HIV and ID Observations

If you’re not immersed in the ID or the Infection Control world, you might not be aware that there’s currently quite the controversy about whether doctors should wear white coats.

I almost wrote “raging controversy” — but the adjective “raging” doesn’t really fit the sort of people who specialize in Infection Control, who are some of the most measured, data-driven, and methodical individuals in all of medicine. You know the stereotype of the brash, volatile, and cowboy surgeon, the person that everyone tiptoes around?

These Infection Control folks are the polar opposite.

Still, a white coat controversy does exist, and it goes like this:

1. You can culture all kinds of scary bacteria from the sleeves of white coats.
2. Doctors don’t launder their white coats very often.
3. These bacteria could be transmitted to patients.
4. Therefore, doctors shouldn’t wear white coats.

Not surprisingly, some have advocated a “bare-below-the-elbows” approach to doctors’ attire, and famously the British National Health Service has made it policy, banishing ties as well  (and predictably not pleasing everyone). There was a tremendously entertaining debate on the topic this year year at IDWeek — such a pitched battle it almost met the “raging” criteria, but not quite (you could tell the combatants really liked each other). Right here in Boston, one of our current ID fellows feels quite passionately about the issue, and writes frequently on the topic.

The missing piece in the controversy, of course, is a definitive study showing that patient infection rates are actually reduced when a bare-below-the-elbows (often abbreviated “BBE”) strategy is adopted. Short of that, we’re all essentially hostage to whomever sets these policies wherever we work. And our hospital’s policies basically follow those of Society for Healthcare Epidemiology of America (SHEA), which “balance professional appearance, comfort, and practicality with the potential role of apparel in the cross-transmission of pathogens.”

In other words, wear white coats if you want, but keep them clean.

This data void, however, gives me permission to ruminate over some of the important and not-so-important questions that inevitably come up when contemplating white coats, and our ambivalent feelings about them.

Specifically:

• Why do some doctors wear them now, and some don’t? My wife the pediatrician said if she or one of her practice partners showed up in a white coat, the office staff would view it as bizarre as if they showed up dressed as a Roman centurion. She didn’t actually say that, but you get the idea — pediatricians don’t avoid white coats because of infection risk, but because they are considered potentially scary to kids. Meanwhile, the brilliant and fearsome Chief of Medicine during my residency considered us housestaff essentially naked unless we were wearing white coats, and the Chief Medical Residents kept a few extra in their offices on days he took Residents’ Report in case we showed up white coat-less — kind of like the maitre d’ at the formal restaurant keeping a few extra blazers in the coat closet in case someone arrives without a jacket.
• What do the patients want? Demonstrating that she was a far more compensated medical student than I, one of my classmates during medical school actually published a study evaluating patients’ preferences on doctor attire. Yes, patients liked white coats back then, jeans not so much. It’s one of many such studies appearing in the medical literature over the years; a systematic review of them is summarized in this paper published in the British Medical Journal. Consensus? Patients still seem to like them, but of course for every opinion about the reassuring message of professionalism conveyed by the white coat, there’s an opposite view that they reinforce outdated hierarchical structures in healthcare.
• What should doctors wear if they don’t wear a white coat? The obvious first thought is scrubs, but there are a few problems here. First, scrubs are basically utilitarian pajamas, and can get pretty nasty unless washed daily. Second, they don’t offer much in the way of insulation, a huge issue in the winter and in ubiquitous over-air conditioned interiors. Third, scrubs can be very unkind to certain body types, male and female alike. (You know what I mean.) Fourth, they have basically no storage space — cell phone, wallet, that’s it — forget the reflex hammer, ophthalmoscope (though it’s useless to me), or pocket manual, and wearing scrubs makes your stethoscope a permanent half-necklace. Finally, the public has lots of negative feelings about scrubs — especially when they see doctors wearing them outside the hospital, which means to adopt scrubs as standard gear means changing when you get to work, ugh. And if not scrubs? Men probably clean their suits less often than they wash their white coats, and my daughter told me recently that button-up short sleeved shirts on men are a huge fashion faux-pas, to be avoided as much as backpacks with wheels and belt clips for cell phones. Who knew?
• If white coats go, what happens to the “White Coat Ceremony” during medical school? Apparently, 97% of medical schools now have a White Coat Ceremony, the purpose of which is “to welcome new students into the medical profession and to set clear expectations regarding their primary role as physicians by professing an oath.” Does that oath now include a specified frequency of laundering, including minimum water temperature and the need to use bleach? By the way, you youngsters might be surprised to hear that these solemn and moving rituals are relatively new. Back when I was in medical school, they just left you in a room alone with a cadaver, turned out the lights, and timed how long you could stay there before you screamed for help.
• How would New Yorker cartoons designate doctors if white coats were abandoned? This is a very important question. Take a look — the overwhelming majority have the MD in a white coat, and those few that don’t typically involve surgeons in the OR. Here’s one of the rare exceptions to the above rule and 1) the guy is wearing long sleeves (not BBE!), and 2) it’s not that funny. I’d give it a 7 out of 10 on the funniness scale — now this one is funny. Note that this brilliant cartoonist often adds the head mirror to the white coat, just so you couldn’t possibly think that the white-coated person in his cartoon might be an insurance salesperson or an airline pilot.

Ok, so controversy not resolved. Please vote!