- Long-sleeved white coats may be transmitting multidrug-resistant organisms, including Staphylococcus aureus and gram-negative nonfermenters; in response to research data, the British Medical Association banned lab coats, long sleeves, watches, jewelry and ties in patient care to reduce contamination
- Some have resisted the removal of the white coat from a physician’s attire in the U.S., believing it is a symbol of professionalism, and gathered data suggesting a patient’s expectations and perceptions may improve patient satisfaction when white coats are worn
- Overall, medical errors, including hospital acquired infections, are the third leading cause of death in the U.S. However, as measurement tools have serious limitations, researchers believe this number may be higher, leading a team from Johns Hopkins to request the CDC change data collection methodology as it may be incorrectly informing many research and public health priorities
- Strategies to protect yourself and your loved ones include being a vocal advocate to reduce the likelihood mistakes are made, downloading and using the surgical safety checklist from the World Health Organization if surgery is scheduled, and insisting those caring for you wash their hands before contact
For some, simply seeing a physician in a white coat is enough to spike your blood pressure. This condition, known as “white coat hypertension” or “white coat syndrome,”1 happens when the blood pressure readings in your physician’s office are higher than they are in a different setting.
While it was once believed white-coat high blood pressure was triggered by stress from your doctor’s appointment, some think it might be a signal you’re at risk for high blood pressure as a long-term condition.2 To move away from the additional stress the sight of a white coat may bring to patients and their families, some doctors, such as pediatricians and psychiatrists, have stopped wearing them.3
Over the last 100 years, the white coat has been the unparalleled symbol of science and medicine.4However, expectations about whether physicians should use a white coat or not is likely a moot point as these long-sleeved symbols of medicine have been shown to transfer bacteria from one patient to the next.5,6,7
Medical Clothing May Transmit Nosocomial Infections
Tertiary hospitals care for patients who require specialists at the request of a primary or secondary medical care personnel.8 The target of these hospitals is to treat the sickest or those needing care they could not get elsewhere.
Research now shows that when physicians use long-sleeved white coats, they may become agents transmitting multidrug-resistant organisms. In one study9 published in the Journal of Clinical and Diagnostic Research, a cross-sectional survey of bacterial contamination of medical students’ coats was done on four different areas of the coat — collar, pocket, side and lapel.
The students reported most had washed their coat within the past two weeks, yet the researchers found the sides of coats were highly contaminated with Staphylococcus aureus, Staphylococci and gram-negative nonfermenters.
Wearing a white coat may have a role in the transmission of pathogenic microorganisms and these researchers recommended physicians should possess two or more coats at any time, and that alternatives, including a universal protective gown, should be considered to reduce the spread of potentially dangerous bacteria.10
The results of this study support many others. While any articles of clothing can become contaminated, with wide sleeves and long length, these white coats come in contact with patients more frequently and are laundered less often than clothes physicians wear daily.
In a study from Brazil,11 researchers evaluated medical student coats and found microorganisms including gram-positive cocci, S. aureus and coagulase-negative Staphylococcus species. Another systematic review of 72 studies12 looked at contamination on white coats, neckties, stethoscopes and mobile electronic devices.
Contamination rates varied across the studies and by electronic devices, but in general researchers discovered up to 32% of the items tested were contaminated with methicillin-resistant S. aureus and gram-negative rods. Few studies looked for Clostridium difficile, and Enterococcus was found less frequently.
The UK Banned Long-Sleeved White Coats in 2007
The British Medical Association (BMA) began acting on this news in 200613 when they recommended physicians refrain from wearing functionless pieces of clothing such as ties, and avoid wearing clothing from the clinical setting outside the health care environment.
The BMA board of science warned physicians to presume there would be some degree of contamination on clinical clothing, even when it was not visibly soiled.14 Interestingly, the BMA’s recommendation to eliminate certain pieces of clothing to reduce the spread of bacterial contamination between patients was met with resistance.
Some who didn’t want to change supported their viewpoint using surveys to determine patient and physician clothing preference,15 and others believed hospitals should supply physicians with a clean coat each day.16
The BMA’s recommendations went further at the end of 2007 when the National Health Service, which provides health care for all U.K. citizens, banned the use of long-sleeved white coats.17 The dress code also meant doctors would be required to wear short sleeve shirts and were banned from wearing watches, jewelry and neckties to reduce potential contamination.18
The Power of the White Lab Coat
Those who have resisted removal of loose, long-sleeved white coats from a physician’s dress code may believe there is power behind the white coat. Up to the 1800s, medical doctors did not practice as they do currently. With the scientific method came reason and proof instead of relying on mysticism and old wives’ tales.19
Doctors often dressed in formal black coats to portray a serious profession.20 With the spread of medical care and the origins of germ theory, treatments were tested against control groups and doctors became scientists. As this happened, they removed formal dress jackets in lieu of a clean white coat, which was the scientists’ uniform of the day.
Nearly 100 years later the white coat continues to be an iconic symbol. In 1993 it became a rite of passage used in almost all medical schools as students are inducted, much like a graduation cap and gown ceremony.21 So, intertwined in the argument to reduce bacterial contamination in hospitals is the question of the power behind the white coat.
Some believe it’s a symbol of professionalism22 while others find it’s a symbol of hierarchical elitism. In 2018, the Association of American Medical Colleges reported 97% of medical schools have a white coat ceremony.23 The Mayo Clinic has now instructed their physicians to wear only business attire in an effort to break the barrier between physicians and patients.24
A large study25 from the University of Michigan surveyed 4,062 patients from 10 academic medical centers and found 53% thought how the physician was dressed was important to them as they were receiving care. One third agreed it influenced their satisfaction, and compared to other forms of formal dress, the white coat was more highly rated.
The researchers concluded patients’ expectations and perceptions of their physicians’ dress varied by contact and region, but policies addressing dress code may help improve patient satisfaction.
In what appeared to be an apparent disregard for research showing bacterial contamination found on the symbolic white coat, Dr. Christopher Petrilli, lead author, commented,26 “What we wear is such an easy thing to modify. At a time when we’re all trying to be more patient-centered, doesn’t it make sense to do what people want?”
Ten years ago, The New York Times27 reported the American Medical Association expressed concerns of bacterial transmission from physician lab coats. At the time they were studying a proposal doctors would give up lab coats for good. In the same article was a physician’s comment saying, “The coat is part of what defines me, and I couldn’t function without it.”
Medical Error May Be the Third Leading Cause of Death in the US — Or Greater
Medical mistakes are made in the operating room, in the emergency room and in the doctor’s office. Authors in a 2005 Canadian Journal of Surgery analysis28 said medical errors represent a serious public health problem and threat to patient safety. They called for accurate measurements of the incidence of medical error as few studies had measured it directly.
Instead, researchers have adopted measurements of error as largely dependent on adverse outcomes or injury. As a result, some research has suggested more than 250,000 people die each year due to medical errors and millions more are harmed by medication-related mistakes.29,30
A team from Johns Hopkins points out the Centers for Disease Control and Prevention’s method of collecting statistics does not classify medical errors on the death certificate. In response to their research results, the authors wrote a letter to the CDC asking for a change in the collection methodology as the list of cause of death is used to inform many research and public health priorities.31
As a result of serious limitations, the list neglects to identify medical error, which ranks as the third leading cause of death in the U.S. Lead author, Dr. Martin Makary, surgeon from Johns Hopkins University, commented in an interview:32
“You have this overappreciation and overestimate of things like cardiovascular disease, and a vast underrecognition of the place of medical care as the cause of death. That informs all our national health priorities and our research grants.”
Hospital-acquired infections kill more people each year than diabetes. Records from 2002, the most current available, show each year 1.7 million are infected and 98,987 die from health care-associated infections.33 The World Health Organization (WHO) reports health care-associated infections are the most frequent adverse events in healthcare worldwide. They report 37,000 die annually from these infections in Europe and many more could be related.34
Medical Mistakes and Nosocomial Infections Create a Health and Financial Burden
The WHO reports35 that while there is a 1 in 1 million chance an individual will be harmed during air travel, there is a 1 in 300 chance a patient will be harmed during health care. Many of the statistics impacting health care costs from medical error are presented in this short video.
According to WHO,36 these mistakes result in 15% of health care spending and hospital infections affect 14% of all patients admitted worldwide. A study37 using a literature review of four studies found a lower limit of 210,000 deaths each year associated with preventable harm in hospitals.
However, the researchers noted limitations may lead to a true number of premature deaths associated with preventable harm to be higher, estimated closer to 400,000 each year.
Unfortunately, at this point the real number of deaths attributed to medical mistakes is unknown as most death certificates do not list the trigger. Researchers from Johns Hopkins Medicine believe these shortcomings hinder research and keep the issue out of the public eye.38
Patient Safety Is Crucial
The National Opinion Research Center (NORC) at the University of Chicago is an independent social research organization. In 2017 they released survey results presented at the 10th annual IHI/NPSF Lucian Leape Institute Forum & Keynote Dinner.39
The survey found 21% of adults in the U.S. had a personal experience with medical error. The nationwide survey was done with 2,500 adults, expanding a 1997 survey conducted by the National Patient Safety Foundation. After personal experience, 31% of Americans reported knowing someone with whose care they were closely involved, who was affected by a medical error.40
Few reported worrying about patient safety, and 80% believed it was the responsibility of health care providers, leaders and administrators, as well as family members and patients. Dr. Tejal Gandhi, Chief Clinical and Safety Officer of the IHI/NPSF Lucian Leape Institute commented:41
“The survey results show that Americans recognize that patient safety is a critically important, but complex, issue. The focus on diagnostic errors and the outpatient settings closely parallels other research in this area and confirms that health care improvers need to take a systems approach to safety that encompasses all settings of care, not just hospitals.”
What To Do To Protect Yourself
In this interview with Andrew Saul, Ph.D., we discuss the importance of being your own health advocate. Once at your doctor’s office or in the hospital, you are at risk of a medical mistakes. You and your family are the best safeguards against experiencing a medical error. This is particularly important for children and senior citizens.
Any time you are hospitalized, be sure you have a personal advocate present to ask questions and take notes. It helps reduce the likelihood of mistakes when someone asks, “What is this medication? What is it for? Who is supposed to get it? What’s the dose? Are there side effects?” Merely asking the questions signals to personnel that they are being held accountable.
Another step you may consider if someone you know is scheduled for surgery is to print out the WHO surgical safety checklist,42 which may be downloaded free of charge here and may help you protect against preventable errors. Also, remind personnel (and visitors) to wash their hands and change gloves before touching you.
Needless to say, avoiding hospitalization is your safest bet. You may be able to reduce your risk of hospitalization by maintaining optimal health following specific strategies you’ll find in my previous article, “Medical Errors: STILL the Third Leading Cause of Death.”
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