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It's time for doctors to hang up the white coats for good

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On a warm August 2004 day in Philadelphia, I joined 150 first-year medical students on stage at the University of Pennsylvania to celebrate the start of our medical careers. The dean called our names and, one by one, draped short white coats around our shoulders. We then stood together as a class and recited the Hippocratic Oath, reflecting on the importance of becoming humanistic physicians. My parents had driven up from Kentucky and proudly sat in the audience. It was a powerful ritual and a memorable day.

Is that really clean?

During my four years of medical school, I wore that short white coat on the hospital wards. After graduation, I moved to California and traded in the short white coat for a long one. Residency was exhausting. I was on call for 30 hours every few nights, my coat became sullied, and it was difficult to keep it pristine even with frequent washing. Once, after rounds in the intensive care unit, the attending physician took me aside. 鈥淒o a better job washing that coat,鈥� he admonished me. 鈥淧atients and their families shouldn鈥檛 see you like that.鈥� But even with bleach, my coat never regained its original luster.

Several years later, I am an infectious diseases fellow at Massachusetts General 黑料吃瓜群网 and Brigham and Women鈥檚 黑料吃瓜群网 and help teach the Harvard Medical School students when they do their infectious diseases clinical rotations. When I came here, I was given new white coats embroidered with the names of the prestigious institutions where I work. But I have never worn them.

And now, with a few years of experience, I have come to believe that we should get rid of white coats and reorient rite-of-passage ceremonies away from them.

You wouldn鈥檛 want to be cared for by a doctor who doesn鈥檛 wash his or her hands. You wouldn鈥檛 want to be operated on with instruments that weren鈥檛 sterilized or stay in a hospital room that wasn鈥檛 cleaned regularly. Why would you want to be treated by a doctor wearing a white coat that hasn鈥檛 been washed in a week? Many white coats are like MRSA 鈥� they are dirty. And it鈥檚 time to hang them up for good.

What鈥檚 crawling on that white coat?

According to the :

Health care personnel (HCP) apparel can hypothetically serve as a vector for pathogen cross-transmission in healthcare settings; however, no clinical data yet exist to define the impact of HCP apparel on transmission.鈥�

Does the absence of evidence equal evidence of absence?

and , physicians at the University of Iowa, have studied this issue in depth. They admit that while transmission to patients hasn鈥檛 been definitely proven, there is that it could occur. But no one has ever funded the necessary studies to find out for sure.

Unfortunately, a randomized trial of white coats would cost upwards of US$20 million, and this money has not been budgeted by the National Institutes of Health, the premier research organization of the federal government. In the bigger picture, Perencevich and Edmond argue that just like we don鈥檛 need a randomized trial to prove that parachutes save lives, we also don鈥檛 need a trial of white coats. The circumstantial evidence that many of them are covered in germs is sufficient.

The Gross Clinic.

White coats are about communicating an ideal

Physicians haven鈥檛 always worn white coats. Until the late 19th century, surgeons operated wearing black coats, as Atul Gawande explained in his fine article, .

Although Edinburgh physician Dr Joseph Lister had discovered that being free of microorganisms (antisepsis) reduced the risk of hospital-acquired infections, it took years for doctors to get rid of their black coats.

Gawande wrote:

鈥�hand washing was still perfunctory. Surgeons soaked their instruments in carbolic acid, but they continued to operate in black frock coats stiffened with the blood and viscera of previous operations 鈥� the badge of a busy practice.

But, Gawande goes on, some surgeons wanted to promote a different vision of their profession.

A few pioneering Germans, however, seized on the idea of the surgeon as scientist. They traded in their black coats for pristine laboratory whites, refashioned their operating rooms to achieve the exacting sterility of a bacteriological lab, and embraced anatomic precision over speed.

And white coats took off. They have always been a symbol, but the white coat ceremony is actually a recent invention, having been developed in 1993 by the . This ceremony is now a mainstay at the majority of medical schools and many nursing and allied health schools as well, meant to connect student to the 鈥渘oble tradition of doctoring.鈥�

And it鈥檚 not just tradition that keeps physicians in white coats. Doctors give a variety of reasons for wearing them 鈥� to carry papers, because hospitals are cold or for a confidence boost when facing a stressful situation. Female physicians also face the challenge of being misidentified if they don鈥檛 wear a white coat.

Yet the situation is notably different in many countries in Europe. In the United Kingdom, for example, physicians simply don鈥檛 wear white coats when seeing patients because they have adopted a 鈥渂are below the elbows鈥� policy. In the UK, only pathologists and other laboratory based physicians wear them, and those coats don鈥檛 leave the lab.

You are still a doctor without the white coat

A few months ago Dr Vineet Chopra and Dr Sanjay Saint wrote an article that patients prefer white coats. They suggested that formal attire with long-sleeved shirts and ties for men and business attire for women be worn while they conduct a survey of thousands of patients from the US, Italy, Switzerland and Japan.

I disagree. from Scotland suggested that patients feel that their doctors鈥� appearance was not as important as compassion, politeness and knowledge. Only half of patients felt that the style of clothing mattered. And patients felt an impression of cleanliness and good personal hygiene were more important. In fact, patients preferred a 鈥渟mart casual鈥� style of dress, which conformed with a 鈥渂are below the elbows鈥� dress code policy. This would presumably reduce the transmission of bacteria to patients if rigorous handwashing were employed.

And in any event, patient preferences are primarily shaped by cultural norms rather than medical evidence. Patients rarely perceive that white coats can be covered with bacteria, that coats are infrequently washed, that white coats can make a health care worker鈥檚 , and that coats could lead to serious infections.

Patients also don鈥檛 realize that this with little action in the United States.

The culture of medicine is very powerful, and old habits, like white coats, are hard to break. But doctors are still doctors whether they wear a coat or not. And even if white coats inspire trust in some patients, whatever theoretical benefits the coats may have aren鈥檛 worth the downsides. There is no harm in avoiding white coats, but there could be danger in wearing one.

Primum non nocere. First, do no harm, my fellow physicians. That starts with rethinking the white coat ceremony.

, Infectious Diseases Fellow ,

This article was originally published on . Read the .