Dressing Well and Keeping our White Coats until the Evidence Tells Us Otherwise
The problem of healthcare-associated infections (HAIs) and the morbidity that they cause is gaining more media attention with each passing week. The numbers are mind-boggling: according to the CDC over 700,000 HAIs occur nationwide in acute care hospitals, affecting almost 5 percent of all hospitalized patients1.
In addition to the costs in human suffering, there’s also the financial burden, estimated at $10 billion a year for the five most common infections2; ventilator-associated pneumonia, surgical site infections, catheter-associated urinary tract infections. Clostridium difficile colitis, and central line-associated bloodstream infections.
It’s also understandable (and expected) that as the scale of this problem becomes more publicized, and the Center for Medicare and Medicaid Services (CMS) is increasingly tying reimbursements to hospital infection rates, healthcare organizations everywhere are ramping up efforts to lower their numbers. Being the most visible frontline specialty, the role of hospital medicine doctors is absolutely crucial in leading the fight. All of us who practice at the frontlines will be familiar with the common day-to-day infection control methods employed on the floors, such as gloves and gowns for patients with vancomycin-resistant enterocci, or droplet precautions for patients with influenza.
But more needs to be done, and many other novel ideas are being put forward. There have been calls for special lights on badges that turn green when hands are washed, video taping all doctors and nurses, everyone wearing newly cleaned scrubs every day, and even encouraging patients to regularly ask their doctors if they’ve washed their hands.
A further approach that’s being proposed and increasingly talked about is a strict “bare below the elbows” rule for all healthcare professionals. This would completely change the way doctors dress by banning white coats, long sleeves and any watches or jewelry. For the males, ties would also be banned. It’s a strategy that’s already been used overseas. In 2007 the United Kingdom’s National Health Service banned all doctors in the country from wearing long sleeves and ties. I left the NHS to start my residency here in America a couple of years before that. Not that the medical world is ever a fashion contest, but the United Kingdom probably went overnight from having some of the best-dressed and professionally attired doctors in the world to having them arriving to work in short sleeves and open collars. No white coats to be seen (however, slightly different over there, because it was typically only medical students who used to wear white coats anyway). The measure was a drastic change and one that was met with a fair degree of skepticism. Is there actually any evidence that long sleeves and ties spread infection?
A look at the available scientific evidence tells us that although some studies have shown that clothing can potentially become contaminated with bacteria3, there have as yet been no studies that have demonstrated a direct causation or shown that restrictive dress codes make any difference at all to infection rates. One such study from New York that specifically looked at neckties and found that they could carry pathogens4, received some attention in the news media, but did not establish any causality. It’s entirely plausible that the same results may have been found if doctors’ other garments were swabbed. Indeed, a larger study in the Journal of Hospital Medicine found that there was no difference in MRSA contamination of physicians’ white coats with that of newly laundered, short-sleeved uniforms after an eight-hour workday. After just three hours, the cleaned uniforms already had 50 percent of the colony counts that they did at eight hours. Furthermore, contamination of the skin at the wrists of physicians wearing either type of clothing was the same5.
Despite the ban in the NHS being in place for seven years, recent government data from the UK suggests that hospital infection rates remain stubbornly high. Statistics show that 1 in 16 people treated at a hospital contract an infection, what the National Institute for Health and Clinical Excellence called “unacceptably high.”
Could a “bare below the elbows” scenario become mandated here? In 2011 the New York State Senate proposed that exact policy (without the support of the state’s Medical Society). It hasn’t become law yet. More recently, the Society for Healthcare Epidemiology also suggested the same approach6.
At the other end of the spectrum, the American Medical Association said in 2010 that there was “little evidence linking clothing to infection rates” and called for further research before adopting restrictive dress codes. Of course, over here we don’t have a single authority that can overnight impose such severe measures on doctors and hospitals. The same goes for having a handful of politicians with excessive power (who usually have no healthcare or scientific qualifications) who may be eager to get the headlines as “infection fighters,” such as happens in many countries with centralized systems.
Without any compelling evidence, banning all white coats, long sleeves and ties may thus be a step too far. There’s also another big downside to doing this: patients actually quite like their doctors dressing professionally (as do customers in any arena). In one study 400 patients were shown pictures of a doctor in various outfits; including professional-looking with a white coat, scrubs and sneakers, and jeans with a t-shirt. The results showed that overwhelmingly patients preferred their doctor to be dressed professionally with a shirt and white coat7. The same went for female physicians too, minus of course the tie. The authors concluded that wearing professional dress could favorably influence trust and confidence-building in the medical encounter.
So what can hospital doctors do on a daily basis that really works? Find out tomorrow in Part II.
Dr. Suneel Dhand MD
Dr. Suneel Dhand is board-certified in internal medicine. He was born in London and grew up in Berkshire, England. Suneel went to medical school at Cardiff University and then moved across the pond, completing his internal medicine residency in Baltimore, Maryland. He currently lives in Boston, and practices as a hospital medicine physician.
Suneel’s clinical interests include frontline healthcare quality improvement, improving hospital processes, enhancing patient experience, and healthcare information technology development and integration. He regularly writes and speaks about these topics. As well as his clinical duties as a frontline doctor (which he enjoys the most), Suneel has experience in the implementation of hospital IT systems, and was the lead hospital physician for the successful implementation of a Computerized Physician Order Entry (CPOE) system in Worcester, Massachusetts. Suneel also has experience in a number of different healthcare environments and systems. In addition to practicing as a physician up and down the East coast, including in Florida, he previously worked in the United Kingdom’s National Health Service, and undertook an elective experience in Australia, where he worked with the Royal Flying Doctor Service.
Suneel held a faculty position with the University of Massachusetts Medical School as an Assistant Professor of Clinical Medicine, regularly teaching medical residents and students. He has authored numerous articles in clinical medicine that have been published in leading medical journals, covering a wide range of specialty areas. He has also authored chapters in the “5-Minute Clinical Consult” medical textbook. His other main area of interest is preventive medicine and wellness, and he is the author of two well-being books; High Percentage Wellness Steps, and the historical fiction book, Thomas Jefferson: Lessons from a Secret Buddha.
When he is not working in the hospital or on healthcare-related projects, Suneel enjoys running, cycling, playing tennis and golf, traveling (he tries to visit a different country every year), and getting back to London as often as possible!
Follow Suneel on twitter: @SuneelDhand
1. Magill SS et al. Multistate Point-Prevalence Survey of Health Care-Associated Infections. N Engl J Med 2014;370:1198-208.
2. Zimlichman E et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46
3. Wiener-Well Y et al. Nursing and physician attire as possible source of nosocomial infections. Am J Infect Control. 2011 Sep;39(7):555-9.
4. American Society For Microbiology. “Doctor’s Neckties: A Reservoir For Bacteria?” 104th General Meeting of the American Society for Microbiology ?May 23-27, 2004, New Orleans, Louisiana
5. Burden M et al. Newly cleaned physician uniforms and infrequently washed white coats have similar rates of bacterial contamination after an 8-hour workday: a randomized controlled trial. J Hosp Med. 2011 Apr;6(4):177-82.
6. Bearman G et al. Healthcare personnel attire in non-operating-room settings. Infect Control Hosp Epidemiol. 2014 Feb;35(2):107-21.
7. Rehman SU et al. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005 Nov;118(11):1279-86.