Monday, August 3, 2009

White Coats: Medical Professionalism or Infectious Risk?

Anyone who's seen me striding about the hospital knows that one of my distinctive Cmar-isms is that I always roll up the sleeves of my white coat, as well as my shirt. Far from being a mere affectation, to me it serves two important purposes, both related to infection control. One is that with sleeves extending to the wrist, there's a chance that they will become dirty or contaminated while examining a patient, and the bacteria involved could be passed on by said sleeves to the next patient I deal with. Secondly, it is easier to wash my hands between seeing patients more thoroughly without having soap and grime absorbent fabric right next to them.

While this represents my personal choice, and not an institutional policy, there is a growing level of concern nationally about the role that physician dress might play in the spread of infections in the hospital setting. Many studies have documented that items which come into contact with patients, from stethoscopes and pens to neckties and shirt sleeves, can easily become contaminated with organisms that can cause serious infections in otherwise ill hospitalized patients. Bugs that can cause life-threatening infections and are difficult to treat, such as Methicillin-Resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (often abbreviated "C. diff."), are of prime concern.

Looking at things from that perspective, it seems obvious that a few simple changes in professional dress - getting rid of long sleeves and neckties, for example - would be an easy way to reduce the transmission of virulent organisms among patients, as well as encouraging physicians to wash their hands. In fact, the National Health Service in the United Kingdom did just that in 2007, instituting a "bare below the elbows" policy in all hospitals that bans long sleeved white coats and shirts, as well as long neckties. However, these changes on the NHS's part have met with some controversy.

For one thing, there isn't a robust body of evidence that looks specifically at how much such a change would actually decrease the rates of hospital-acquired infections in patients. More importantly to some, the white coat has been a symbol of physicianhood for over 100 years. Many doctors and patients alike believe they should not be done away with, because they represent the professionalism of physicians, and their knowledge of both the science and the art of medicine.

As recently reported by the Washington Post, the American Medical Association is currently debating a proposal made at its recent annual meeting to recommend against physicians wearing white coats. In addition to the infection control and professional respect issues noted above, some have opined that the white coat has changed from a symbol of trust to one of possible anxiety for patients. In fact, some doctors have taken to going without their white coats to affect a more casual rapport with their patients, especially in a time when health care is sometimes seen as an industrial, uncaring machine.

There are many nuances to this issue, and it's one that will not be resolved soon, especially in our current health care climate. Until the time when more science and firmer policies are available, I'm going to keep rolling up my sleeves, and of course, washing my hands.

What do you think?

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