|Year : 2016 | Volume
| Issue : 2 | Page : 161-165
Doctors' white coat and the evidence boondoggle: Microbiology, desiderata, symbolism, or professionalism decorum?
Bhaskara Pillai Shelley
Department of Neurology, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||20-Dec-2016|
Bhaskara Pillai Shelley
Department of Neurology, Yenepoya Medical College, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shelley BP. Doctors' white coat and the evidence boondoggle: Microbiology, desiderata, symbolism, or professionalism decorum?. Arch Med Health Sci 2016;4:161-5
|How to cite this URL:|
Shelley BP. Doctors' white coat and the evidence boondoggle: Microbiology, desiderata, symbolism, or professionalism decorum?. Arch Med Health Sci [serial online] 2016 [cited 2017 Jul 27];4:161-5. Available from: http://www.amhsjournal.org/text.asp?2016/4/2/161/196180
“What a strange power there is in clothing.”
-Isaac Bashevis Singer
Nobel Prize-winning author Isaac Bashevis Singer asserts that the clothes we wear do hold considerable power and sway. The father of modern medicine, Hippocrates also advised on the professional image standards that doctors should “be clean in person, well dressed, and anointed with sweet-smelling unguents.” The history of doctors' white coat attire dates back to the late 19th century. The white coat is not only the most recognizable universal symbol of the medical profession but is also regarded as the attire that symbolizes the purity of purpose and honor the tradition of “doctoring” and for being the cornerstone of professionalism. The white color represented a symbol of purity and dedication to “do no harm” and an emblem of trust, belief, and hope for the patients.
It is interesting to note that the concept of acceptable attire for doctors is constantly evolving from the time of Hippocratic Oath 2000 years ago to the early and late 19th century. The long-standing tradition for doctors to wear a white coat worldwide has been widely questioned in the recent years. Is not the doctor's white coat the “desiderata” or “decorum” for professionalism? The raging controversy that I would like to call it as “white coat debate” stems from a few equivocal studies over the past two decades that showed microbial flora could be cultured from white coat sleeves and pockets. This raised a theoretical problem of the white coat being endangered and to be considered as a “fomite”, a physician attire attributable to cross infection and nosocomial infection rates.
The “microbiology of the white coat” gets perpetuated by other possible factors such as (i) white coats are laundered infrequently and (ii) contaminated white coats could serve as a vehicle for bacterial transmission to patients. Based on this biologic plausibility and risk for cross-infection, the medical fraternity is faced with panoply of vexing questions: Is not colonization (contamination) with bacterial flora different from transmitting them to another person? Is it time to hang up the white coat to have infection control? Are we justified to proclaim the “death of the white coat?” Is there a trade-off between the postulated cross infection rates and possible impact, if any, on the doctor–patient relationship? Do patients prefer their doctors in white coat? Is there an effect of doctor's attire on patient perceptions and preferences? Does looks matter? What do we, as doctors, need to wear today? Is there an evidence-based dress code for doctors in the new millennium? To provide answers to these questions, I would opine that we certainly need to “scientificate” on the microbiology of the white coat, and ponder whether the white coat is just desiderata, symbolism, or professionalism decorum.
Addressing more on the traditionalistic concept of the doctor's white coat, I would like to dwell on “White coat ceremony” adopted by many Western medical schools. This is done for the incoming medical students at the beginning of medical school to reinvigorate the human and humanitarian aspects of a doctor in addition to the science of medicine, exemplified by a “white coat lecture” on patient caring, empathetic care, and on “primum non nocere.” The white coat ceremony is the result of a vision by Dr. Arnold P. Gold, who in 1993 instituted the first White Coat Ceremony at the Columbia University College of Physicians and Surgeons in New York. The ceremony epitomizes the centrality of compassion, empathy, altruism, respect, duty, and honor in patient-centered care as symbolized by the wearing of a white coat for the first time in a ceremony as one embarks on a medical career.
In the 1980s, literature has dwelled on contamination of protective clothing and nurse's uniform, cloth-borne cross-colonization, and infection. Subsequently, an ever increasing surge in interest in studying the microbial flora on doctor's white coat to assess the risk of cross-transmission of pathogenic microorganisms became evident. It is not surprising to note a similar trend in interest from India with publications from Madurai (Srinivasan et al.; Chennai) in 2007, Manipal (Priya et al.; Karnataka) in 2009, Bengaluru (Banu et al.; Karnataka) in 2012, Guntur (Pydi et al.; Andhra Pradesh) in 2015, Pune (Saxena et al.; Maharashtra) in 2013, Hyderabad (Noor and Jayanthi; Telangana) in 2016, and Shivamogga (Naik et al.; Karnataka) in 2016. Perhaps, the white coat debate in India was stirred up by a BMJ 2015 Views and reviews article titled “Doctors and medical students in India should stop wearing white coats.”
The “death of the doctor's white coat” as harbingers of infection was ushered in the United Kingdom's NHS trust in 2007. The British Department of Health published guidelines for health-care worker uniforms that banned the white coat from hospitals in England was based on the Thames Valley University report 1 (TVU1). TVU1 stated that “the hypothesis that uniforms/clothing could be a vehicle for the transmission of infections is not supported by the existing evidence” and TVU2 found “no good evidence to suggest uniforms are a significant risk.” TVU2 further warned, “It is essential that the evidence is considered in a balanced way and not over-emphasized in the development of uniform policy.” The United Kingdom changed the doctor's dress code to the “Non-coat bare-below-the-elbow” (BBE) policy. However, I wonder if we have undisputable evidence that BBE works, especially in doctors with hairy forearms and tattooed forearms that in my view could be even hazardous and unprofessional. I would not hesitate to state that it would be a delusional move to “ban white coats” in any country based on a few inconclusive “disputed” data.
Is not colonization with bacterial flora different from transmitting them to another person? The TVU reports 1 and 2 and various other studies in literature did not show robust unequivocal evidence that methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus (MRSA), Vancomycin-resistant enterococci, Clostridium difficile, and Gram-negative organisms colonizations of white coat are directly causally linked to nosocomial (health-care associated) infections. I reiterate that no studies have reported direct evidence of transmission of microorganisms from white coats to patients too. To move beyond the white coat and cloth-borne colonization, would not items such as doctors' pens, smartphones, pagers, stethoscopes, personal digital assistants, neckties, computer keyboards, hospital telephones, tourniquets, and sphygmomanometer (blood pressure [BP]) cuffs also serve as potential vehicles for microbiological flora? Other than the doctor coat's long sleeves, ties, and shirt sleeves, would not our ethnic dress code variations in India (dupatta, Kurtas-Salwar Kameez-Churidars) and personal items we have such as wrist watches, jewelry, finger rings, and identification badges be potential vehicles for pathogens, notwithstanding our own personal hygiene (nails, hair, beards, and moustaches)?.
In 2004, an Israeli medical student, Steven Nurkin, tested the neckties of doctors and clinical staff at the New York Hospital Medical Center of Queens and found that nearly 50% were infested with S. aureus, potentially pathogenic bacteria. Interestingly, a few studies (Cormican et al., 1994; Smith et al., 1996; de Gialluly et al., 2006; Baruah et al., 2008; Jain et al., 2014; Zargaran et al., 2015) are available in literature that investigated the potential role of BP (sphygmomanometer) cuffs (BP cuffs) in the spread of bacterial infections (S. aureus, coagulase-negative Staphylococcus, diphtheroids, MRSA, and Acinetobacter baumannii) in hospitals. Do we then need disposable BP cuffs in hospitals? If not, do we have a defined, standardized sterilization procedure for BP cuffs in our hospitals?
Stethoscopes are essentially “an extension of the physician's hands” and therefore could be substantially contaminated and could contribute to the risk of cross-transmission of microorganisms. A few noteworthy studies (Zachary et al., 2001; Bukharie et al., 2004; and Leontsini et al., 2013 from Greece; Uneke, 2010 from Nigeria; Bhatta et al., 2011 from Nepal; Gopinath et al., 2011 from Vellore, Chennai; Gupta et al., 2014 from Maharashtra, India; Longtin, 2014 from the USA; and Balapriya, 2016 from Chennai, India) do certainly confirm that the concept of “infectious stethoscopes” contaminated with pathogenic as well as nonpathogenic microorganisms. These fomites could be potential reservoirs of resistant nosocomial pathogens and risk for nosocomial infections. Do we regularly disinfect our stethoscopes using isopropyl alcohol to reduce bacterial colony counts used to minimize the possibility of spreading infectious agents in hospitalized patients? Interestingly, a study in Toronto did point out that elevator buttons to be colonized by bacteria than toilet surfaces. The authors concluded that the use of good hand washing, use alcohol-based hand sanitizer before and after touching the buttons, and educating the doctors and public about the importance of hand hygiene to be the solution to reduce the rate of colonization. I would say that there is clearly an urgent need to identify effective transmission mitigation strategies for all physician accessories and other ubiquitous items that cannot be laundered including BP cuffs, stethoscopes, other over-looked fomites items, and surface environment in the health-care settings.
I wonder whether doctors are dressed to kill or to uphold a dress code in the “art of doctoring.” Are doctors to be considered as “fomites?” Should doctors wear a shirt or would a smart T-shirt be appropriate? Since hands are the main locus of patient–doctor interaction, should handshakes be also prohibited in hospitals during the healing encounter between patients and doctors? Do we need to ban neckties or seek alternatives such as to tuck ties into shirts? Should all items deemed as physicians accessories be also banned in hospitals? In my informed opinion, lighting the funeral pyre for the doctor's white coat just represents the tip of the iceberg as far as fomites and nosocomial infections are concerned. Most importantly, how many of us are aware that the doctor's white coat, other physician accessories eluded to earlier be potential vector of pathogenic bacteria, and to be incriminated in the horizontal transmission of pathogens within the hospital. What would be the clinical implications these potential fomites have on hospital cross infections and infection control policies? Do we have a defined, standardized sterilization procedure for such incriminated fomites in our hospitals? Are we aware and do we have a defined doctor's white coat laundering practices or policy in our hospitals? Do we need to be educated on white coat laundering practices? Instead of wasting time on the dress code, BBE policies, and doctor's necktie, should not we invest precious time in educating and securing efficient hand hygiene promotion strategies according to worldwide recommendations?
On the flip side of “the microbiology of the doctor's white coat” on this “white coat debate” is the patient perspective on doctor's attire. Doctors in a white coat; what do patients think? Does physician attire influence patient satisfaction? Is our appearance and dress code important to our patients and its possible impact on the doctor–patient relationship? Is there any value for an old symbolic dress code, the white coat, in the new millennium? Do clothes make the doctor? Do we need to address the patients' perspective on how doctors dress? Is there an effect of doctor's attire on the patient perceptions and preferences? Do patients prefer doctors to wear a white coat, name tag, and stethoscope? Is the white coat important for establishing comfort, trust and confidence, and satisfaction of patients that is quintessential for high-quality care, patient outcomes, and better clinical practice? Let me throw some light on these interesting questions.
Several studies have explicated the patients' preference for physician attire and the effect of doctor's attire on the trust and confidence of patients. Many studies (Ikusaka et al., 1999 [Japan]; Gooden, 2001 [Australia]; Douse et al., 2004 [UK]; Rehman et al., 2005 [USA]; Gheradi et al., 2009 [UK]; Bond, 2010 [UK]; Najafi et al., 2012 [Iran]; Shrestha et al., 2012 [Nepal]; So ECT et al., 2013 [Hong Kong]; Landry, 2013 [USA]; Fox, 2016 [USA]; Hurihara et al., 2014 [Japan]) reported patient preference for white coat and patients reported this choice of attire in conferring greater confidence and belief in a doctor's abilities, facilitate better communication, family rapport, fostering the doctor–patient relationship, and harnessing therapeutic empathy. Interestingly, in the Hong Kong study, the patient preference for doctor's white coat was maintained even after an educational intervention on the potential risks of microbial contamination since most patients did prefer doctors to launder their white coats every few days. A study by Madhumitha et al. (2015), from Apollo Hospitals, Chennai, also showed an overwhelming patient preference for doctors wearing the traditional white coat during the doctor–patient encounter. However, there are other studies, i.e., Fischer, 2007 [USA]; Menahem et al., 1998 [Israel]; Sebo et al., 2014 [Switzerland]; Cha et al., 2004 [USA]; and Hueston and Carek, 2011 [USA] that have reported contradictory conclusions about patient preference for doctor's attire. Notably, a study from Scotland (Aitken et al., 2014) suggested that the patients felt that doctors' appearance was not as important as compassion, politeness, and knowledge and did prefer “bare-below-the-elbows” workplace attire in addition to the impression of cleanliness and good personal hygiene. The recent TAILOR study  (2015) (Targeting Attire to Improve Likelihood of Rapport) through a systematic review examined the influence of physician attire on patient perceptions including trust, satisfaction, and confidence. This review of thirty studies involving 11,533 patients from 14 countries did reveal that 70% had a preference for a formal physician attire and white coat. This was influenced by age (more prevalent in older patients), geographic location (Europe and Asia), and the setting and context of care. Will heightened awareness on the doctor's white coat as a potential pathogenic hazard wither the symbolism and patients' preference of the white coat? Are patient preferences primarily shaped by sociocultural norms rather than medical evidence? On the endangered coat, are we mistaking the forest for the trees? Perhaps, I would conclude that more research needs to be done on this “knowledge gap” and “the jury is still out” on this perspective!
Do clothes make the doctor? Does the 1978 Nobel Prize in literature author Isaac Bashevis Singer's quote “What a strange power there is in clothing” hold water in the glass of our knowledge? Is our appearance and dress code important to our patients and what could be the possible impact on the doctor–patient relationship? As a doctor with a passion in brain-mind behavior and healing outcomes, I would state that sometimes and more often a white coat is not just a white satire (akin to a priest's robes, a lawyers black coat, or a police officer's uniform) since I believe that clothes do have an effect on our cognitive processes. The symbolism of the doctor's white coat certainly underpins what scientists call “enclothed cognition” and a growing scientific field called “embodied cognition.” Shakespeare's Hamlet, “the clothes doth oft proclaim the man” evidence does make reference that people form judgments about others based on the clothes that they wear. Drawing from research on “enclothed cognition” by Adam and Galinsky  (2012) evidence does underscore the profound and systematic influence of clothes on the wearer's psychological processes and behavioral tendencies. Furthermore, an interesting study from Korea in 2012 (Chung et al.) investigated whether doctors' attire influences the perception of empathy in the patient–doctor relationship during a therapeutic encounter. The study revealed that the patients preferred a white coat that served as an effective tool not only to establish a good patient–doctor relationship but also enhanced confidence, trust, and empathy.
In an era of “evidence-based medicine (EBM),” how do we answer these myriad of questions posed in this editorial? Is it time for evidence-based dress code for doctors? Although the United Kingdom has implemented the “non-coat and bare-below-the-elbow” policy in 2007, what's paradoxical is that no studies have indeed compared the effect of doctor's white coats or the BBE policy on hospital nosocomial infection rates. Is the absence of evidence an evidence for absence? Do we need to be radical protagonists of EBM to solve this “white coat debate?” Do we need a crossover or controlled trial (funded research) to tailor a “level 1” evidence-based doctors' dress code to solve this “white coat debate?” In an era where the image of a doctor is tarnished where the levels of trust and respect once extended to this “noble profession” is substantially eroded, I wonder whether we need to calculate a number needed to dress; analogous to the number needed to treat [NNT], and report an odds ratio as in EBM nosology? I would say “No” since a randomized trial of white coats, unfortunately, be expensive. Another reason for a “No” would be the “parachute trial” quoted in medical lexicon that just like we do not need a randomized trial to prove that parachutes save lives, we also do not need a trial of white coats. Is this sophism necessarily right: “That's all very well in theory, but it won't do in practice” in this hotly debated topic?
What is the value of the traditional white coat in the New Millennium? The White Coat - Is it time to make a change to hang up the traditional physician shine cloaked in a neatly starched and ironed white coat? Although it was Hippocrates about 2000 years ago who said a physician should be “clean in person, well-dressed, and anointed with sweet-smelling unguents”, physicians have not always worn white coats until about 100 years ago. Until the late 19th century, surgeons operated wearing their traditional black coats. The white coat was borrowed from scientists in their laboratories to give doctors a more professional look and to lend credibility to the science of medicine and art of doctoring. It also meant to give physicians a cloak of scientific validity for their treatments and to represent purity and cleanliness, all praiseworthy qualities of a healer. This shift in doctor's dress could be seen clearly in two different paintings by Thomas Eakins of operating theaters in the United States, separated by just 14 years (The Gross Clinic, 1875 and The Agnew Clinic, 1889). I would say that the culture of medicine is very powerful, and old habits, such as white coats, die hard and resist change. Therefore, in the New Millennium, has the time come for “sharing slow ideas” to facilitate a change to abandon white coats in the medical fraternity?
To conclude, it's my view, that a “white coat funeral approach” when evidence base is nonexistent will do more harm than good, it is premature and a reductionist step that is akin to “Throwing out the baby with the bathwater!” To transcend the duality and think within the paradoxes of the “white coat debate,” the “microbiology of the white coat” and the “evidence boondoggle” will be to emulate a nonpartisan, pluralistic “above-the-line thinking” to the real world professionalism to foster a relationship-centered care for a holistic well-being of our patients. Such pluralistic steps will be to offer practical interventions such as Herculean programs to foster awareness, sensitize, and highlight scrupulous decontamination, urgent need for improved sterilization techniques and sanitization, strict compliance with hand disinfection policies, “rolling up the long sleeves,” “cuffs-above-the-wrist,” and perhaps encourage white coats with short sleeves. We need to formulate guidelines and practices on the wearing and laundering of white coats (doctors to possess two or more coats, laundering of coats at least once in a week or once in 3 days, hot water wash with bleach 10 min wash at 60°C that will remove almost all microorganisms followed by a cycle in the dryer, or ironing for further thermal disinfection) that white coat to be left at hospital and to prohibit the use of white coat during travel, in canteens, hostel rooms, or in public places. In addition, doctor's dressing guidelines during clinical practice (no wrist watch and jewelry) and wearing of plastic aprons will be useful. Specific disinfection procedures for BP cuffs and other contaminated surface environments in health-care settings need to be enforced to eliminate the risk of cross-contamination.
In my opinion, being a pluralistic society, we need to carefully consider and balance patient's deep-rooted perception of “professional image,” their perceived values of the white coat against the potential risks of white coat contamination and potential source of hospital-acquired cross infections. Across the culture of medicine, the white coat is certainly a symbol of knowledge, a standard of professionalism and an emblem of the trust, compassion, and honor, and fabric that encapsulates the doctor–patient relationship. In addition, the white coat does protect the doctor from pathogens and spillages, and white coat pockets also allow us to carry books for “portable knowledge” to learn the art and science of medicine (Washington manual, Antibiotic guide, hospital's antibiogram for antibiotic stewardship, pocket reference books, The Stanford guide, critical care manual, notepad, etc.) and instruments (stethoscope, reflex hammer, ophthalmoscope, and flashlight). I wonder what would be the fate for “The White Coat Pocket Guide Series” for interns, residents, students, and practitioners in West if white coats are to be tossed away?
I must admit that I am, and always have been, the sacred white coat wearer when seeing patients. The reason why Britain decided to ban white coats in 2007 is not convincingly evidence based; perhaps, the only country in the world to enforce the ban on white coats; so why should we ban white coat in India? With this controversy, I still wear my white coat but I have a better awareness, knowledge, and concern regarding the microbiology of the white coat and strictly enforce the measures needed to help prevent this putative mechanism of nosocomial infections. Since the profession of medicine is under siege; our resistance must be professionalism; the white coat should not be ditched, instead effective white coat handling and maintenance, white coat hygiene campaign and the WHO multimodal hand hygiene improvement strategy will solve this issue between the Scylla and Charybdis. A simplistic advice “Keep white coats clean, wash them often, and have additional spare coat available” is worthwhile. Ultimately, the “nail in the coffin” will dwell upon the collective wisdom of medical fraternity with their prevailing sense of professionalism to make a personal choice about their dress code for the next century.
Since the jury is out on this heavily debated topic, and before we make sweeping uniform policy decisions on the doctors dress code, I, belonging to an older generation of doctors would end this piece of editorial on the “white coat debate” by reiterating that there is indeed no substitute for a gentle, concerned physician with an engaging, friendly, empathic demeanor. But then I ask 2 questions: Is attire important? Yes! Is personality important? Certainly! Patients' attitudes on professional attire do matter and so does the decorum for professionalism. Everything is important! Statutory boards such as Medical Council of India/Indian Medical Association could take an appropriate position in the “white coat debate” by recommending more research, giving credence to the little evidence that the white coat may play a role in transferring pathogens, before implementing resolutions or guidelines on the ban of white coats or adopting the UK's BBE policy.
To my mind, to address the issue of white coat microbial contamination and possible cross infection, I wash my white coat more frequently. I would advocate white coat cleansing/laundering practices to reduce the “white coat bioburden” and indeed supportive of coat-wearing tradition of doctors in India. This certainly works for me! What's your take on it?
“The garment makes the man.”
-An ancient Greek saying
“Be the change that you wish to see in the world.”
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