Are White Coats Turncoats?

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Guest student blog by William W. Motley, Neurogenetics Branch, NINDS, NIH, Bethesda, MD, USA (wmotley@gmail.com)

I was recently admitted to medical school and am excited to start my training to be a physician. Soon I will symbolically celebrate the beginning of my medical education at a white coat ceremony.

I am looking forward to joining a profession that constantly strives to innovate in its effort to improve outcomes. But the white coat uniform is a tradition that has persisted for too long and undermines our commitment to improvement. White coats introduce another vector for pathogens and reinforce hierarchy in medicine—to the detriment of the objectives of physicians.

Doctors’ coat cuffs harbor virulent bacteria1, 2. Often worn outside the hospital on coffee breaks, white coats are not treated as an aseptic barrier as they are in laboratories. White coats provide a vehicle for pathogens within the hospital and between the bedside and the curbside. British health officials have responded by issuing plans to eliminate white coats and encourage physicians to roll sleeves up to the elbows3. Hospitals in the US should follow suit.

When presented with short coats, medical students are effectively asked to submit to a dress code that establishes a hierarchy amongst healthcare providers. Medical researchers have conducted studies and shown that breaking down the hierarchical structure through team training exercises and simple checklists reduces surgical error4, 5. Rigid ranks inherently silence the concerns of those lower on the totem pole and result in missed opportunities to identify errors. Stopping use of white coats can help teach future physicians a valuable lesson in humility. By eliminating attire as a marker of hierarchical importance in the quest to improve care, we will encourage students to realize that doctors, nurses, technicians, and even students play a role in recognizing and stopping medical mistakes.

I realize that gaining the trust of a patient is an important part of effective doctoring and that this uniform helps instill confidence. A baby-faced 27-year-old, I would probably benefit from such a strong symbol of authority. But I hope that my communication skills (learned in medical school and before) and knowledge will be more effective tools than an infrequently laundered coat.

I think that more medical schools should start welcoming students with a stethoscope ceremony. White coats are superfluous uniforms; stethoscopes are important diagnostic tools. Stethoscopes also symbolize an even better way to gain the trust of a patient: by listening to them, and by listening to the evidence.

1. Wong D, Nye K, Hollis P. Microbial flora on doctors’ white coats. BMJ. Dec 21-28 1991;303(6817):1602-1604.

2. Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of health care workers’ white coats. Am J Infect Control. Mar 2009;37(2):101-105.

3. The traditional white coat: goodbye, or au revoir? Lancet. Sep 29 2007;370(9593):1102.

4. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. Jan 29 2009;360(5):491-499.

5. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. Oct 20 2010;304(15):1693-1700.

William W. Motley has submitted his PhD thesis in a combined program between the National Institutes of Health and the University of Oxford. This fall he will start his MD training at the University of Pennsylvania.

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