The long-standing tradition for doctors to wear a white coat has been widely questioned in recent years. Arguments against continuing this practice tend to center around a) infection risk and b) the possible impact on the doctor-patient relationship.

Many prominent doctors are calling for a "bare below the elbows" (BBE) approach. Peter Pronovost, MD, director of the Armstrong Institute for Patient Safety and Quality, writes on the Armstrong Institute blog: "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% said they laundered their white coats monthly or never. Less than 3% 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, MD, an infectious diseases physician at Massachusetts General Hospital in Boston, MA, agrees with Pronovost. On his blog, Lederer also makes the point that, "White coats are so widely worn they no longer serve to identify who the doctors are. They're just a habit. And I think they should be retired."

Lederer points out that healthcare-associated infections (HAIs) are a top cause of illness and death. He reports than an estimated 721,800 HAIs occurred in the United States in 2011, leading to 75,000 deaths.

With the emergence of drug resistance, medication choices for the treatment of many bacterial infections are becoming limited, Lederer warns. "The relative role of clothing (white coats, ties, etc) in transmission of HAIs has long been a topic of controversy," he writes. "However, what's indisputable is that white coats are coated with pathogenic bacteria and have the potential to transmit infections to patients. There is no harm in avoiding white coats. But there could be danger in wearing one."

The white coat has been a fixture in medicine since the late 19th century, prior to which doctors wore black. The switch to white was made to symbolize that medicine is a profession based on science.

Some of those who fear the infection risk from white coats also believe the coats are elitist and represent an unhelpful barrier between doctor and patient. Conversely, other doctors believe they engender trust in the physician. Paul E. Sax, MD, clinical director of infectious diseases at Brigham and Women's Hospital, Boston, MA, says the evidence does not support giving up white coats. They have "a lot of cultural significance", he says.

On this aspect of white coat wearing, Lederer writes: "The discussion about white coats goes well beyond the bacteria crawling all over their fabric." He states that physicians traditionally dominate in the doctor-patient interaction. His petition against white coats includes the line, "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."

"We clinicians can take off our white coats, roll up our sleeves, organize and mobilize. We can take steps to improve quality and safety," he writes.

Interestingly, the Virginia Commonwealth University School of Medicine in Richmond, VA, has taken a unique stance on this issue. Michael B. Edmond, MD, chief of infectious diseases, started wearing scrubs to work following the United Kingdom’s white coat ban in 2008.

The next year, his hospital brought in a voluntary policy encouraging staff members not to wear a coat, and go bare below the elbows. Now, 80% of hospital staff are BBE. Edmond has now moved to the University of Iowa Hospital & Clinics and plans to institute the same policy there.

In summary, Peter Pronovost writes in his Armstrong Institute blog post: "Studies disagree on whether patients prefer the white coats - some find them reassuring, but others 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.

"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."

References:

Pronovost P. Why White Coats Should Be Optional. December 18, 2015. https://armstronginstitute.blogs.hopkinsmedicine.org/2015/12/18/why-white-coats-should-be-optional/. Accessed January 11, 2016.

Lederer P. http://philiplederer.org/whitecoats/. Accessed January 11, 2016.

Sax PE. HIV and ID Observations. http://blogs.jwatch.org/hiv-id-observations/index.php/should-doctors-still-be-allowed-to-wear-white-coats-you-decide/2015/11/01/ Accessed January 11, 2016.

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