Michael Edmond, MD, MPH, MPARichard P. Wenzel Professor of Internal Medicine │ Hospital Epidemiologist

It’s Time to Hang Up the White Coat!

Goals

• To raise awareness of the role of clothing in the transmission of pathogens in the healthcare setting

• To examine the conflict between optimal infection prevention and professional values with regard to clothing

The patient-provider encounter

• Common points of physical contact– Hands/

wrists– Sleeves– Stethoscope– Wristwatch

Contact precautions

• Patients with epidemiologically important organisms:

– Placed in a private room or cohorted with another patient infected or colonized with the same organism

– All persons don gowns & gloves on entry to the room

• Based on the evidence that clothing can become contaminated & the assumption that pathogens on contaminated clothing can be transmitted to patients

Bare below the elbows:

How it began

• In January 2008, the UK’s NHS mandated measures to decrease MRSA & C. difficile in the healthcare setting – Public reporting by hospitals on:

• compliance with infection control & cleanliness standards• all MRSA BSIs & C. difficile cases

– Greater use of single rooms, cohort nursing & better management of isolated patients

– Extension of the hand hygiene campaign to the outpatient setting

– Bare below the elbows

Bare below the elbows

• Short sleeves

• No wrist watch

• No jewelry except wedding band

• No neck ties

• No white coats

• Intent: allow good hand/wrist washing, & avoid contamination of sleeve cuffs

Postulated role of white coats in the transmission of pathogens

Patients’ skin & environment are contaminated with pathogens

White coat becomes contaminated via contact with patient or

environment + infrequent laundering

Pathogens are transmitted from the white coat to a subsequent

patient

Contamination in the clinical setting:

NecktiesStudy Pathogen N % positive

Ditchburn I 2006

S. aureus 40 20

Nurkin S2005

S. aureus

Gram-negative rod

Aspergillus spp

42

42

42

29

12

2

Lopez PJ2009

S. aureus 50 26

Contamination in the clinical setting:

White coats

Study Pathogen N % positive

Wong D1991

S. aureus 100 29

Loh W2000

S. aureusAcinetobacter

10057

Osawa K2003

MRSA 14 79

Treakle AM2008

S. aureus 149 23

Uneke CJ2010

S. aureusPs. aeruginosa

1031910

Munoz-Price LS2012

S. aureusAcinetobacterEnterococcus

2232325

Study Pathogen N % positive

Perry C2001

MRSAVRE

571438

Munoz-Price LS2012

S. aureusAcinetobacterEnterococcus

9711113

Krueger CA2012

S. aureus 268 33

Contamination in the clinical setting:

Scrubs & Uniforms

Survival of Pathogens on FabricLength of survival (days)

Organism Cotton Polyester

S. aureus (methicillin S) 4, 5, 19 10, 12, 56

S. aureus (methicillin R) 4, 5, 21 1, 16, 40

E. faecalis (vancomycin S) 11, 33 >90, >90

E. faecalis (vancomycin R) 18, 22 73, 80

E. faecium (vancomycin S) 22, 90 43, >90

E. faecium (vancomycin R) 62, >90 >80, >80

C. albicans 1, 3 1, 1

C. parapsilosis 9, 27 27, >30

A. fumigatus 1, 10, >30 1, 7, 30

Neely AN, Orloff MM. J Clin Microbiol 2001; 39:3360-3361.Neely AN, Maley MP. J Clin Microbiol 2000;38:724-726.

White coats & scrubs:

Frequency of laundering

Mean frequency (days)

Munoz-Price LS et al. Am J Infect Control 2013;41:565-7.

N=160

White coat:

Frequency of laundering

Pellerin J, Edmond MB et al. Unpublished data, 2013.

Survey of 183 attending physicians, housestaff and medical students

Transfer of pathogens from white coat to skin

Time

(min)

Number of organisms inoculated onto lab coat

106 105 104 103 102

MRSA

1 + + – – –

5 + + – – –

30 + + – – –

VRE

1 + + – – –

5 + + – – –

30 + + – – –

PRA

1 + + – – –

5 + + – – –

30 + + + – –+ = organism transferred from coat to skin

Butler D, Edmond M. J Hosp Infect 2010;75:137-138.

Experimental transmission of bacteria to patients• Clothing was inoculated with Micrococcus (distal tie or

corresponding area on shirt, cuffs of long and short sleeves)• Standardized 2.5 minute exam was performed on a mannequin• Mannequin cultured

Mannequins contaminated

With tie Without tie

Long sleeve 4/5 1/5

Short sleeve 2/5 0/5

Tie vs. no tie: p = 0.036Long sleeve vs short sleeve: p > 0.05

Weber RL et al. J Hosp Infection 2012:80:252-254.

Summary of evidence:

White coats & the cycle of transmission

Component Strength of evidence

Pathogens contaminate patients’ skin & the environment

Conclusive

White coats become contaminated with pathogens

Conclusive

White coats can transmit pathogens Some in vitro evidence

Removal of white coats reduces infection rates

No evidence to date

Biologic plausibility

When is biologic plausibility enough to support a change in practice?

• Potential for benefit

• No risk for harm

• Minimal cost

But without strong evidence for benefit, we should recommend, not mandate, the new practice

The action threshold

• The action threshold is the probability of an outcome at which it makes sense to undertake an intervention OR how sure to you need to be?

• AT = harm / improvement

0% 100%

Cancer chemotherapy

Antibiotics for strep pharyngitis

Gross R. Making Medical Decisions, 1999:45-51.

Parachute use to prevent death and major trauma related to skydiving

• Objective:  To determine whether parachutes are effective in preventing major trauma related to gravitational challenge.

• Design:  Systematic review of randomized controlled trials (RCTs).• Main outcome measure: Death or major trauma.• Results:  We were unable to identify any randomized

controlled trials of parachute intervention.• Conclusions:  As with many interventions intended to prevent

ill health, the effectiveness of parachutes has not been subjected  to rigorous evaluation by using RCTs.  Advocates of evidence based medicine have criticized the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organized and participated in a double blind, randomized, placebo controlled, crossover trial of the parachute.

 Smith GCS, Pell JP. BMJ 2003;327:1459-1461.

Conventional wisdom:The paradox

• On the basis of the same evidence:– We are willing to wrap ourselves in plastic &

restrict patients to their hospital room (contact precautions)

– We are not willing to eliminate white coats & ties

Origin of the white coat

Late 1800s: Earliest use was in the operating room

Instruction in Surgery: Scene in the Operating Room Amphitheater of the Massachusetts General Hospital, Boston, 1888.

Early 1900s: Physicians began to wear white coats outside the OR to reinforce the stereotype of physicians as scientists

Howard Kelly, MD Professor of Gynecology, Johns

Hopkins Hospital, 1920

Functions of the white Coat

• Storage

• Protects clothing

• Identification

• Warmth

• Symbolism

The White Coat as Symbol

• Purity• Cleanliness• Superhuman power• Candor• Trust• Integrity• Goodness

• Hierarchy & authority• Control• Social & economic

privilege• Inclusion in an elite

community• Separation from the

mass of society because of superior knowledge & thinking skills

Blumhagen DW. Ann Intern Med 1979;91:111-6.Wear D. Ann Intern Med 1998;129:734-7.Flannery MC. Thyroid 2001;11:947-51.Russell PC. Teach Learn Med 2002;14:56-9.

Reasons for wearing a white coat

Warmth12%

Munoz-Price LS et al. Am J Infect Control 2013;41:565-7.

N = 160

Pellerin J, Edmond MB et al. Unpublished data, 2013.

Percentage of respondents who believe the white coat can transmit pathogens

White coat as vector?

Surveys of patient attitudes regarding physician attire

Which doctor would you prefer?

• Graduated near the bottom of his class

• Failed board certification exam on first attempt

• Has difficulties with communication

• Several nurses & medical students have filed complaints against him for dehumanizing comments

• Graduated near the top of his class

• Scored at the 95th percentile on board certification exam

• Numerous patients have written letters to hospital administration regarding his kind demeanor & exceptional availability

Patient preference studies

Hathorn IF et al. Clinical Otolaryngology 2008;33:505-506.Pothier DD et al. British Medical Journal 2007;335:684-b.Neiderhauser A et al. Military Medicine 2009;174:817-820.Palazzo S, Hocken DB. J Hosp Infect 2010;74:30-34.

Site Setting N Findings

UK ENT clinic 93 •49% preferred shirt & tie•40% preferred scrubs•11% preferred open collared shirt, sleeves

UK ENT clinic 100 •76% preferred no tie•63% preferred no white coat

Virginia OB-GYN clinic

328 •61% preferred scrubs•86% preferred no white coat or didn’t matter

UK Inpatients 75 •82% felt doctors should not be expected to wear ties

•75% felt doctors should not wear white coats•83% felt scrubs acceptable

Flaws in many studies of patient attitudes regarding physician attire

• Lack external validity– Mostly small, single center studies

• Confounding– Age

– Geography/culture

– Socioeconomic factors

• Bias– Infer professionalism on the basis of attire– Underestimate how patients choose their doctors– Ignore context

Patient preferences for physician attire:Impact of education

Initial Response (%) After intervention (%)

Traditional (tie, white coat) 52 22

Scrubs 24 62

No preference 24 8

Unsure 0 8

Monkhouse SJW. J Hosp Infect 2008;69:408-409.

Before & after survey of 50 randomly selected surgical inpatients in a British hospital

Intervention: patients were given evidence-based information on contamination of clothing

Patient preferences for physician attire:Randomized studies of actual encountersMethod Findings Conclusion

596 patients

Emergency Dept.

Half of patients cared for by MD in white coat + shirt/tie or blouse/slacks vs. half cared for by MD in white coat + scrubs

No significant difference between the groups on 6 questions assessing satisfaction with care

No relationship between appearance & satisfaction110 patients

Pre-op visit by anesthesiologist

Half seen by MD in suit & tie vs. half seen by MD in jeans, open collar shirt & tennis shoes

Post-visit interview: 70% disapproved of jeans, 67% tennis shoes; no significant difference b/w 2 groups with regard to selection of descriptors denoting professionalism or approachability

Baevsky RH et al. Acad Emerg Med 1998;5:82-84.Hennessy N. Anaesthesia 1993; 48:219-222.

“I have had the good fortune to encounter a wide and rich spectrum of opinions from patients, friends, and colleagues on the matter of proper physician attire, perhaps encouraged by my absent white coat, absent necktie, shaved head, bilateral black hoop earrings, and tattoos covering approximately 17% of my skin (according to the Lund-Browder burn chart). With only one exception (a mildly demented man in heart failure), every one of the uncommon suggestions to upgrade my appearance for the sake of patient care has come from a physician colleague. In contrast, there have been countless moments of connection with patients who confided that some aspect of my appearance made them feel more comfortable… One can only hope that each doctor-patient interaction affords the participants the chance to transcend the cursory impressions of attire and engage in the “real” work of medicine, the alleviation of suffering and the healing potential of a positive, productive relationship.”

Bianchi MT. J Gen Int Med 2008;23:641-3.

Matt Bianchi, MD, PhD

Differences between humanism & professionalism

Characteristic Humanism Professionalism

Types of problems Universal Local

Sources of learning Human experience Socialization into profession

Motivation Human welfare Strengthening of professional identity

Primary duty To other humans; to society

To the professional group

Cognitive basis Postconventional thinking: judging behavior through deliberation about universal values

Conventional thinking: judging behavior by comparison with the accepted social norms of a specific group

Outcome Links physicians to patients

Separates physicians from patients

Modified from: Goldberg JL. Academic Medicine 2008;83:715-722.

Humanism Professionalism

•Empathy•Compassion•Respect•Integrity

•Appropriate dress•Demeanor•Language•Habits•Touching strangers•Blend clinical care with teaching

•Envision medicine as a science

•Protection of the autonomy & integrity of the profession

•Courage•Loyalty•Patience•Humility

Adapted from: Goldberg JL. Acad Med 2008; 83:715-722.

The White Coat Ceremony

“We do not need to teach students how to put on their white coats, but how to take them off. Rather than cloak the students in the coats of the elite, I would borrow a scene from the 1991 film The Doctor and dress students in the common garb of human frailty: a hospital gown. Vulnerable and slightly exposed, they could stand in front of a crowd that only slightly outnumbers the daily census of an average hospital room and pledge never to forget how unforgiving medical care can be stripping patients down to their bare humanity. Perhaps students would thus embark on their medical education with a reminder of what they share with their patients rather than what sets them apart.”

Goldberg JL. Acad Med 2008; 83:715-722.

What do patients want from their doctors?Observations from both ends of the stethoscope

• Competency• Access

– Undivided attention & active listening during the encounter

– Ability to contact the doctor readily & to be seen quickly when necessary

• Interest in them as patients and people

VCU Medical Center Infection Control Committee recommended (but did not mandate) a bare below the elbow approach in the inpatient setting, 1/09

Scaling back contact precautions

• Patients colonized or infected with MRSA or VRE are placed on contact precautions only under the following conditions:– Outbreak situation– Wound drainage that is not contained within a

dressing– Uncontained respiratory secretions

Preliminary findings 6 months after discontinuing contact precautions for MRSA & VRE

• Institution-wide surveillance (~850 beds) for all device associated infections:

MRSA VRE Device days

CLABSI 1 2* 19,160

CAUTI 0 0 11,807

Possible/probable VAP 0 0 3,431

TOTAL 1 2* 34,848

*both VRE infections were met criteria for mucosal barrier injury BSI

Summary:

Clothing & pathogen transmission

• Clothing has the potential to transmit pathogens• The white coat serves the doctor & the profession

to a much greater extent than the patient– Vestigial article of clothing that is neither necessary

nor sufficient for good patient care

• Maximizing patient safety should trump concerns for “professional” appearance

• SHEA guidance document on healthcare worker attire is in press

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