Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor,
Dept. of Podiatric Medicine,
Surgery & Biomechanics
College of Podiatric Medicine
Western University of
Health Sciences,
St, Pomona, CA

There are questions about the cleanliness of white coats that has, in some minds, given them the image of contamination instead of cleanliness.

Is the White Coat Dead?

This past weekend, we at Western University of Health Sciences had our Commencement ceremonies to open the 2011 academic year. Since the University has 9 colleges and 22 programs, it is a pretty sizable affair with plenty of pomp and circumstance. In addition to this large event, we also have smaller white coat ceremonies to welcome our new students to podiatric medical school. Probably all podiatric physicians in practice since the mid-1980’s have undergone this ceremony. But has the white coat seen better days? With questions about the cleanliness of white coats as well as recent movements to ban their use, one has to wonder, is the white coat dead?

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When I was in private practice, I only occasionally wore a white coat. However, in academic medicine, it is the norm. The powers that be seem to have a strong desire to delineate some visible difference between attendings, residents, and students, and what more visible way is there than a white coat? Additionally, because many of us in academia rotate through several hospital clinics, it’s useful to have something to carry your “stuff” in. But is this really a good idea? Are we putting our patients at risk in order to wear a certain article of clothing?

In the United Kingdom, the use of white coats has been banned since January of 2008, instituting a “bare below the elbows” (short sleeves, no watches, no jewelry, no white coats) hospital dress policy (Lancet 2007). Unfortunately, the issue is muddied by the fact that no strong studies have linked contaminated clothing linens with nosocomial infections.

Are we putting our patients at risk in order to wear a certain article of clothing?

In 2007, England’s National Health Service stated, “There is no conclusive evidence that uniforms (or other work clothes) pose a significant hazard in terms of spreading infection” (Jacob 2007). The apparent motivation for this change was public sentiment that there was an increased risk of infection, rather than an actual demonstrated increased risk.

However, a recent study published in the American Journal of Infection Control found contamination of white coats by Staphylococcus aureus (both MSSA and MRSA) (Treakle 2009). I’d imagine we’d be likely to find a reasonable amount of E. coli and C. difficile on the coats of those who don’t wash their hands. What has not been demonstrated yet is that these contaminated white coats actually p nosocomial infections. It seems to be a logical step to reason that if the coats are contaminated with skin flora, and skin flora cause the majority of skin and skin structure infections, then the coats are likely to be capable of causing infection.

White coats have been BANNED in the United Kingdom since 2008

This logical syllogism may sound reasonable except for one issue: the laundry. White coats have the potential to be laundered regularly, which is likely to decrease the bacterial counts. Compare this to the men’s dress tie. Doctor’s ties are rarely cleaned (they typically must be dry cleaned to prevent damaging the tie). As such they have been shown to have higher bacterial counts than shirts (Ditchburn 2006).

Ok, so we don’t actually know the answer to the dirty white coat question. We know coats are dirty, but we don’t know if they actually cause disease besides the logical progression I described above. High quality research is definitely necessary to put an end to this question.

Then in the meantime, what should we do? What do we replace the white coat with? If we eliminate the white coat, here are some options as I see them:

Replace them with nothing. i.e. wear dress clothes.
Eliminate all “hanging” cloths such as ties.
Wear short sleeve dress shirts (for those who want to wear dress clothes).
Wear scrubs.

I would suggest eliminating the white coat in favor of either scrubs or some new style of “dress medical” clothing (perhaps a polo-type shirt and light pants) that must be changed when entering and leaving the hospital or private office.

Of course, each of these options has problems. Without protection, the dress clothes will presumably become as soiled as the white coat. Eliminating ties is good, but that still brings us back to the now dirty dress shirt. Wearing scrubs is OK, but some doctors want to maintain a more formal appearance.

Until we know the truth (both whether white coats cause infections and to what extent), it’s impossible to make a very strong recommendation. However, far be it from me not to put in my two cents. I would suggest eliminating the white coat in favor of either scrubs or some new style of “dress medical” clothing (perhaps a polo-type shirt and light pants) that must be changed when entering and leaving the hospital or private office. I’m not sure how successful this idea is likely to be since it would require a cultural shift in how we view dress for medical professionals (as well as the increased cost of new clothing), so for now, it’s either dress in scrubs and change them often or bleach that white coat every day. Either way, lose the tie! Best wishes.

Keep writing in with your thoughts and comments. Better yet, post them in our eTalk forum. Best wishes.

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Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

References:

Ditchburn I, et al. J Hospit Infection, 2006; 63: 227-236.
Jacob G. Uniforms and workwear: an evidence base for developing local policy.
UK Department of Health 2007:10. Follow this link.
Lancet, Sept 2007; 370(9593): 1102
Treakle A, et al. Journal of Infection Control, Mar 2009; 37(2): 101-105.