Even as someone who works in the healthcare industry, the physicians white coat sometimes makes me cringe. This response is not the same juvenile fear I would feel decades ago when the white coat signaled oncoming needles and cold examination tables. Instead, now when I see the white coat, I can’t keep myself from wondering how many hundreds of patients that white coat rubbed up against, and how many millions of contagions are currently brushing up against my skin and clothes. Gloves get changed, the crinkling paper on the examination bed gets rolled out, and everyone uses copious amounts of hand sanitizer. But goodness sake, am I the only one who is noticing the Trojan horse coming on white?
The debate on whether or not to keep the white coat has been ongoing pretty much since the inception of this garb. On one hand getting rid of the white coat should, in theory, reduce the number of hospital-acquired infections (I should mention that you should count yourself fortunate if your doctors washes his or her white coat once a week). On the other hand, the white coat has become a symbol of authority, many years of tough education, and what seems like even more years of lost sleep. The white coat is an earned badge of perseverance and prestige, and understandably, few are willing to let go of this honor. But the tides are certainly changing in the face of this nearly hundred-year old Victorian symbol of purity, sanitation, and science. The white coat is slowly disappearing from practices around the world.
I recently came back from an interview at Mayo Clinic. At interviews, the suit is the typical give-away that signals to others that you’re not from around there. At a typical university hospital, your black or grey suit makes you stand out in a sea of white coats and sea green scrubs. People wish you good luck because they know that you’re not one of them.
Mayo is a different picture. While it is one of the world’s meccas of medicine and healthcare, walking around Mayo Clinic feels more like walking around a five star hotel currently hosting a business conference, where there just happen to be a curiously large number of identical navy blue wheelchairs. All physicians at Mayo wear suits. On my interview here, I must have followed the wrong group of suits at least three times; everyone looks like they’re on their interviews for residency or medical school.
The rationale behind the white coat restriction makes sense given Mayo’s fervent dedication to maximizing patient care and comfort. The belief goes that the white coat builds a barrier between the patient and the physician and thus increasing the opportunities for the patient to feel anxious. In a patient survey that Mayo conducted, they found that patients felt most comfortable when their physician wore scrubs, followed by a semiformal wear or a suit, followed last by a white coat. In order to maintain their high standards of professionalism (which would be harder to maintain if everyone wore scrubs), Mayo decided to go with the suit and forgo the white coat. The only members of the Mayo Clinic team allowed to wear white coats in the presence of patients are those in scrubs coming from or going to the OR.
Mayo is not alone in its measures to improve the patient experience. Pediatricians and psychiatrists, for instance, are known not to wear white coats when dealing with their particularly vulnerable patients who might be more impacted by visual cues. As UCLA medical student Jean-Phillip Okhovat puts it, “Not wearing a white coat makes it less intimidating for the parent and child, and makes it a more personable experience. It makes the hospital environment less scary for everyone involved. I think the white coat creates an artificial barrier – creating an immediate sense of hierarchy.” In psychiatry, in particular, there are also safety reasons not to wear a white coat. Yang Yu, a medical student from UC Irvine recalls her rotation in psychiatry: “mentally ill patients can perceive the white coat as a threat, and can see it as a target for aggression. I have definitely seen medical students get attacked by patients while wearing the white coat.”
While older generations still tend to trust a doctor who is wearing a white coat, the trend is that the majority of younger generations prefer that their physicians not wear the white coat at all (Douse et al., 2003). In Denmark, patients do not expect their physicians to wear a white coat; while in the other Scandinavian nations, younger generations prefer that their physicians not wear white coats at all (Anvik et al., 1990).
In a study published in the British Medical Journal in 2005, researchers examined the preferences of 202 inpatient and 249 outpatients. It was shown that patients preferred doctors to wear semiformal attire (defined as dark trousers with a long-sleeved shirt and tie for men, and dark-colored skirt or trousers with a blouse for women) to white coats, formal wear, and casual wear. The most preferred appearance of a physician was with semiformal attire with a smile (Lill et al., 2005).
While Mayo focuses its white coat ban rationale from the standpoint of improving patient care, many others scrutinize the white coat from the standpoint of infection. The issue of the cleanliness of white coats has been central to the debate. The grim reality is that white coats are not washed as often as they should be, and can act as a petri dish collecting “samples” from one patient to the next. And as someone who spends most of my time in the hospital, I can attest to the fact that white coats are not washed nearly as frequently as they should be.
The sides of the white coat, followed by the collars and pockets, were found to be contaminated with S. aureus, coagulase negative Staphylocci, Gram negative non fermenters, and Gram positive cocci resistant to penicillin, erythromycin, and clindamycin (Banu et al, 2012). The cuffs of the white coat were also found to harbor a great amount of bacteria, mainly attributed to the area’s moistness especially after frequent washes of hands. Hospital-acquired infections in the United States leads to an estimated 17,500 to 70,000 deaths per year and an added expenditure of over $4.5 billion.
The National Health Service in the UK has already banned the use of long-sleeved white coats and adopted a “bare below the elbows” rule to reduce unnecessary infections transmitted by sleeve cuffs. In addition to this measurement, the NHS has also banned ties, watches, and jewelry. Scotland became one of the first nations to ban the use of the white coat outright. Strict new regulations require that doctors leave their uniforms in the work place before heading out in order to reduce cross-contamination. Uniforms are laundered on site, and have already shown to significantly reduce infections.
The debate on whether or not to keep the white coat has been heated among doctors. If anything, the right to wear the white coat is the symbol of many difficult years of education and training. And for good reason, wearing the white coat certainly makes you feel proud and authoritative. Every July and August of each year, recently admitted medical students don fresh white coats at White Coat Ceremonies to symbolize the beginnings of this arduous yet rewarding journey towards becoming a physician. But the tides are slowly changing, as the white coats are then retired at graduation. As Yale Medical School professor Don Berwick put it at commencement:
“Those who suffer need you to be something more than a doctor; they need you to be a healer. And to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off.”
“When you take off that white coat in the sacred presence of those for whom you will care – in the sacred presence of people just like you – when you take off that white coat, and tower not over them, but join those you serve, you become a healer in the world of fear and fragmentation.”
(Photo: Seattle Municipal Archives)