Would my white lab coat be better put to use when I carve the Christmas roast than when seeing patients?
After all, we know that these coats can be covered with pathogens, including drug-resistant ones, which may be transmitted to patients. They are cleaned infrequently: In a survey of physicians, nearly 58 percent said they laundered their white coats monthly or never. Less than 3 percent washed them daily or every other day. What is the harm in adopting a "bare below the elbows" policy for health care professionals — as has been done in the United Kingdom — to reduce the chance of transmission?
Philip Lederer, an infectious disease specialist in Boston, is one of the latest to argue that the white coat, long a symbol of the medical profession, ought to go the way of the nurse's cap. On his informative and frequently entertaining White Coats website, he lays out a convincing case as to why we should voluntarily stop wearing white coats. While raising the infection risks, he points out that the coats are not solely the mark of physicians, but also physician assistants, nurse practitioners, nurses and other health care professionals. "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," he writes. The Boston Globe recently picked up on his efforts and highlighted the issue, as did National Public Radio.
Will this be the tipping point or just another scientific issue that goes on unresolved? The white coat debate may be new to some, but it has been raised on and off for the past several years within the infection control community, with no clear end in sight. The Boston Globe reported that there is just one organization in the U.S. that encourages clinicians to hang up these coats: Virginia Commonwealth University School of Medicine.
"Show Me the Data"
In the medical community, like many scientific communities, we frequently demand convincing evidence before committing to new protocols and policies, or before approving a new drug or device. Yet there are cases in which clamoring for evidence or demanding that evidence come from randomized clinical trials can serve to redirect and deflect arguments, a sort of scientific filibuster.
On this debate, this deflection often involves pointing out that there has been no trial to clearly demonstrate that the coats are responsible for hospital-acquired infections. Such a trial would cost many millions of dollars, and even then, the results may not be definitive.
Certainly, we benefit when the efficacy and safety of a new cancer drug is determined in a clinical trial. But arguing that we need a trial to establish the infection risk presented by white coats, Lederer says, is akin to saying that we need to prove it’s safer to wear a parachute before jumping out of an airplane. We don't need clinical trials when the theory is strong — a person with no parachute will almost certainly die — the causal relationship between the intervention and outcome is direct and short, and the outcome is immediately observable and unambiguous.
Few things in medicine have these attributes. Theories are uncertain or evolving, causal pathways circuitous and long, and outcomes delayed and difficult to measure. But the white coat issue comes close.
Moving the Debate Forward
What is missing from the white coat debate and many others is a framework for resolving the tension and uncertainty to move forward. Such a framework would focus on clearly identifying what problem we are trying to solve and might include answering:
- What do we know now?
- What don’t we know?
- What would it cost to get better information?
- If we take action and our hypothesis — white coats cause infections — is correct, what are the potential benefits? If we act and this hypothesis is incorrect, what are the risks?
- If we don't take action, what are the potential benefits and risks?
- How might we mitigate these risks or enhance the benefits?
My stance: 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.
The real cost of abandoning white coats, it seems, has less to do with preventing infections and more to do with the potential emotional or social consequences. We often say that people do not fear change itself; rather, they fear loss. Symbols and rituals play important roles in our lives, and loss of these may cause distress for some. To influence change, we need to seek to understand and mitigate that loss of perceived stature or power. Can we replace the white coat with a new symbol that says, I am a physician? I am not sure what that would be, but if we found an answer, it might help advance this debate.
Read More on the White Coat Issue:
- Lab Coats and Scrubs Don't Make the Physician (Kevin MD blog)
- It's Time for Doctors to Hang Up the White Coats for Good (The Conversation blog)
- Controversies in Hospital Infection Prevention
When one is a patient in a large teaching hospital, it is impossible to determine which doctors are part of the treatment team versus those who hold a mild interest in their case. Interns are still doctors, but rare is the patient who can immediately differentiate between the intern, fellow, and attending staff physician. Patients are visited by a steady stream of health care professionals throughout the day, and they all look the same in a white coat. Consequently, a patient may mistakenly give vital medical information to a doctor who may only have a mild interest in their case, and is not part of the treatment team. When a patient provides information about their illness or symptoms, the patient is assuming that the information will be shared wth the treatment team, and the patient may or may not bring up the subject again.
Ditch the white coat in favor of color-coded team IDs so that the patient can immediately identify the doctors and other healthcare professionals on their treatment team, and also reap the benefit of having the various spores, viruses and other microbes removed from their environment. It may keep the physician healthier too.
Thanks so much for such a thoughtful blog post.
All I would add is a thought experiment. Imagine that you or a loved one has gotten sick with a deadly cancer, say acute leukemia, and needs a bone marrow transplant to survive. The transplant is given and you / your family member is now neutropenic.
Knowing what we know now, would you want a health care worker wearing a white coat to enter the hospital room?
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What a great topic! in healthcare we sometimes take things for granted without giving it another tought of how things can be better. Identifying the treatment team is a struggle for patient families. I have seen those white coats hanging on doors for months. Lot of hospitals do not have on site laundry for employee. Can we replace the white coat with a new symbol that says, I am a physician?
Maybe YES !
In the UK we ditched white coats about five years ago - in response to concerns about infection control. This hasn't changed us - people see to be able to identify us as doctors - our #hellomynameis name badges give that away, or perhaps the stethoscope and if in doubt, ideally we say, 'hello, my name is Rod, I am your doctor!'
Dear Rod Kersh-
I have been in touch with Kate Granger from the #hellomynameis campaign-- that's a natural next step for American health care. But how to get it adopted over here?
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Where do you suggest we put all those things bedside doctors need and use??? Stethoscopes, otoscopes and speculums, hammers, prescription pads, antibiograms,alcohol pads,scissors (for wound bandage removal) pens, culturette vials,patient lists, access cards and multiple ID badges, etc. ???some of us actually use those things and don't have pockets in our jeans for them
Short of the Stethoscope nothing you listed should be carried around from room to room or patient to patient and or is no longer necessary since we have shifted to EHR.
I sure hope you aren't taking speculums and scissors from patient to patient? Atleast in our hospital all such items are available in each exam room and or are disposable. The rest is either in the software of the facility or on the trusty now mandatory iPhone etc..
Our access card/ID must be "prominently applied to the outermost garment at eye level to a standing patient" (cough cough as he wretches)
If you haven't watched enough TV then you need to understand that patients EXPECT that we will have our Steth proudly draped across our necks and NOT hidden inconspicuously in a labcoat pocket for fear that we actually might actually not use it in every visit and for "in depth analytical purposes" 🙁
Doesn't anyone ever notice people talking on their ubiquitous smart phones while using the public bathrooms to dispose of their excrements and not wash their hands afterwards? What kind of germs are those? Is the world going sterile? Should we just go nude? There are good germs and bad germs, commensals, symbiotic, and pathogens. Somebody made an apropos comment at the NYSSA PGA meeting let week to the effect that perhaps, along with the disposable laryngoscope handles and blades, we should also use disposable anesthesiologists and disposable surgeons!
And, regarding displaying the ID badges on our chests at eye level, let's just remember to be politically correct and not discriminate against short people or tall people while we're doing it!
I have one simple question. What is the infection rate in the UK since they went away from white coats and have the bare the elbow policy? If it made a difference in the UK then maybe we should consider it, if not, then what is the hubbub all about? Sorry, that's 2 questions!
Just curious, why don't providers wash their white coat as often? Is it just due to lack of time? Or does washing the coat, ruin it? Also, can they make the coat out of anti-microbial material? I know it will be more expensive, but that could solve the issue. Lastly, instead of doing a large study on patient infections, could they just look at the rate of providers being infected themselves? I would imagine if your clothes are covered in pathogens, you increase the risk of being exposed personally. So look at providers and see if providers who wear white coats are more likely to become sick with an infection as opposed to providers who don't wear white coats. Obviously you would want to compare in a similar care setting with similar roles.
I have watched the debate on this topic for some time. There are clearly some facts - clothes you wear (including white coats) and instruments such as stethoscopes can be contaminated with pathogenic bacteria. There is plenty of documentation that healthcare workers (not just doctors) don't launder the white coats (and lab coats) that they wear often enough (nor clean the instruments they carry). There obviously is good evidence that healthcare workers can transmit infections between patients. I guess where I struggle on this debate is whether getting rid of white coats or going "bare below the elbow" will actually make any difference in rates of infection. A colleague of mine in the College of Public Health had his students sit in different areas of the hospital to see how many healthcare workers wore their scrubs in public and patient care areas of the hospital. As you might expect it was common to see surgeons, residents, ICU staff, and others in the cafeteria or other public areas in the scrubs (with or without white coats) they were wearing for patient care - some come to work in them from home or wear them home. I know that is likely that the clothes healthcare workers wear or the scrubs they use in patient care get laundered more commonly than white coats do. I am not one to insist on an RCT to prove that getting rid of white coats will reduce infection rates - but certainly there should be the opportunity for some natural experiments using well designed time series analyses, etc to see if policies of getting rid of white coats will actually make a difference.
When I opened my solo practice more than 25 years ago, I quickly abandoned wearing a white coat. I felt like no matter how I washed or dry cleaned them, they quickly looked dingy and dirty. I think some of my patients probably felt I wasn't really a doctor without one but an equal number liked that I seemed more approachable. The way I treated my patients had a lot more to do with how they viewed me as a doctor than if I was wearing a white coat or not.
"Can we replace the white coat with a new symbol that says, I am a physician?"
Perhaps we could put this icon on our badges and elsewhere:
Is this a political blog or are we interested in patient safety? It's tempting to shed our pathogen laden white coats, stethoscopes, etc and go topless, but does it really make a difference? Should we care? There is a slippery slope here, when we indulge in behaviors because we "think" it's right. We are scientists, we should behave as such. As an anesthesiologist I raely wear a white coat anyway, but I can no longer wear a cloth hat because someone decided that it poses an unreasonable risk to my patient. No studies, just someone's hunch. I don't like it. Just saying.
Since basically every hospital facility in the country requires an photo ID tag to be worn by every staffer and in most cases the job title is prominently embossed as a "watermark" in vivid colors or similar what do we actually LOSE by taking on the process of dumping the labcoats? We could easily enlarge the tags and require them to be worn at eye level rather then attached to belt loops etc.. Do we need to research EVERYTHING we do even if there is NO risk if we do it and fail? I agree having a labcoat only creates the mental image of a bygone era. As was pointed out years ago nurses wore full length dresses nurses caps and even cross shoulder sacks to carry various items. I remember as a child my aunt who was a nursing supervisor at one the top hospitals in the country would come in after work with her silly white cap and white dress. Today we have re-educated everyone that scrubs are as acceptable. Yes there might be a transitioning period when we initially dump the coats but I MUCH prefer to see a no coat wearing colleague then someone with wrinkled, ink-stained, coats especially the ones with dirty cuffs from obvious non-laundering. Even one day of non-laundering is sufficient to generate enough "cuff stuff" if we actually do wash our hands atleast twice during each patient as we should be to require daily laundering. I don't know about you but my coats (that hang like skeletons unworn on the stand in my office) wouldn't hold up to daily care. Why not simply accept the change like we accepted the change from paper to digits and bite the bullet? If not for the safety of the patient but for a simple "new industry approach"
I think after a few visits EVERYONE will embrace the "Doctor is like me" attitude and feel more comfortable overall. While you are doing it dump the ties as well. I haven't worn a tide since my wedding and that was a Bow nor did I wear one before. They get filthy are no cleanable at all and are uncomfortable.
Time we start to look like humans and so our patients might actually feel comfortable enough to give precise accurate histories and chief complaints
Actually the only time I wear my coat is as a covering over my scrubs or to meet the administration. I agree that there is little "risk" in abandoning the coat. Maybe there are some other "sacred cows" that could be discarded as well. Anyone have any ideas??
When I am in Boston I am in the midst of many hospitals with people in blue scrubs all around; in stores,
restaurants and on the streets. These people are not just doctors but hospital staff. How does anyone
know if they are carrying germs along with bacteria that can not be treated. We are relying on too
many people's idea of sanitizing. Help!
In this post/presentation I discuss how evidence is not knowledge and how you can have knowledge without evidence and how RCTs are ill-suited to answering some/many questions. Our use of them often represents a Ludic Fallacy resulting from lack of common sense.
I am an intern. I love wearing white coat. one problem I noticed with white coat apart from above discussed, was child generally get afraid with coats. They don't interact with doctors with white coats.
Dr. Pronovost, do you still wear your long-sleeve white coat and four-in-hand tie? Or have you opted for some other dress.
I agree that the white coat does not make for a better provider, but I like the pockets. As a female our shirts, slacks etc, do not always come with pockets. I role my sleeves up for better hand washing. Is there any guarantee if we ditch the scrubs that those who do not routinely launder their lab coats will wear any cleaner "street" clothes. As far as the stethoscope goes, I have one for each room and it is wiped clean between every patient.
I wonder what we will find on culturing people's shirts, ties (if any), pants, shirts or the dirty shoes we walk in with. The White coat does provide a single article that can be cleaned and cover up the rest of the bacteria-colonized clothing we wear.
"We know that white coats can carry pathogens, [as do most clothes] 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. I note a very unenlightened approach in this blog - it's the "well we know this MAY be a problem - we haven't really any proof, but this is a flashy topic to demonstrate about." And the comparison to cancer treatments of possible benefit? How many problems have we seen there? Perhaps we want to remove the junk on the stethoscopes, the coffee cups we carry into the rooms, and the
I don't wear a white coat in my office and sometimes not at the hospital, but the tenor of the argument seems to be one of "majoring in the minors" so to speak.
And while we are at it, let's consider the cell phones we are tapping on and then touching the patient. . . . . .
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Hi ,please help me im a resecher in the field of protective clothing for the doctor especially lab coat please provide me with objective sources and studies pertaining to global standards and objective standard for lab coat .
with greetings and thanks you
Its a huge theme! in healthcare we from time to time take belongings for decided without philanthropic it another consideration of how equipment can be improved. identify the conduct team is a move violently for enduring relations. I have observe persons white coats hanging on door for months. Assortment of hospitals do not contain on site laundry for employee
I am 80 years old and have never stayed in a hospital overnight for anything other than childbirth, and I hope to keep it that way. Two neighbors in my high-rise entered a hospital for treatment of a medical condition and died, in one case of an infection contracted in the hospital, in the other of uncontrollable bleeding when an artery was pierced in an attempt to insert a port for medication delivery. Patient safety is a big concern, and there is an organization that is rating hospitals on that basis. I often think of poor Dr. Semmelweis, who was ostracized long ago in Europe for suggesting that doctors wash their hands after working with cadavers before examining their maternity patients and between patients. Doctors were too arrogant to accept the idea that they were killing their patients, many of whom were dying in childbirth.
I want to add to my previous message how much I appreciate the efforts being made to alleviate the problem of hospital-acquired infections, including doctors such as Philip Lederer and Peter Pronovost, the Leapfrog group rating hospitals for patient safety, Hopkins' Armstrong Institute for Patient Safety and Quality, and the media focusing on the issue.
I just found this blog and I'm so excited! Thanks for sharing your insights to issues that really
speak to the challenges of our profession in the 21st century.