1. It’s Time to Hang Up the White Coat!
Michael Edmond, MD, MPH, MPA
Richard P. Wenzel Professor of Internal Medicine │ Hospital Epidemiologist

2. 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

3. The patient-provider encounter
• Common points of physical contact
– Hands/
wrists
– Sleeves
– Stethoscope
– Wristwatch

4. 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

5. 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

6. 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

7. 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

8. Contamination in the clinical setting:
Neckties
Study
Ditchburn I
2006
Nurkin S
2005
Lopez PJ
2009
Pathogen
N
% positive
S. aureus
40
20
S. aureus
Gram-negative rod
Aspergillus spp
42
42
42
29
12
2
S. aureus
50
26

9. Contamination in the clinical setting:
White coats
Study
Pathogen
N
% positive
Wong D
S. aureus
100
29
Loh W
S. aureus
Acinetobacter
100
5
7
Osawa K
MRSA
14
79
Treakle AM
S. aureus
149
23
Uneke CJ
S. aureus
Ps. aeruginosa
103
19
10
22
32
32
5
1991
2000
2003
2008
2010
S. aureus
Munoz-Price LS Acinetobacter
2012
Enterococcus

10. Contamination in the clinical setting:
Scrubs & Uniforms
Study
Pathogen
N
% positive
Perry C
2001
MRSA
VRE
57
14
38
Munoz-Price LS
2012
S. aureus
Acinetobacter
Enterococcus
97
11
11
3
Krueger CA
2012
S. aureus
268
33

11. Survival of Pathogens on Fabric
Length 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
1, 10, >30
1, 7, 30
A. fumigatus
Neely AN, Orloff MM. J Clin Microbiol 2001; 39:3360-3361.
Neely AN, Maley MP. J Clin Microbiol 2000;38:724-726.

12. White coats & scrubs:
Frequency of laundering
Mean frequency (days)
N=160
Munoz-Price LS et al. Am J Infect Control 2013;41:565-7.

13. White coat:
Frequency of laundering
Survey of 183 attending
physicians, housestaff
and medical students
Pellerin J, Edmond MB et al. Unpublished data, 2013.

14. Transfer of pathogens from white coat to skin
Number of organisms inoculated onto lab coat
Time
(min)
103
102
+
+
–
–
–
5
+
+
–
–
–
+
+
–
–
–
1
+
+
–
–
–
5
+
+
–
–
–
30
+
+
–
–
–
1
+
+
–
–
–
5
+
+
–
–
–
30
PRA
104
30
VRE
105
1
MRSA
106
+
+
+
–
–
+ = organism transferred from coat to skin
Butler D, Edmond M. J Hosp Infect 2010;75:137-138.

15. 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 = 0.036
Long sleeve vs short sleeve: p > 0.05
Weber RL et al. J Hosp Infection 2012:80:252-254.

16. 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

17. 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

18. 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
Antibiotics for
strep pharyngitis
0%
Gross R. Making Medical Decisions, 1999:45-51.
Cancer
chemotherapy
100%

19. 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.

21. 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

22. 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

23. Functions of the white Coat
•
•
•
•
•
Storage
Protects clothing
Identification
Warmth
Symbolism

24. The White Coat as Symbol
•
•
•
•
•
•
•
Purity
Cleanliness
Superhuman power
Candor
Trust
Integrity
Goodness
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.
• Hierarchy & authority
• Control
• Social & economic
privilege
• Inclusion in an elite
community
• Separation from the
mass of society
because of superior
knowledge & thinking
skills

25. Reasons for wearing a white coat
Warmth
12%
N = 160
Munoz-Price LS et al. Am J Infect Control 2013;41:565-7.

26. White coat
as vector?
Percentage of
respondents who
believe the white
coat can transmit
pathogens
Pellerin J, Edmond MB et al. Unpublished data, 2013.

27. Surveys of patient attitudes
regarding physician attire

28. 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

29. Patient preference studies
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
75
Inpatients
• 82% felt doctors should not be expected to
wear ties
• 75% felt doctors should not wear white coats
• 83% felt scrubs acceptable
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.

30. 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

31. Patient preferences for physician attire:
Impact of education


Before & after survey of 50 randomly selected
surgical inpatients in a British hospital
Intervention: patients were given evidence-based
information on contamination of clothing
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.

32. Patient preferences for physician attire:
Randomized studies of actual encounters
Method
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
Post-visit interview: 70%
110 patients
disapproved of jeans, 67%
tennis shoes; no significant
Pre-op visit by anesthesiologist
difference b/w 2 groups with
regard to selection of
Half seen by MD in suit & tie
descriptors denoting
vs. half seen by MD in jeans,
open collar shirt & tennis shoes professionalism or
approachability
Baevsky RH et al. Acad Emerg Med 1998;5:82-84.
Hennessy N. Anaesthesia 1993; 48:219-222.
No relationship
between
appearance &
satisfaction

33. “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
Matt Bianchi, MD, PhD
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.

34. 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.

35. Humanism
•Courage
•Loyalty
•Patience
•Humility
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
Adapted from: Goldberg JL. Acad Med 2008; 83:715-722.

36. 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.

37. 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

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

41. 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

42. 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

43. 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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blog!
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www.stopinfections.org
OR
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OR
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@eliowa
@mike_edmond