 HAIs occurred in the US, leading to 75,000 deaths. Antibiotics have been a critical tool since the discovery of penicillin in the 1920s, saving the lives of millions of people around the world. Today, however, the emergence of drug resistance is reversing the miracles of the past eighty years, with drug choices for the treatment of many bacterial infections becoming increasingly limited. Meanwhile, reducing transmission of multidrug-resistant organisms and Clostridium difficile in hospitals is a critical priority. Infections caused by these pathogens are increasingly common and are frequently associated with adverse outcomes.

The relative role of clothing (white coats, ties, etc) in transmission of HAIs has long been a topic of controversy. However, what’s indisputable is that white coats are coated with pathogenic bacteria and have the potential to transmit infections to patients. This discussion got ramped up in July 2015 with Vineet Chopra and Sanjay Saint’s article on The Conversation. on TAfter they published their article, Mike Edmond and Eli Perencevich responded quickly on their blog. In September, Philip Lederer published an article on The Conversation, “It’s time for doctors to hang up the white coats for good.”  Subsequently, there was a debate between Mike Edmond and Neil Fishman at ID Week which received media attention and there has been ongoing discussion on Stopinfections.orgPhilip Lederer’s blogPaul Sax’s blog, and on social media. This story is gradually being picked up by the mainstream media as well.

A few additional points:

  • White coats are a symbol, no doubt about it. They are popular among many (but not all) doctors and patients. Their use been tacitly encouraged by the Arnold P. Gold Foundation’s White Coat Ceremonies.
  • First-year medical students don’t have a choice when they are urged to participate in a white coat ceremony. If a medical student declined to put on a white coat in front of one’s peers, that would be socially unacceptable.
  • More and more medical students are reported that their superiors have attempted to influence their dress.
  • We believe the Arnold P. Gold Foundation should stop including “white coats” as a part of its welcoming ritual.
  • We have respect for the history of medicine, but we believe in engaging with tradition, rather than blindly accepting it is a hallmark of professionalism.
  • Patients don’t have a choice if their doctor is wearing a white coat or not. It would be almost impossible for a patient to tell his/her doctor to take off the white coat and tie and re-wash their hands. Physicians traditionally dominate in the doctor-patient interaction.

However, the discussion about white coats goes well beyond the bacteria crawling all over their fabric. Many clinicians feel disempowered and burned out. And many patients are frustrated about health care costs and quality. Communication is often lacking in the health care encounter and the relationship between doctors, nurses, and patients is beginning to fray.

A few more points to ponder:

  • As the Right Care movement has pointed out, modern medicine offers important benefits yet it also has the capacity to cause harm
  • Americans spend $2.9 trillion annually on health care and much of that is waste
  • Despite the Affordable Care Act (Obamacare), many people lack access to high quality, affordable health care
  • Clinicians are often relegated to the role of clicking off check-boxes on an electronic medical record and have very limited time with patients
  • Insurance companies, drug companies, hospitals, and government bureaucrats control the health care system, not clinicians and patients
  • Much of health care seems to revolve around the “business of medicine,” aka billing
  • Quality of care is often inconsistent, as the media frequently reports, making hard-working clinicians feel disillusioned
  • Care is quite frequently not patient centered because clinicians are so busy and rushed

Enough is enough.

We clinicians can take off our white coats, roll up our sleeves, organize and mobilize. Like Rosie the Riveter during World War II, we can each take steps to improve quality and safety.

Take a few minutes and think back to why you went into health care in the first place. Quoting the RightCare Movement:

“A more just and compassionate world where health and health care are basic rights. Where patients are safe from unnecessary diagnosis, treatment, and harm. Where patients’ wishes are respected by their caregivers. Where clinicians serve as healers, and as advocates for those who are most vulnerable and in need of care, and where health care exists for the benefit of patients, communities and nations.”

Along with signing this petition and taking off our white coats, even busy doctors and nurses can commit to the following three actions:

1) I will clean my hands at every opportunity. I will also wash my stethoscope and limit the number of fomites (watches, ties, cell phones, etc, that I bring in proximity to the patient). I will not prescribe unnecessary antibiotics. Primum non nocere. First, do no harm.

2) I will provide patient-centered health care, despite the time constraints that I face in my busy clinical practice. Try to take the time to find a chair and sit down next to your patient and avoid looking at the Electronic Medical Record/ computer screen. Health care should be an equal partnership between clinicians and patients, and listening/ mindfulness goes a long way.

3) I will “think beyond the exam room” and become an empowered clinician by working in my community. I will consider joining progressive organizations such as:

Those of us who have taken off our white coats are not saying we are any “better” than clinicians who are still wearing them. Doctors and nurses wearing white coats are good, educated people and are not causing bad clinical outcomes. We are worried about possible harm from coats (as well as hand hygiene, other foamites, and excessive antibiotic use). We think our plan is a reasonable way forward– a middle ground.

If you choose to keep wearing a white coat, I suggest you wear it in the lecture hall, not the patient’s bedside.

If you choose to wear it at the patient’s bedside, please make sure to wash it every single day. That’s a lot of work, but your patients deserve it. And please wash your hands.

If you agree with us that it’s time to take off our white coats, stop HAIs, save antibiotics, and deliver high quality health care to everyone, please sign this petition, share it with family and friends, and please join us in this work. Thank you.

best regards,

Philip Lederer

cc: Eli Perencevich, Mike Edmond, Tim Lahey, Anthony Cannella

IMG_8950
White coats.
An alternative symbol?
Replace white coats with the symbolism of “Rosie the Riveter”

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This FAQs website is far from being perfect, and if you find any grammatical or content errors please contact me by email. I “interview myself, below.

Who are you?

My name is Philip Lederer. I’m an infectious diseases fellow (physician) in Boston.

What training have you received?

I went to medical school, did internal medicine residency, worked in Mozambique for a year, trained at the CDC in the EIS (“disease detectives”) program, and am now taking care of patients and doing research.

What’s your central argument?

White coats may transmit dangerous bacterial pathogens to patients because they are rarely washed. I think white coats are unnecessary and health care workers should voluntarily stop wearing them. This includes medical students, whom I don’t think should be forced to wear white coats on their clinical rotations.

What does the World Health Organization (WHO) say about safe hospitals?

They have developed a useful framework for making hospitals safer. But I think they could go a lot farther with a focus on healthcare associated infections (HAIs) and antibiotic overuse.

Expand on why you think white coats should go.

White coats are probably causing preventable bacterial infections in our hospitals, although we don’t have proof of transmission or know how many infections might be occurring. We have proof that many white coats are covered with dangerous bacteria like MRSA and it is plausible that they may be transmitted to patients. Eli Perencevich from Iowa has asked, “how many infections each year attributable to white coats nationwide are acceptable? Are 100 infections acceptable? What about 1000 infections, or more?” We have no idea how many infections may be occurring. What percentage reduction in that rate would strongly justify an elimination of white coats? These are questions clinicians and patients should be discussing.

What’s your favorite section on this FAQs website?

The “Comments” section, below. If you only have a few minutes, scroll to the bottom of this website, because some of the comments are quite poignant (especially Simon Agolory’s, Nicholas Teodoro’s, and Kate Granger’s.

Why are you writing about white coats when there are other fomites that have been linked to transmission and require education regarding cleaning (e.g., stethoscopes, computer keyboards)?

I am passionate about making hospitals safer. I fully support cleaning (or getting rid of) all unnecessary foamites. White coats have a certain symbolism, and attract attention, as will be clear if you read through this website. White coats are symbols, emblems of a physician’s commitment to uphold the ideals of the doctoring profession. The lack of focus on infection control/ antibiotic stewardship shows a lapse in the ideals of many physicians. We need more attention to white coats so we can improve infection control and antibiotic stewardship activities.

Are you on a “crusade” to get rid of white coats?

I was accused by one doctor of being on a “crusade” but I disagree with that terminology. First of all, remember the history of the Crusades. They were quite violent and I’m a pacifist. Rather than a crusade, I want a informed discussion about white coats and making hospitals safer globally. I’m on a mission, similar to Peter Pronovost or Don Berwick, to improve quality of care by reducing nosocomial transmission of pathogens like MRSA/MSSA, multi-drug-resistant gram negative rods, Clostridium difficile (C diff), tuberculosis, MERS, Ebola, influenza, etc. I want medical students, health care workers and patients to take infection control and antibiotic stewardship much more seriously. Getting rid of white coats serves as a platform to raise awareness and motivate people to change. That is even though change is extremely difficult, as Robert Kegan and Lisa Lahey describe in their book.

Are white coats a simple, black and white issue?

No. This is a very complex issue, as I outline on this website. It leads to heated emotions for some people who feel strongly about white coats (pro or con). It has to do with how we think about our roles in the hospital, our identities, and the clothes we wear. The data around white coats are limited and the stakes around this debate are high (life and death, actually, when you are talking about HAIs). Tim Lahey remarked, “here we are, repeating medical history, and arguing back and forth, back and forth, about whether one person’s common sense trumps another person’s lifelong habit. So many examples of this back through the years, with the final verdicts going in both directions, and of course until the answer arrives the vehemence of medical belief is inversely proportionate to the quality of relevant data.” Yet, I think our overall mission should be Primum non nocere. White coats may cause harm. Therefore, we should hang them up. #safehospitals

Primum non nocere. First, do no harm
Primum non nocere

Who wears white coats?

Not just doctors, but also physician assistants, nurse practitioners, nurses, pharmacists, phlebotomists, medical assistants, medical students, PA students, NP students, nursing students, etc. White coats are so widely worn they no longer serve to identify who the doctors are. White coats do not make you a better clinician or improve your fund of knowledge. They’re just a habit. And I think they should be retired.

What bacteria might be transmitted from white coats to patients?

Staph aureus (MRSA/MSSA), VRE, gram negative rods, C Diff, etc. We don’t know how frequently this might be occuring. A randomized trial to investigate white coats would be very expensive.

There is no randomized, controlled trial (RCT) evidence that getting rid of white coats will reduce transmission to patients. 

That is true. There is also no RCT evidence that parachutes save lives when you fall out of an airplane at 5000 feet. For white coats, the appropriate studies have not been done, and the “absence of evidence does not equal evidence of absence.” One of my colleagues wrote me that this phrase should be in a Dr. Seuss book, but I think it’s important.

However, there is some evidence: Mike Edmond conducted a simulation study that proved that micrococcus could be transmitted from ties and white coats to mannequins after a 2.5 minute standardized physical exam. And a lab study demonstrated that white coats could transmit VRE, MRSA and pan-resistant Acinetobacter to pig skin.

To conduct an study of white coats, we need to ask a few questions. What data do we need, what study would we design to collect that data, and how much would study cost?

What does the Society for Healthcare Epidemiology of America (SHEA) say about white coats?

SHEA writes: “Facilities may consider adoption of a bare below the elbows (BBE) approach to inpatient care as an infection prevention adjunct, although the optimal choice of alternate attire, such as scrub uniforms or other short sleeved personal attire remains undefined.”

What do you think about the SHEA statement?

I think SHEA made their argument because there are no data that removal of white coats reduces infection rates and no data to tie wearing a coat reduces transmission of infection. However, “the absence of evidence does not equal evidence of absence.”

Do we need a research study to prove that white coats lead to bacterial transmission?

Here we get to the heart of the matter. It would certainly be nice if a whole genome sequencing study was done to prove transmission. However, such a study would be expensive, large, andtime consuming, and I believe there’s no need for white coats or a large study. If someone is willing to conduct such a study, take the advice from Sharon Peacock from the University of Cambridge who emailed me, “You could use sequencing to define the effect of white coats in transmission but it would be a large job. Coats would have to be sampled repeatedly over time, together with the population that they care for to find a bacterial genetic match. The amount of effort this would require will depend on the prevalence of carriage in the population (one could look at MSSA and MRSA to increase the power), and other factors such as rates of coat laundering, hand washing efficiency, etc. One may also want to sample staff carriage to work out directionality. The issue is that since most pathogens are likely transmitted via hands, and the same pathogens may be on the hands and coats, even with whole genome sequencing could we be sure whether the organism that was transmitted came from the hand or the coat? Dr. Peacock’s answer was, if you have the genomes of the isolate from the patient, the hands and the coat, you would need to compare the degree of relatedness. If they all sit within a cloud of diversity, directionality could not be defined.

How big of a problem might transmission of bacterial pathogens by white coats be?

We have no idea. White coats could be causing a handful of infections or many infections. But even one preventable infection is too many, because I believe white coats don’t offer any real benefits to patients.

White coats offer no benefit to patients? Don’t patients prefer their physicians to be in “professional attire?”

There are a number of studies and the results are complicated. Vineet Chopra and Sanjay Saint wrote about preferences in their article, and Mike/Eli wrote a rebuttal on www.stopinfections.org. The main thing I would say is “patients” are not uniform. A 90 year old woman in a nursing home in Ann Arbor is very different than a 18 year old HIV positive man in Mozambique. I think the unifying factor across cultures is patients want high quality, safe, affordable healthcare, and a clinician who listens to them/cares for them. I don’t think white coats are necessary to achieve that kind of health care. If white coats help encourage trust, that’s good but that trust can probably occur without white coats. If white coats lead to paternalism, that’s not good.

Are you arguing that white coats should be banned? 

No, as Mike Edmond has described, we think health workers should voluntarily give them up during the clinical encounter.

What does that mean?

If you choose to keep wearing a white coat, I suggest you wear it in the lecture hall and hallways of the hospital, not at the patient’s bedside.

Where would I hang it up as I go into the hospital room?

Our hospitals need to invest in high quality hooks outside each and every hospital room.

Are there any poignant stories you would like to share about doctors and white coats?

A friend of a friend was diagnosed with metastatic cancer and wasn’t have a response from chemotherapy, radiation, and surgery. She was frequently admitted to the hospital. This woman was actually a doctor, having completed internal medicine and oncology training. Given what she had seen in her work as a physician, she was worried about acquiring a nosocomial infection like MRSA or C diff. Therefore, she had a sign put on her hospital door that said, no white coats please. If a doctor admitted to the hospital wants no white coats around her, we should all ask for the same treatment.  Lets all voluntarily take off our white coats and have #safehospitals.

What would I wear instead of a white coat?

Slacks and a shirt with the arms rolled up (or a short sleeve shirt). Or scrubs. Mike Edmond advocates for a vest for warmth. I would suggest wearing the vest under the scrubs. Make sure you follow the SHEA recommendations on laundering and the recommendation of a hot cycle, preferably with bleach.

We also are considering a replacement symbol, like Rosie the Riveter, to demonstrate our cause (have a health care worker) with their fist in the air and have BBE as the slogan.

An alternative symbol?
An alternative symbol?

How often should I wash / change my clothing (scrubs or other clothing)?

Daily. Follow the SHEA recommendations.

What about introductions to patients? They need to know who I am.

A big, visible name-tag will do that, with a loud, friendly introduction. Kate Granger has done incredible work on introductions in the UK, through the #hellomynameis campaign. She wrote me, “We’ve not had white coats in the UK for over 10 years. I think the white coat is just another barrier between doctor and patient, personally I would never wear one nor expect my juniors to wear one. You’re right, it does have a relationship to #hellomynameis in that introductions are essentially about breaking down barriers, flattening hierarchies and redressing power imbalances too. Patients and doctors collaborating together as equal partners – now there’s an idea!”

What about the UK?

The UK implemented BBE a few years ago, but there were apparently too many changes in UK along with BBE to link reductions in transmission to one intervention.

I get so cold in the hospital. I shiver. I need my white coat. 

Wear a vest. We need #safehospitals.

I don’t like vests.

Which do you dislike more, C diff or vests?

Hospitals really are too cold. Vests aren’t good enough at keeping me warm. 

Talk with your hospital CEO about raising the temperature? Carry a parka around and leave it at the nurses station when you go into the patient room, and then put on the parka when you are writing your note?

I need my pockets to carry my papers/ pens/ calipers/ candy bars/ stethoscope. I need my white coat. 

Buy a Patagonia Atom sling from REI. It costs $49 and can be easily washed.

I really, really, really need the pockets on a white coat and really don’t want to wear a sling. 

Are you absolutely sure you need your white coat for the pockets? Do have absolutely have to carry a pager? Maybe your pages can get forwarded to your smartphone and you can carry that by itself. Do you really need to carry your keys? Maybe there’s a locker you can leave your keys in. Do you really need your wallet? Maybe a single credit card is enough for the dining room cafeteria. What about a pen? If you wear shirts with a breast pocket, a pen can go in there, or hanging on your ID lanyard. What about your patient list? That can go in the back pocket of your pants, or if you wear a vest, they have inside/outside pockets. Women’s clothing generally has less pockets than men’s clothing, but it’s not impossible to construct a “FFFF” wardrobe with a little bit of effort.

What’s an “FFFF wardrobe,” Dr. Lederer, and how the heck do you know about women’s clothing, given how frumpy of a dresser you are?

Because I attended a lecture about it! FFFF clothing will enhance your professional image.

  • Fit– determine your retail sizing
  • Fabric– Greatly aids a polished appearance
  • Function– make your wardrobe work overtime for you
  • Flair– professional dress does not have to be boring

What else do you know about women’s business attire, Dr. Lederer?

Women can engage in “capsule dressing”– They can have few pieces of clothing, but many looks. That is, women should build a smart “base wardrobe.” There is power in black, gray, navy, and red (also brown, camel, maroon, olive, winter white and beige). Capsule dressing creates many looks and few pieces of clothing. It incorporates color and patterns effectively.

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Are you voting for Hillary Clinton for President? 

I’m not going to say. This website is nonpartisan. But you probably can tell from my Twitter feed whom I am supporting.

I don’t want to wear a sling because it is dorky. And I don’t have the money to retrofit my wardrobe. And it’s impossible for me to get rid of any of the stuff I am used to carrying. By the way, how’s that sling working out for you?

I was once called “Dora the Explorer” by one of my colleagues because of my sling. It hurt me deeply and I am considering seeking therapy. But what’s more dorky is potentially spreading bacterial infections around the hospital and harming patients.

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No, a backpack is too dorky. I’d rather be spreading bacteria around the hospital. 

Are you sure you’re in the right profession?

You must have an ulterior motive for getting rid of white coats, Lederer.

If I have an ulterior motive, it’s that hospital infection control is neglected in America and around the world. I’ve written/spoken about TB infection control for years. But few Americans care about TB since there are so few cases here. But most Americans go to the doctor, and none of us have any way to know if our doctor washes his/her coat. At least with hand washing, we can see if the doctor washes his/her hands upon entering the room. White coats bring the issue of nosocomial transmission of pathogens home. By getting rid of white coats I think we can help develop a movement of people focused on quality and patient safety. #safehospitals.

You must have another ulterior motive for getting rid of white coats. I don’t buy your first ulterior motive. 

Ok, here’s the deal. I think America’s health care is completely broken, and downright corrupt in many cases. Just check out today’s article in the New York Times for evidence.  Our fee-for-service model encourages unnecessary, harmful care, despite the passage of the Affordable Care Act (“Obamacare”). I’m not a health policy expert, but discussions with people like Adam Gaffney and Tom Peteet have convinced me that we need dramatic change in medicine, with a single payer (universal health coverage), community-based primary care, patient engagement using smart phones, etc. You can read my views on throughout this blog. If we can get rid of white coats, we can make other changes to our health care system too. It’s going to have to come from the bottom up, and will ideally be led by patients and medical students. Most doctors have too much of a “skin in the game” to support real change.

Do you have any other ulterior motives for getting rid of white coats?

I want more people to call me Dora.

dora real
Dora; Lederer; Perencevich; Edmond

Ok, but you must have a secret, selfish motive.  Aren’t you just trying to make a name for yourself by railing against white coats? Or aren’t you trying to strike it rich in the garment industry?

We are all selfish creatures, so you can make that argument, but I would hope that it isn’t true. And regarding money and clothing, see Sam Wurzel’s comment, below. This is really about patient safety.

What experiences have you had that made you against white coats?

  • Working in Botswana and Mozambique, where nosocomial TB transmission is common. I have known a number of doctors and nurses who have come down with TB which they probably caught in the hospital, including a good friend of mine. Studying the history of the Tugela Ferry XDR-TB outbreak. We’ve written about this issue, here.
With my friend/colleague Noe Massango, in Mozambique.
With my friend Noe Massango, in Mozambique.
  • Being an EIS officer at the CDC and learning how outbreaks occurs. For example, I was among the group of CDC officers who worked on MERS Coronavirus during the summer of 2013 and subsequent MERS Indiana investigation in 2014. I left CDC before Ebola really took off but its transmission was also nosocomial in many cases.
With my colleague, Ginny Lipke, during the EIS conference. I was a Lieutenant Commander in the USPHS.
In full uniform at the  CDC.
  • Being an ID fellow at Harvard and seeing the overuse of antibiotics and hospital-associated infections.

But white coats prevent me from taking home deadly bacteria to my family. They keep my clothing clean underneath my white coat.

You would potentially spread deadly bacteria around the hospital on your white coat so you can keep your clothing underneath clean, and your family “safe?” Do what they do in the United Kingdom. Change your clothes in the hospital before you go home. Or take your clothes off immediately when you get home and put them in the laundry basket and wash them on the hot cycle / with bleach, following the SHEA recommendations.

I think patients have more confidence in my recommendations when I wear a white coat. I need my white coat. 

That may be the case. It may also not be the case. I haven’t seen any proof of it. If you find any, let me know. I think patients want a doctor who listens to them and is knowledgable and caring and follows up with them after they leave the clinic/hospital. I don’t think patients want a paternalistic doctor.

But white coats are a tradition. They are important to me as a doctor. I’ve been wearing my white coat since the first day of medical school, the white coat ceremony. It gives me self-confidence. I need my coat.

Ahh, the white coat ceremony. More on that later. It’s true that white coats have been around for quite a while, and you could call them a “tradition.” White coat ceremonies only started in 1992, as I described in my article. But traditions can change. Black coats changed to white coats.  And #safehospitals are more important than tradition.

I am too busy to dress well and am embarrassed about my rumply clothes. I don’t know how to look fashionable while taking care of patients. 

I have sympathy for you. I also do not consider myself a good dresser. My friend recently told me to go to the Gap to buy new clothes and I didn’t have any idea where it was. As is described elsewhere on these FAQs, scrubs would do the trick. The surgeons and ER doctors wear scrubs. Why can’t we all?

I’m embarrassed about my body because I am overweight. A white coat helps conceal how out-of-shape I am.

I’ve been overweight intermittently during my training and know very well how body appearance affects self esteem. Self-esteem and self-confidence are important. Our society is discriminatory of people who are overweight. But we don’t need white coats.

Everyone else in the hospital is wearing a white coat. 

If everyone else were jumping off a cliff, would you jump too?

What do other infectious diseases (ID) doctors think about this?

Many ID doctors agree with me and others disagree. Scroll to the bottom, to the “comments” section of the blog, for more supportors/detractors. Some of the most vocal advocates for getting rid of white coats are Mike Edmond and Eli Perencevich, who run the Stop Infections blog, but others including Tim Lahey and Anthony Cannella. On October 10, 2015 at ID Week, Mike Edmond debated Neil Fishman and Mike’s arguments against white coats are here. The “party line” from SHEA and the infection control community is that white coats should be laundered frequently and health workers should wash their hands before and after every patient encounter. However, both of these steps are often omitted because people are busy, overworked, careless, etc. You could argue that the health system is set up for people to fail. As Brian Yablon and I learned from our visit to Cuba, the “party line” is often incomplete.

I’ve been a doctor for 40 years and have always worn a white coat. Do you suggest I get rid of my coat now?

Yes.

I’ve been a doctor for 40 years and have never worn a white coat. Do you suggest I start wearing a white coat now?

No.

I only see patients in the clinic, not in the inpatient setting. Should I get retire my white coats?

Yes.

I am a psychiatrist. I don’t touch the patients. Should I get rid of my white coats?

I have no idea.

What happens in Europe?

In England, white coats are not worn. Clothing is laundered for free by the hospital in many settings. Ask the British doctors on Twitter what they think of white coats. If there’s any British doctors who are willing to weigh in (Kate Granger did, on this website), I’d be very grateful.

I wash my coat weekly and immediately if it is soiled. I don’t see any bacteria on my coat. Am I ok?

Bacteria are invisible. MRSA or C diff can get on your coat on Monday and spread over the hospital all week long. While it’s true that we are all covered by fecal patina and personal microbiomes, we should be trying to reduce the number of pathogenic bacteria on our skin/clothing. Also, few American hospitals offer convenient laundry service to have white coats washed daily.

What about gender/race?

This has come up several times on my blog (1,2,3). I am a white male, so I can’t speak from experience on this, but it’s clear that female and minority physicians are often discriminated against in the hospital setting by patients and by other health care workers. This is an extremely important issue and needs much more attention. Period. Minority physicians are in very short supply as Nikole Hannah-Jones recently made clear in the New York Times. However, I don’t think gender/race are sufficient justifications for keeping white coats.

When I was pregnant I wore a white coat to conceal the fact that I was gravid. 

That is interesting. Pregnant health care workers need to be supported. But it doesn’t mean that we need white coats.

What about causality, white coats, and nosocomial infections? 

In epidemiology we talk about Rothman’s “Sufficient and component cause model.” Basically, it’s a model of causation to facilitate the conceptualization of epidemiologic problems. A cause is an event, condition, or characteristic that plays an essential role in producing an occurrence of the disease. The cause of any effect must consist of a constellation of components that act in concert. A sufficient cause is a set of minimal conditions and events that inevitably produce disease. A component cause is an individual event, condition, or characteristic required by a given sufficient cause. A necessary cause is a component cause present in every sufficient case. I think white coats are a component cause but not a necessary cause. Certainly transmission of MRSA from a doctor’s hands to a patient could occur from someone not wearing a white coat.

What about paternalism and the symbolism of the white coat?

The white coat means different things to different people. Eric Topol has written about paternalism in his recent book. Lisa Rosenbaum also wrote a powerful article about the topic. Topol argues that “it’s not just the skill/art of the doctor that’s important. Patients should be asked what they want with respect to their medical information and be given everything they want.” I believe some doctors are more paternalistic than others and I would like less paternalism in medicine.

Do you agree with Mike Edmond when he writes that white coats are “all about the doctor’s ego?”

In some, but certainly not all cases. I do think humility is quite important for physicians. Arrogance/confidence is common and perhaps useful in some cases (heart transplant surgeon, cutting open someone’s chest, and then something goes wrong?), but is far too common in medicine. And maybe we actually want a humble cardiac surgeon who is willing to admit when s/he does something wrong.

What about cell phones, ties, watches, etc?

All can be foamites. We should minimize their use when around patients.

Getting rid of white coats isn’t going to make a difference if people don’t start washing their hands better.

Getting rid of white coats will hopefully lead to a *lot* more attention for infection control and overuse of antibiotics, leading people to wash their hands better. What we’ve done so far has not worked. President Obama’s plan for combating antibiotic resistant bacteria is a nice start but it will require much more attention. We need health care workers and patients to stand up and say, “this changes now. I am going to change my antibiotic prescribing/ hand-washing behavior.” To do that, people must overcome their “immunity to change” as Robert Kegan argues.

What about the Gold Foundation and white coat ceremony?

The first white coat ceremony was in 1993 and they are sponsored by the Gold Foundation. I think white coat ceremonies are unnecessarily encouraging medical students to wear white coats. Medical students are given white coats in the beginning of medical school and effectively forced to wear them during many of their core clerkships and OSCEs. To the Gold Foundation: I would be very happy for the welcoming ceremonies to stay around to discuss the importance of humanism in medicine, but I want the white coats to be retired.

Screen Shot 2015-10-18 at 9.31.11 AM

You are against white coat ceremonies?  Are you against humanism in medicine?

On the contrary. I am a vocal advocate for humanism in medicine. I also think we need to be professionals, but white coats aren’t necessary for that.

What would you say to medical students?

Primum non nocere (First, do no harm). Realize that medical school student experience with white coats vary dramatically. On pediatrics rotations, no one wears the white coats. On other rotations and when doing OSCEs, they are expected. First, speak with your classmates about how they feel about white coats. After that, speak to your medical school advisor or dean and ask him/her to consider changing your white coat ceremonies to a “welcome ceremony.” They can give out a stethoscope or something else instead of a white coat. It will still be a meaningful event.

I believe you don’t respect tradition in medicine. White coats are an important part of our culture/history as doctors. 

On the contrary, I am fascinated by medical history. Any time I am at Massachusetts General Hospital and have the time, I go up to the Ether Dome and try to do some writing. When I worked at Maputo Central Hospital in Mozambique, I would always try to go to the hospital’s museum which focused on Portuguese colonial medicine. I think we should all closely examine our history/traditions and consider if they are still relevant in 2015.

What about Dr. Abraham Verghese’s emphasis on the ritual of the physical exam and the “Stanford 25”?

I’ve admired Dr. Verghese for years since I read “My Own Country.”  It was one of the books that shaped my career as an HIV doctor and observer. (Verghese was in Tennessee and I grew up in Kentucky. My wife is currently a doctor at BMC where Verghese trained). I took Arnold Weinstein’s “Literature in Medicine” course at Brown and we discussed Dr. Verghese’s books and he came to visit our class once, which was a memorable highlight. I loved “The Tennis Partner” and wish that book were more widely read, especially in the context of the disaster that is addiction in America. I also have “Cutting for Stone” in a prominent place on my bookshelf. When my wife and I visited Ethiopia, we enjoyed talking about that fine book. I admire the work of the Stanford 25.  I think the physical exam and ritual in medicine are very important. The “Ipatient” is getting in the way of the doctor-patient relationship. But white coats aren’t necessary to do a good physical exam or have a good relationship with the patient or complete the physical exam “ritual.” They don’t wear white coats in England and they examine patients there. I’d like to hear a conversation between Kate Granger and Abraham Verghese. Kate Granger is a doctor in England with metastatic cancer and has written on this webpage about hierarchy and communication in medicine. She is against white coats.

I believe removing white coats is “empty symbolism” because it doesn’t address hand washing and it may substitute an empty symbolic act for the real thing (washing hands). 
I disagree. In the difficult, lengthy process of convincing people to take off their white coats, there will be a large amount of attention on the importance of hand washing and that will hopefully lead to less transmission.

You’ll have to pry my white coat off my cold, dead body. 

That seems a bit extreme.

Patients, should you ask your doctor why s/he is still wearing a white coat?

We’re told by the pharmaceutical industry to “just ask your doctor if this medication is right for you.” It seems like white coats are a reasonable issue to discuss as well. His/her answer will give you a sense of how seriously your doctor takes infection control. Just ask, in a non-threatening manner, “Would you mind telling me why you wear a white coat? I heard they are frequently covered with dangerous bacteria like staph aureus.”

Will it be easy to ask your doctor about his/her white coat?

No, probably not, as Maureen Dowd has written. But it is important to do. If patients start speaking up about making hospitals safer, that will spur people to act.

Why are you so obsessed with C diff? 

It’s a bad guy. It makes people really sick. It’s like “Darth Vader” from Star Wars and “The Joker” from Batman. And C diff can be cultured from the hospital environment, including items in patient rooms as well as the hands, clothing, and stethoscopes of healthcare workers. Yet we don’t take hand hygiene or antibiotic stewardship seriously enough.

Screen Shot 2015-10-17 at 8.38.03 PM
Toxic megacolon

Why are you so obsessed with Staph Aureus (MRSA/MSSA)?

Staph aureus is a bad guy. I It causes really bad infections and kills people. It’s like Hans Gruber in ‘Die Hard’ or Hannibal Lecter in ‘The Silence of the Lambs.’ It is most commonly transmitted to patients via the transiently contaminated hands of healthcare workers. That means, we don’t wash our hands well enough/often enough in the hospital. Maybe by taking off our white coats, we can spur people from their complacency and do a better job with hand washing.

Staph aureus in a wound. Gram positive cocci in clusters from a knee aspirate.
Staph aureus from a knee aspirate. Gram positive cocci in clusters under 1000x magnification
my patient had subacute leg pain and on MRI Was found to have femoral osteomyelitis with extensive adjacent pyomyositis, due to staph aureus
my patient had subacute leg pain and on MRI Was found to have femoral osteomyelitis with extensive adjacent pyomyositis, due to staph aureus

Why are you so obsessed with Klebsiella and other resistant gram negative rods?

These gram negative rods can be very resistant and cause life-threatening nosocomial infections. Take a glance at this article if you are interested in learning more.

What about a social media campaign to take off our white coats?

You can Facebook/ Tweet/ Instagram about this using the hashtag, #safehospitals

Do you ever wear a white coat, Dr. Lederer?

Yes, I do.

When?

I wear it around my apartment in Boston when it’s cold, during wintertime. Especially when I am cooking.

Why?

It’s fun.

What do you cook when wearing your white coat?

Usually bean soup. I like red lentil soup.

But you never wear it in the hospital?

No.

Isn’t that a bit sacrilegious to wear a white coat around your apartment but not in the hospital?

I’m not a priest. And my white coat is not a cassock.

But the chairman of cardiothoracic surgery or neurosurgery might feel differently.

That’s ok.

Are you sure you’re right about all this white coats stuff?

No. “The best lack all conviction, while the worst / Are full of passionate intensity.” — W.B. Yeats

Still not convinced that white coats might cause harm?

Lets do a thought experiment. Imagine the person you love most in the world (say your parent/spouse/child) is admitted to the hospital after a terrible car accident with multiple fractures and internal bleeding. S/he is in the intensive care unit for a week barely holding on to life. S/he is intubated (a breathing tube down the throat), has multiple IV lines, and had several surgeries. You are completely exhausted. In fact, you are in a panicked, distraught daze, half-awake, half-asleep. This feels like a nightmare that you can’t ever awake from no matter how hard you try. The ICU doctors and nurses are coming and going at all hours and you never really know who they are. They seem knowledgeable and you have confidence that they are working hard to bring your loved one back to health. But you are also nervous because you recall hearing on television about infections being transmitted in hospitals and you want to make sure your family member doesn’t catch something bad. One morning, at 6 AM, a doctor you don’t know comes into the room. He looks like a resident but doesn’t really introduce himself. You are in a daze after not sleeping last night, on the fold-out couch next to the bed, with all the alarms going off. This doctor is friendly. S/he is wearing a white coat. How do you feel? Now do the same thought experiment and imagine that s/he is not wearing a white coat. How do you feel?

I think you are totally insane. There can’t possibly be anyone else who feels as jazzed up about white coats as you do.

Au contraire. Call up Drs. Eli Perencevich and Mike Edmond at the University of Iowa. They  are my role models in this endeavor.

Comments

If you want to comment, or add your name to the list of health care workers who pledge to give up his/her white coat, please email me at embracingprevention@gmail.com and Tweet/ Instagram/ Facebook to #stopinfections

  • Simon Agolory (CDC)– “This is great and I agree with you 100%. We had an outbreak of MDR Klebsiella at an Oncology ward a few years ago and it claimed one of our patients. All affected patients were immobile which indicated that  it was spread by healthcare workers. Losing any life because of something preventable like transmitting an infection through what we wear should be an issue for any one in our profession especially since we all take an oath to do no harm.”
  • Kate Granger “We’ve not had white coats in the UK for over 10 years. I think the white coat is just another barrier between doctor and patient, personally I would never wear one nor expect my juniors to wear one. You’re right, it does have a relationship to #hellomynameis in that introductions are essentially about breaking down barriers, flattening hierarchies and redressing power imbalances too. Patients and doctors collaborating together as equal partners – now there’s an idea!”
  • ZDoggMD– “Hi Philip! Great site. I hadn’t thought much about white coats specifically until I read your piece. I NEVER wear them, just intuitively. I think they represent a barrier (to everything except infection, haha). “
  • From a CDC epidemiologist/microbiologist– “As a microbiologist, I feel like they are ridiculously dangerous.  Like playing with a loaded gun.  I would never consider wearing a lab coat out of the lab and a lab coat is much cleaner! It’s a pity that folks will risk the health of all for their own narcissistic need for perceived power or respect. It’s just frustrating to have spent so many years trying to understand how bugs become resistant at a molecular level and then trying to work on effective therapeutics when so much development and transmission of resistant bugs can be prevented by clinicians, sometimes doing simple things.  It really feels like I’ve worked hard to clean up someone else’s mess!   In EIS I investigated an outbreak of a rare infection among cardiovascular surgical pts.  We initially thought it could be a common product, but turned out to be environmental.  One culprit– surgeons were given fleece jackets embroidered with their credentials. Since the hospital was cold, they’d wear them outside and inside–everywhere but during surgery, including post op recovery visits!  Oiy!”
  • Nicholas Teodoro, medical student-  “I think hierarchy is a big reason for the perpetuation of the white coats in medical school. It’s this ‘you’ve made it and here is your badge of honor’ sense and yet they give it to you before you’ve even started. Maybe if they spent more time helping us develop integrity, compassion, communication, etc, truly important traits as physicians, instead of focusing on “traditional symbols” of medicine. I’d rather my patient respect me for my empathy for them and skills than the coat I am wearing, and neat pins I have.”
  • Judy Stone “I agree with the idea of not wearing white coats and generally didn’t in my own practice, but it goes beyond that. Where I work now, I am expected to. Being a woman, it is also needed for acknowledgement from patients and other attendings. Change your clothes in the hospital before you go home” is nice, but not very practical, as there are no lockers outside the OR, and limited access there. Besides white coats, many physicians wear suits, so that they look “professional.” These, too, are rarely dry-cleaned and are likely to spread nosocomial infections. I have long advocated for HCW to be able to have scrubs provided or laundered by the hospital, especially if contaminated by blood. They refused d/t cost. Unless something like that is mandated, I don’t see it happening. Do you?”
    • My response- Thanks Judy! Agree, gender/race are extremely important. That was explored above on the 3 links “What about gender/race?” I think it’s practical to change clothes, there are bathrooms, lockers in my hospital. Agree regarding suits (and fleece/ track jackets which are very common). In England, scrubs are provided and laundered. I don’t know about mandating this, that adds another layer of complexity and potential opposition.
  • From an internist in California–  “I think you already addressed my biggest concern (i believe at one point you claimed to have no knowledge about patient preference). Overall, in a system where the minority of health care providers wash their hands between patient encounters, perhaps the value of removing white coats doesn’t seem so great to me. (that’s a rather weak rebuttal, i am aware, but it’s how i think about it). What about:
    – finally penalizing people for not washing hands/stethoscopes between encounters
    – marking patients with resistant organisms as they are transferred around the hospital (i’m not sure this is done now)
    – adding shoe protection to standard PPE — it is ridiculous that i walk around my c. diff patients rooms with uncovered shoes which then track c. diff spores throughout the hospital.
    – reducing HAIs and the spread of resistant organisms is much bigger than white coats, and perhaps i can see the value as part of a broader package, but the singular act of removing a white coat? Not enough to overcome my preference to wearing one. In addition, the more I think about it, the more I think removing white coats is empty symbolism. 
    1. It doesn’t address the many pieces of reducing HAIs and spread resistant organisms such as hand washing
    2. There may be real problems created by this such as for minorities/women. or it may remove a tool which helps with communication/trust. (There is similar evidence for this as for the benefit of removing white coats)
    3. People may substitute and empty symbolic act for the real thing (washing hands). This is how I feel about “retweeting”
    • My response: Thanks, “internist!” I agree that there are bigger etiologies of nosocomial transmission than white coats. But if we get rid of white coats, that might lead to HCWs paying more attention to hand hygiene/antibiotic stewardship? (Not to mention the paternalism issues). I’ve been in contact with medical students, trying to get them on board… They are often forced to wear white coats for OSCEs, clinical rotations, etc, because their medical schools/ attendings force them to… I don’t think it’s right. They don’t wear white coats in England and they provide fine medical care. I agree we need to crack down on people not washing hands, C diff transmission, etc. And I don’t think it’s empty symbolism, as I discuss above.
  • Tim Lahey– “Great start Phil! I’ve suggested some additional questions a reasonable interlocutor might ask, below.
    1. My infection control team is busy and underfunded. How high priority is this infection control intervention compared to others?
    2. What is the expected magnitude of benefit to patients of transitioning to a BBE approach?
    3. Did programs who made the transition detect unintended consequences that our program can mitigate by addressing them in advance?
    4. Should stethoscope hygiene messaging be included? If so, what? (What about ties? Scarves? Burkhas? Turbans?)
    5. What microbiological data exist regarding microbes on forearms vs white coats and their link to microbes transferred to patients?
    6. How much does the extra Purell used to wash all those hairy forearms cost?
    7. I’ve recently been called Dora the Explorer, and it hurts me deeply. From whom can I seek counseling.
  • Celso Khosa– “I like ‘The absence of evidence is not the evidence of absence.’ Here some doctors after working in the wards hang their coats on the driver seat and then pick up their children at the school.”
  • Ben Sigelman– “RE the whitecoat thing: I’m not that upset about it, really… but I appreciate where you’re coming from! To me, the ID angle is not nearly as compelling as the paternalism/bedside-manner angle… I’d rather hear an argument about how we want patients to feel, and focus on getting MDs to do a better job of getting them there. And maybe whitecoats are a part of that (or maybe they aren’t), but that’s just my two cents. Fight the good fight, Lederer!”
  • Ben Fogel– “Love it.  Had me laughing at a few points.”
  • Matt O’Brien – “Phil, you’re a crusader. I like it a lot”
  • Prabhjot Singh “I think you are right. I don’t wear a white coat for two reasons (1) infection risk and (2) barriers with my patients. I dress nicely as a sign of respect to them and their expectations instead. I also don’t wear a tie when I see patients for reason #1”
  • Eric Topol– “Well done (as usual!) All the best, Eric”
  • ID Attending at MGH- “I’m against them, as fomites. (Same with ties, and I roll my shirt sleeves.) Never wore one all through training”
  • Jason Goldman– “Great post, love it.  You are starting to convince me. One of the nice things about HAI research is that the turn-around time is very short.  Find the ichiest white coats and culture the grime around the sleeve cuff.  Other studies would follow naturally (i.e. test white coats from primary team after episode of HA-C. diff, etc, etc).  It doesn’t need an RCT… You should do some of these studies!!”
  • CDC Physician who wished to remain anonymous-“You’re persistent Phil! I personally always wore my white coat (except heme:onc rooms) because a) it allowed me to carry lots of stuff and b) I was often cold. I was comforted by the requirement for PPE in caring for patients with MRSA, VRE, etc or histories of those bugs (carriage or infection). That said, use of scrubs which are washed AT the hospital would be great. Our hospital only gave us 3 scrub sets that WE had to wash AT HOME. Pretty gross. Except at the NICU–we could obtain and turn in scrubs there for washing. I do think a study could help here to show transmission. I thought there was a study done in England which prompted their shift from white coat use. I know I’m rambling but I hear what people say about the white coat ceremony. While ceremonies are important, I do think it’s bogus because at that point in time you haven’t actually done anything but be accepted into medical school and show up. I think something should commemorate the moment but haven’t thought enough about what that would be. And no sling thank you. Totally dorky. But no matter what you carry, there is still potential to carry bacteria room to room or patient to patient, right? So you got to leave it outside the room.”
  • Jonathan Colasanti-  “Nice piece Philip. You make a compelling case. As I watched Drs. Edmond and Fishman duke it out under the lights in San Diego, I walked away pretty convinced that white coats are certainly not a beneficial entity (nor even essential) in the physician’s toolkit. Whether or not it’s truly detrimental is tougher to say for sure but there is certainly some evidence pointing to the plausibility of white coats contributing to nosocomial infections. Though we lack RCTs demonstrating that doffing of the white coats for good will lead to plummeting rates of hospital acquired infections, the question becomes do we really need the RCT? There’s the parachute example about why not everything needs an RCT, but I prefer one I once heard Dr. Paul Farmer use -“I don’t have an RCT that says providing basic nutrition to hungry children is the right thing to do, but it just makes sense, right?” (a paraphrased quote from many years ago). That’s kind of where I think the white coat debate falls – Do we need the RCT or does it just make enough sense? I’ve heard a lot of people complain about where they would put everything that they keep in their white coats – Do we need more than smartphone and stethoscope (yes in that order)? Because obviously with healthcare dollars saved every hospital room can be equipped with ophthalmoscopes, reflex hammers, ecg calibers, and whatever else one lugs around! I don’t know what to do when everyone on rounds carries a bag around, dragging from patient room to patient room to the airport and beyond?!? By the way – enjoy the hate mail you’ll be receiving in a couple of weeks when patients around the country are driving their docs “loco” when asking: “Why do you wear a white coat… you think you’re better than me?”
  • Sam Wurzel– “I think there is a business opportunity to make a new kind of garment that resembles a white coat but is like scrubs in that it is washed everyday by the hospital. I think you can solve all the problems and address all the concerns that way.”
    1. My response to Sam- I think this is on the right track. We need a thicker, warmer version of scrubs that can be washed every day, with a nametag embroidered into the cloth, that is very large…
  • Susannah Graves– “Consider an alternative: white coats with short sleeves to be washed daily (as scrubs are) by the hospital. These would serve some of the purposes doctors like them for (pockets, keeping their clothing free of the unexpected blood/feces etc that occasionally happens). Furthermore it would probably encourage men (who wear long sleeves more often than women, at least in my hospital) to roll up their sleeve so they don’t look “dorky” in short sleeved white coats. I don’t necessarily think that the white coat is bad as a uniform per-se, and I think patient-centered care can be conducted in-uniform as well as out.”
  • Matt Crull- “Are you opposed to white coats because you have to wear a short white coat again [short coats are commonly worn at Mass General]?  I don’t need any additional convincing.  I don’t normally wear a white coat anymore.”
  • Jen Rosenberg– “Can we get some lab to swab all of our white coats (and ties) into a petri dish and see what grows? Perhaps the rad onc departments can radiate those white coats in the evenings and kill off bacteria.”
  • Mark Ryan– “The FAQs are funny and engaging. EMT or ER scrub pants have loads of pockets so you could avoid the Dora sling if desired.”
  • Sanjaya Senanayake– “It looks good”
  • John Mandrola- “Ask your doctor why he or she is wearing a white coat. Superb post”
  • Infectious diseases doctor from Houston- “I actually round british style. Bare from the elbow down.”
  • An infectious diseases fellow at Harvard- “Get rid of them and go with hospital-supplied, freshly laundered scrubs all the way! The biggest downside is that medical students wouldn’t have anywhere to store their 19 lbs of paper scratch sheets. The problem with getting rid of white coats  is that I track everything home with me. Hence the need for scrubs.”
  • Another infectious diseases fellow at Harvard- “As you know from our previous discussions, I don’t feel too strongly about this topic either way. What I love is that prior to your talking to me about this last year, I had never given this topic too much thought. I really like that you not only feel strongly about this but you are actually doing something about this since you do feel so strongly about it. If you truly believe that wearing white coats transmit more pathogens than not wearing white coats, then I will try to become convinced. In the meantime, FYI, I have already started to not wear my white coat as often this week. Baby steps for me :) I guess the big thing for me that I have a problem understanding is how many patients is too many before we need to change coats/scrubs/shirts. What I mean is, some days I see 10-15 pts, other days only 2-3. Surely wearing the same scrubs or non-white coat top when you see 10-15 pts in one day is worse from a spreading pathogens perspective than it is when you only see 2-3 pts? That’s why I argue the extreme (change between every single patient), because I agree with your point that we shouldn’t accept transmitting even 1 bug. Therefore, I prefer to think of these things in a more binary fashion. Meaning, if we want to completely diminish transferring pathogens via clothes/white coats, then why aren’t you arguing for changing shirts in between each patient? (Other than because of the lack of practicality of course)”
    • My response- “I think the best we could do in “the extreme” would be what surgeons do– i.e. scrub up before going in to see each patient, put on a sterile gown, mask, etc. (short of full PPE for Ebola. But it’s way too expensive, not practical, and not needed.”
  • Pradeep Natarajan– “Nice post! I don’t wear a white coat for all the reasons you describe. I also avoid wearing ties and try to keep my sleeves rolled”
  • Rebecca Coonney- “A thought-provoking piece”
  • John Mandrola- “Ask your doctor why he or she is wearing a white coat. Superb post from ID specialist and writer, @philiplederer
  • Lakshman Swamy “Interesting. There may be a diff btwn inpt & clinic. I don’t wear one, I have a fleece vest. What about smart phones? Smart phones often seen out in contact precaution rooms, never cleaned. Bigger concern to me than white coats.”
  • Anna Reisman- “White coats, begone! (Or washed daily)”
  • Zackary Berger- “I don’t wear a white coat and admire ‘s crusade to get rid of them.”
  • Marcus Bachuber- “Agree completely with No white coat for me. Also no tie, and sleeves rolled up.”
  • Bich-May Nguyen “The debate reminds me of the BMJ article about whether parachutes save lives. Just because something is regarded as tradition doesn’t mean we should keep doing it. I hate wearing my white coat. I’m petite, they never fit right, and I don’t wash it as often as probably recommended. It acts as a barrier to the patient-physician relationship and I’m sure it spreads germs. Hospital-strength germs. I’m an attending now so I don’t carry as much stuff in my pockets, but your suggestion of that backpack is nicer than a fanny pack! Also, can we talk about people wearing scrubs out in the general public? I think that’s disgusting, too. People should definitely go to work in street clothes, change into scrubs at work, and change back before going home.”
  • Adia Benton- “A basic skim makes me wonder why having a protocol for washing white coats wouldn’t also work.”
  • Kirsten Bibbins-Domingo- “Excellent discussion on getting rid of the white coat”
  • Sarah T MD- “You have done an excellent job of compiling so many important points about the traditional white coat in medicine. I started practicing in 2000 and have never worn a white coat. Sure it would be a convenient way to carry my phone, prescription pad and pen, but I have always seen it as a barrier between me and the patient. Personally, I think it only detracts from the patient-physician relationship. Not to mention, I am pretty conscious of the possibility of transmitting infections. Thanks for sharing your message on this topic!”
  • Ilana Cohen- “FYI they don’t have these coats in France. At least I’ve never seen a health professional wear one there…. only butchers. The white coat per se is not something I have any attachment to personally but I don’t think that professional uniforms are bad – they quickly code for authority. While loaded, I think that’s important esp for women and people of color who are assumed not to be the doctor. You need to start a medical uniform business!”
  • Mark Stahl- “Where else am I going to keep a reflex hammer, tuning fork, sensory wheel, penlight, Rx pad, DBS programmer, and mini ophthalmoscope? (yeah all of those things are in my white coat pockets right now. OMG I’m a hoarder.) I actually have a semi-serious comment about white coats that echoes some of the comments from the women doctors. As you know I’m, ah, a vertically challenged dude (5’6” on a good day). If I am not wearing a white coat even my colleagues who I know fairly well literally look through me when I see them in the hall. Put coat on- voila- oh, hey, doc! Apparently we need a uniform. With pockets!  If I wear pants and a shirt I might have to actually… Iron said shirt. The horrors.
    • My reply- Thanks! I disagree re Uniform, we can just do pants, shirt, as described above. Short men, women, people of color, people with disabilities, etc. If you aren’t a tall white male, you don’t fit many people’s stereotype of “doctor.” And ironing is no fun but it might be good for the patients.
  • ID physician in Atlanta- “Never liked them. Got in trouble for not wearing mine in med school. Haven’t worn one sense. They felt grungy and elitist. Great pockets though.”
  • Internist– “From your writing, the big four negatives against your campaign are :
    1. no RCT proof
    2. patients like/prefer them
    3. pockets pockets pockets and warmth
    4. hierarchy/tradition is important, and minority/female/short docs need the status symbol
    Overall to me, it smacks a little of charging at windmills (though not nearly as crazy or misguided–you have the best purity of purpose in mind)– i don’t know how it’ll gain enough traction until the generational tide starts turning–but i may certainly be wrong about that if there’s enough of a social media buzz and stuff.”
  • Screen Shot 2015-10-19 at 12.03.25 PM
  • ID Physician at Brigham- “Some older patients expect that doctors “look like doctors.” I get occasional  complaints about fellows without ties and/or white coats—the patients have concerns about who is taking care of them.  I explain that it is ok but they have their beliefs and expectations. White coats can be laundered frequently if people take them to the laundry.  A clean white coat is probably more reassuring than street clothes with the exception of suit and ties  at some hospitals. I believe dress is more for patients than doctors, though if you are drawing blood, etc wearing a coat protects street clothes.  Back in the dark ages when I was training, the chief of medicine would send you home if you weren’t wearing the interns’ white shirt and pants  or didn’t have a tie and either white coat or white pants. If studies show that clothing transmit bad bugs you can bet that hospitals will change the rules and might even provide for clean stuff every day. I asked our infection control people why don’t we outlaw ties like they do in the UK and the answer was no data……i would like to be told not to wear a tie. I think it is largely a non-issue for the moment until there are convincing data one way or another but think that we should be sensitive to patients.”
    • My response- completely agree that we need to consider patient perspectives and it does vary patient to patient. White coats could be laundered daily but the fact is that is not done. The challenges conducting a study are listed above (expense, time, sample size, etc). I don’t see convincing molecular data coming out any time soon about the role of white coats/ other foamites in the role of nosocomial transmission.

dora-the-explorer

Thanks so much for reading. Reading/writing blog posts does take time and we all know that time is in short supply. You and I will both get much more out of this blog if it leads to discussion/dialogue. If you found this post useful and wouldn’t mind leaving a brief comment/sharing on social media, that would be great. Or if you’re shy but are willing to email me a comment that I can post anonymously, I’d appreciate it. As my posts are generally written quickly, if you find any factual errors, please do let me know. Best regards, Philip Lederer

12 thoughts on “White Coat FAQs — making hospitals safer

  1. Consider an alternative: white coats with short sleeves to be washed daily (as scrubs are) by the hospital. These would serve some of the purposes doctors like them for (pockets, keeping their clothing free of the unexpected blood/feces etc that occasionally happens). Furthermore it would probably encourage men (who wear long sleeves more often than women, at least in my hospital) to roll up their sleeve so they don’t look “dorky” in short sleeved white coats. I don’t necessarily think that the white coat is bad as a uniform per-se, and I think patient-centered care can be conducted in-uniform as well as out.

  2. I agree with the idea of not wearing white coats and generally didn’t in my own practice, but it goes beyond that. Where I work now, I am expected to. Being a woman, it is also needed for acknowledgement from patients and other attendings.

    “Change your clothes in the hospital before you go home” is nice, but not very practical, as there are no lockers outside the OR, and limited access there.

    Besides white coats, many physicians wear suits, so that they look “professional.” These, too, are rarely dry-cleaned and are likely to spread nosocomial infections.

    I have long advocated for HCW to be able to have scrubs provided or laundered by the hospital, especially if contaminated by blood. They refused d/t cost. Unless something like that is mandated, I don’t see it happening. Do you?

  3. I agree with the idea of not wearing white coats and generally didn’t in my own practice, but it goes beyond that. Where I work now, I am expected to. Being a woman, it is also needed for acknowledgement from patients and other attendings.

    “Change your clothes in the hospital before you go home” is nice, but not very practical, as there are no lockers outside the OR, and limited access there.

    Besides white coats, many physicians wear suits, so that they look “professional.” These, too, are rarely dry-cleaned and are likely to spread nosocomial infections.

    I have long advocated for HCW to be able to have scrubs provided or laundered by the hospital, especially if contaminated by blood. They refused d/t cost. Unless something like that is mandated, I don’t see it happening. Do you?

  4. I used to walk around the hospital in my white coat, then sometimes hang up before entering rooms. I’d explain to patients that I didn’t want to get “hospital muck” all over them. That’s not to say I was always bare below the elbows, but it allowed me to gel/wash past the wrists, and I was more aware of what parts of me were touching the patient.

  5. Hi Phill! I just cant imagine work at Maputo Central Hospital without wearing a coat whatever the colour! Thats it! I dont feel superior to anyone because of that….and even with the white coat I can also wear a big smile!

  6. Pingback: White Coat Vote

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