Several years ago we learned that British health professionals were told that they could no longer wear ties or white coats. In 2008 the UK’s National Health Service (NHS) banned ties and white coasts for doctors and nurses. The rule was that healthcare staffers needed to be “bare below the elbow.”
The point of the exercise was to try and reduce the risk that patients would be exposed to bad bugs: bacteria, fungi, viruses, etc. If the arms were bare below the elbow it would be easier to wash them thoroughly. The NHS was hoping to reduce the spread of MRSA and Clostridium difficile (C. diff) infections among others.
Sources of Infection:
Doctors have a name for things that transmit infection. They are called FOMITES. The Merriam-Webster dictionary defines fomite as:
“an object (as a dish or an article of clothing) that may be contaminated with infectious organisms and serve in their transmission.”
Long sleeves, white coats, ties, stethoscopes, computer keyboards, doorknobs and jewelry can all harbor nasty stuff. And keep in mind that hospital acquired infections are a huge problem. The CDC has estimated that 100,000 people die in hospitals each year as a result of infections they caught in these institutions.
Resistance By U.S. Doctors:
I used to serve on a Patient Safety and Clinical Quality committee at one of the nation’s most prestigious hospitals. When the NHS announced the banning of white coats, ties and jewelry in the U.K. I asked the experts at this hospital about its plans to follow suit. I wasn’t exactly laughed at, but it was clear that the culture of medicine in America would not give up white coats easily. The infectious disease experts at this institution made it clear that there were no data indicating that white coats posed a problem. Without data they were not about to institute changes.
I was also puzzled to discover that there was no policy on cleaning white coats or ties. Interns, resident and attending physicians determined how often they would clean such articles of clothing on their own schedule.
Dr. Peter Pronovost Challenges His Colleagues:
Peter Pronovost, MD, PhD, is one of the world’s foremost patient safety experts. He is senior vice president for patient safety and quality at Johns Hopkins Medicine. On December 19, 2015 he wrote an article titled, “Why White Coats Should Be Optional.” It should be required reading for patients, physicians, nurses and any health care worker who comes into direct contact with patients.
Here are just a few key points:
“Would my white lab coat be better put to use when I carve the Christmas roast than when seeing patients?
“After all, we know that these coats can be covered with pathogens, including drug-resistant ones, which may be transmitted to patients. They are cleaned infrequently: In a survey of physicians, nearly 58 percent said they laundered their white coats monthly or never. Less than 3 percent washed them daily or every other day. What is the harm in adopting a ‘bare below the elbows’ policy for health care professionals — as has been done in the United Kingdom — to reduce the chance of transmission?”
Dr. Pronovost points out that doctors often resist new ideas unless they can be proven beyond a shadow of a doubt. That is probably why the infectious disease experts completely rejected my suggestion several years ago that going bare below the elbow might be beneficial for patients and reduce hospital acquired infections.
Rejecting the Germ Theory of Disease:
This attitude is reminiscent of the 19th century. In the mid 1800s childbirth was extremely dangerous. Something called childbed fever killed many women shortly after childbirth. In those days doctors did not know about germs.
A physician researcher named Ignaz Semmelweis was practicing medicine at the Vienna General Hospital. He noted that women experienced a much higher death rate after a medical student delivered a baby compared to a midwife.
Dr. Semmelweis discovered that the students were dissecting cadavers in a room next to the maternity wards. They rarely washed their hands after dissections or between deliveries.
The midwives did not deal with the cadavers and thus avoided exposure to such germs. They were far less likely to spread germs from a dead person’s body than were the medical students.
Hand Washing Miracle:
Dr. Semmelweiss suspected that hand washing might make a big difference. He came up with the radical idea that medical students should disinfect their hands after their anatomy labs with the cadavers and between patients. After he instituted this hand hygiene practice the death rate after childbirth dropped dramatically. He didn’t know why the practice worked, he just knew it did.
One might imagine that Dr. Semmelweiss would have become a hero within the medical community and that his discovery would have been quickly adopted. On the contrary. Dr. Semmelweiss became a pariah. His colleagues rejected and ridiculed his research. He was forced into an insane asylum where he soon died. His plea that doctors wash their hands before delivering babies or touching patients was ignored for decades.
The 21st Century Mindset:
Modern medicine likes to pat itself on the back for its patient-centered approach. Yet it seems to us that too many health professionals are willing to accept 100,000 deaths annually as inevitable, just as doctors in the 19th century believed childbed fever was a natural consequence of childbirth.
Dr. Pronovost sums it up beautifully:
“My stance: We could voluntarily ditch the white coats without needing a clinical trial to tell us its OK. We know that white coats can carry pathogens, and it is logical to think that germs could be transmitted from physician to patient. Given that confirming this theory could be prohibitively expensive, we can look at the implications of acting and not acting…
“The real cost of abandoning white coats, it seems has less to do with preventing infections and more to do with the potential emotional or social consequences…”
Read Dr. Pronovost’s brilliant blog here and send it to your doctor or nurse.
Please share your own thoughts about this issue below. Would you think less of your health professional if he or she failed to wear a white coat? What about a tie? Could you bring yourself to ask your doctor to wash his hands or clean his stethoscope? Please vote on this article at the top of the page.